Postpartum depression expert explains birth trauma

Originally written by Jeff Forward for the Houston Chronicle

As doctors, therapists and public health entities put an increasing focus on postpartum depression, another area of concern has also seen increased analysis, awareness and care from therapists across the Greater Houston region: trauma induced by the process of giving birth.

Giving birth to a child can cause some mothers to go into shock, suffer from various mental health conditions and lead to postpartum depression. That potential trauma is being recognized by more medical professionals, obstetricians and gynecologists and therapists across the nation.

For Lorissa Eichenberger, one of the pre-eminent postpartum depress therapists in Texas, the issues associated with the condition, the affect of the COVID-19 pandemic on the child birth and helping mothers cope with the after-effects of traumatic birth experiences are critically important. She works with moms, and at times fathers, in helping them come to terms with traumatic incidents that stem from the intimate, unpredictable and painful experience of giving birth.

Often called a “birth nerd,” Eichenberger is a licensed marriage and family therapist at The Center for Postpartum Family Health in Houston. She talked to The Villager about these issues in the second part of our focus on postpartum depression.

QUESTION: What is postpartum depression?

EICHENBERGER: “Postpartum depression has been around for decades, but in the last probably 10 years or so, we’ve gotten a better handle on diagnosing, assessing, and treating. It is now being referred to as perinatal mood and anxiety disorders, or abbreviated as PMADs. That is the classification that a lot of professionals in our field have developed, so people can understand it is not just postpartum depression anymore. It can manifest into a variety of different symptoms and presentations. Most moms go untreated and undiagnosed. About one in five moms, or as many as two in five moms can develop a perinatal mood disorder. Less than than half will identify that’s what is going on, and maybe half of those moms will get treatment. This means we may be looking at a large number of women who could go undiagnosed and untreated because there is not a lot of information that is publicized on what it actually looks like.”

QUESTION: Are there variations or different types of postpartum depression?

EICHENBERGER: “We have traditional postpartum depression, which is an advanced manifestation of the ‘baby blues.’ So, ‘baby blues’ is the first one, two, or maybe even first three weeks postpartum where we see sadness, crying, emotional shifts. Moms may feel a little disconnected. There is a ton of exhaustion because of sleep deprivation as well. Typically, within a couple of weeks that should resolve or diminish in terms of the level of severity or symptoms. If it doesn’t, and it either starts to increase, or it has different features like irritability or heightened anxiety, then a consultation with a mental health professional for assessment is recommended. One of the hallmarks of postpartum depression is an increase in irritability. That means the mom is having a really hard time tolerating what would seem normal for her to tolerate. So, a person might make a loving joke or a casual statement and where as mom might tolerate that before baby, she can’t tolerate it due to the irritability around it. The mom might be reactive to things in a way she would not normally be.

QUESTION: Are there other symptoms like this that could develop?

EICHENBERGER: “Another hallmark would be insomnia or even hypersomnia. Insomnia is where they are not sleeping. It is not allowing their brain to reset overnight. So, all of those depressive and anxiety symptoms are going to be escalated quickly with a lack of sleep. Newborns take a lot out of you, and it is hard to get sleep with a new baby. You can see where this perfect storm starts to develop. The hypersomnia aspect is the mom is sleeping more than usual, but it is not restorative. They could sleep for a long time, but they still feel exhausted.”

QUESTION: What other aspects of postpartum depression symptoms develop?

EICHENBERGER: “There is another hallmark with a lot discrepancies and myths. Moms that have a hard time connecting to the baby, may or may not have a perinatal mood and anxiety disorder. That bond may not always happen right away. That is not considered universal. There are perinatal mood disorders where moms may feel overly connected to their baby. So that increases their anxiety about leaving their baby with other people or feeling overwhelmed by the pandemic environment. There is this hyper-awareness of protecting. There is a really over-charged connection with the baby. If there is trouble connecting, that does not necessarily mean there is postpartum depression. It can be really common for moms to have a delay in maternal-infant bonds. It depends on circumstances around getting pregnant, what their pregnancy was like, what the birth was like. We are noticing a high correlation of the birth experience having a major affect on the postpartum experience.”

QUESTION: Can you explain that idea, of birth trauma?

EICHENBERGER: “My specialty is working in traumatic birth experiences. When you are looking at birth, birth in general, even though it is considered a normative life process, it is something that is normal to your life. Birth has its own layers of traumatic levels. The body has to go through a pretty traumatic physical process. Whether it is vaginal birth or c-section birth, there are still a lot of traumatic body processes that have to happen. Normally, that is tolerated well when there is a supportive environment and/or the mom feels informed. When the birth mom feels she is informed, knows what happening and appears to have a good connection with the medical providers, we see a lower incidence of traumatic experiences during child birth.

QUESTION: You mentioned the coronavirus pandemic and how that has affected child-birthing, is that also playing a role in traumatic birth experiences?

EICHENBERGER: “The incidences of traumatic birth experiences during the pandemic are increasing. That could be because the level of care has changed focus and protocols due to the pandemic. Some hospitals don’t allow partners to be present for birth, and some do. So you have to think about a new mom going in for a first-time birth, or a subsequent birth, and her partner may not be able to be there. And if they have to leave, they may not be let back in because of the pandemic. The aspect of partner support can look very different now. The other part is, care providers may not be as easily accessible as they were prior to the pandemic. This may be because there are different levels of care needed in different parts of the hospital. It is no longer a guarantee the provider you have been with your whole pregnancy will be there. That has never been a guarantee, but it has been counted on prior to the pandemic. We are now seeing a higher incidence of birth providers not being able to get there on time because of all the other levels of safety protocols.”

QUESTION: Can you describe the different elements or variations of a traumatic birth experience?

EICHENBERGER: “A traumatic birth experience can have a lot of different variations. A vaginal birth seemingly uncomplicated can go very quickly into complex trauma. The risk factors for that are if the mom has any history of trauma coming into the birth. Another risk factor is if the mom does not feel safe in the birthing environment, (or) if the mom has to transfer from one birth environment to another. We’re seeing an increase in out-of-hospital births, which is a great option for low-risk vaginal birth. If there is a need for a medical transfer, which is rare, that transfer can have traumatic elements to it. Think about a woman who is trying to give birth or is giving birth, she has be to loaded into an ambulance and transferred to a hospital. That is an example of a possible traumatic element. Even with an in-hospital birth, a vaginal birth going smoothly, things may suddenly start to go wrong. Or, a provider may start to use interventions to speed up labor, as we are noticing an increase in medical interventions and c-sections. A planned vaginal birth ending up in a c-section can be traumatic experience. The mom may feel out of control or uninformed. Everything is happening so fast, even in non-emergency births and c-sections.”

QUESTION: While maintaining patient privacy, what can you reveal about patients you have treated and their traumatic experiences?

EICHENBERGER: “I run therapy groups for women who have had traumatic birth experiences. When they are coming in, the most common thing that they say is they felt somewhat ‘violated’ and ‘helpless.’ They felt like vaginal or cervical checks were being done without consent or information. Interventions may be happening without consent. Consent can mean different things. It is one thing to sign a piece of paper to consent to medical treatment, but it is another layer of information to actually tell mom, ‘this is what is about to happen.’ When that provider actually provides that verbal connection with mom, when it is possible, when they are communicating, and say, ‘we may need to do a cervical check,’ or, ‘hey, we might need to look at the baby’s heart tone.’ If mom is being spoken to and giving her verbal consent, I am seeing lower incidences and reports of birth trauma. Some providers may not realize how important it can be to do what we call, ‘trauma-informed care.’ Most providers are doing their best to provide quality medical treatment, especially given the pandemic environment and new protocols. I truly believe their intentions are to care for their patients as best they can and to the best of their abilities. I speak with local birth providers often, and I always encourage them to seek out ways to care for their patients using’”trauma-informed care’ when possible.”

QUESTION: What do you tell moms about their experiences to help them recover and heal?

EICHENBERGER “There is a general consensus around the ‘happy and healthy baby, so then mom must also be happy’ in our society. I tell all of my clients, you can be exceedingly happy that your baby is here and still upset about how the baby got here. You can feel both, it is OK. My job is to give moms permission to feel whatever they need to feel and process. If they don’t feel good about their birth, that is OK. You can be happy the baby is here and still be angry about how the birth happened. That is part of the big platform of spreading awareness around birth trauma.”

QUESTION: What advice do you have for dads or partners and family members to monitor for postpartum depression?

EICHENBERGER: “They are going to want to make sure they are watching mom’s sleep. They need to really make sure mom is actually sleeping when she is able to. If you see a disruption in sleep, if they have not slept at all in a couple of days, that needs to be looked at. If that is not resolved, we need to get support in there quickly to talk about treating insomnia. The other sign is a shift in mom’s response that can look like irritability. Those are the top two things to look for. Look for mannerisms or behaviors that are not normal for the mom, not just the ‘baby blues.’ If you see a shift after the first two weeks after birth, get in touch with an OG/GYN or a therapist. It is easier to get clients support now with tele-health, whereas before they may have had to wait weeks and weeks at the beginning of the pandemic. If mom’s symptoms are extreme, you want to act quickly. Make sure there is a supportive environment for mom to come home to. If mom does not feel like she can have a break, she can begin to feel trapped. Isolation is obviously high now, and we’re seeing a higher influx of moms coming in four to six weeks after birth. The isolation level, the lack of family support, the lack of friends, the lack of the mom’s ‘tribe,’ she just doesn’t have as much support as before. We are currently seeing a significant increase in moms calling (for therapy) two to four months postpartum.”