Labor, birth, and postpartum doulas often find themselves doing assessments for depression and anxiety as a normal part of their practices. If clients have responses indicating that they need more resources or support, most doulas are instructed to help their clients to find those resources and to refer on to medical or mental health professionals for further screening and referrals. Symptoms of birth trauma may show up on the Edinburgh Depression Scale or on the Perinatal Anxiety Screening Scale (PASS). The symptoms of a stress disorder – avoidance, intrusive thoughts, negative mood and cognition - are enough to make people feel anxious or depressed. However, the root cause is the birth experience itself, not another mental health condition.
The City Birth Trauma Scale, developed by researchers at the City University of London, is a 29 item scale that is valid for assessing birth trauma in a person who gave birth or in their intimate partner who witnessed the birth. It’s possible for the partner to have an acute or post trauma stress disorder related to the birth while the person who birthed the baby has no symptoms.
The page containing pdf links for both scales and the screening information is here: https://blogs.city.ac.uk/citybirthtraumascale/
The article explaining more generally about birth related trauma disorders and the validation of the scale is here: https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00409/full
Doulas are often on the front line watching births unfold and feeling helpless to influence the type of medical care their clients receive. It is not uncommon for a birthing person or mother to develop an acute trauma disorder or post traumatic stress disorder related to their birth experience. Their articles estimate birth trauma in the United States at 14% for birthing people and around ten percent for partners who witness the birth.
The fifth version of the Diagnostic and Statistical Manual (DSM-V), published in 2018, describes the criteria for stress disorders based on the best evidence available at the time of publication. The DSM-V is used for diagnosing people with behavioral health conditions and for billing purposes by insurance companies. The book, Traumatic Childbirth, by Beck, Driscoll, and Watson was published in 2014, but it is still considered to be a very helpful book for people who experienced their birth as traumatic.
Using the City Birth Trauma Scale In Your Doula Practice
Empowerment of the client is one of the doula’s primary purposes, however the client is the person who defines what makes them feel empowered. Like all things, how we foster that feeling of belief and confidence in one’s self will vary from client to client and family to family. Because of this, I strongly prefer the client to decide that they want to be screened; that the doula has explained ahead of time what the screening process looks like; and what will happen afterwards.
Language choice is very important. So is connecting what you are suggesting with what you have observed in their behavior. In facilitating the screening experience, I want to squash any self-blame or responsibility for having a trauma response. Our birth research shows us that people will often blame or assign responsibility to themselves first when it comes to their birth experience. We know there are many factors that influence an outcome, especially in a hospital birth. When you talk about a trauma response as something your brain decides to do, it can minimize the idea that a trauma response is some kind of personal failing. You might say something like this:
“I’ve been listening to you talk about your birth experience for a while now. I’m wondering if it affected you more deeply than you might realize. We don’t get a choice about how our brains encode our memories. However if your brain is viewing your birth as a trauma, its better to get support for that now rather than later. If you wait, the memory can become more potent over time, and more challenging to deal with.”
“I have a few screening scales we can do. There’s one for postpartum depression, one for postpartum anxiety, and another one related to birth trauma. The birth trauma scale has almost 30 items on it, and each item relates to a different symptom of post-traumatic stress disorder (PTSD). There are several items related to each symptom. So when you are done with the trauma scale, you’ll have a clearer picture of the symptoms your brain is expressing.”
“In our area, there are several support groups for people experiencing postpartum adjustment issues. (List the groups.) In your insurance, these resources are available (list the resources). Online you can connect with these self help support groups (list the groups). Personally I really find these books to be supportive (show the books). Depending on what feels right to you, you could connect with a professional around this or find a supportive group.”
Now, I like to start with the resources available BEFORE I do the assessment. That way the client never has feelings like, “What am I going to do?” Or, “There is something so wrong with me that it can’t be fixed”. I’ve consistently behaved in ways that told the client, “You are in charge”, and, “I will help you figure out what’s right for you”. If you were present at the birth, you probably have a relationship of trust established. However, if you are entering this family’s life as a postpartum doula, you may be doing these assessments in the first weeks of your relationship.
SCORING THE CITY BIRTH TRAUMA SCALE
The scoring section is in two parts. The first page is appropriate for doulas to use and to share with clients. I recommend that the client and the doula score the assessment together or that it be done openly in front of the client. We want them to participate in their own screening. Doing this will help them to assess what symptoms they have and the severity of those symptoms.
In general, PTSD does not heal on it’s own. Post-traumatic stress disorder is a dysregulation of the attachment and defense systems of the brain. Social situations where oxytocin would normally be stimulated are instead assessed as potential danger. The amygdala signals cortisol to be released instead. Treatment involves re-regulating these hormonal responses and the brain’s default assessment that the world is unsafe, rather than safe. This often involves deliberate experiences that involve pleasurable hormonal responses, not just talk therapy.
I do not recommend that you show or look at the second page of the scoring information. It is for clinicians to assess whether the person is severe enough to receive a diagnosis. As doulas we are paraprofessionals, and our role is to screen and refer, not diagnose.
WHEN TO ASSESS USING THE CITY BIRTH TRAUMA SCALE
The first several months after an event are considered the acute period. Behavioral symptoms of trauma differ slightly in the acute period from the post period. Post trauma means four months or more after the original event. Acute trauma symptoms are the same as post trauma symptoms in the mother and/or gestational parent but may also include: crying without realizing it, while carrying on a neutral conversation; holding the baby without awareness or affectionate touches; brain “fog”; feeling emotionally numb; and talking rapidly about nothing important.
In these first months, the brain is still in shock mode and “disorganized” from the stresses of birth and the accompanying trauma. It is striving to regulate itself. If the brain succeeds in emotional and hormonal regulation, the person will heal from the trauma without developing PTSD. However, if the brain remains dysregulated, the classic symptoms of PTSD appear or become stronger around four months after the incident. This is true for anyone experiencing any kind of trauma, including partners, nurses and doulas who were witnesses to a traumatizing birth experience.
Therefore, some clients may benefit from an assessment during the acute period, especially if they are showing symptoms. However, offering follow up visits throughout the first year, i.e. wellness checks, is a future expansion for doula services that allows for mental health screenings, parenting resources, feeding resources, and continued communication between doula and family members.
If you want more ideas about expanding Postpartum Wellness Visits into your practice, check out my FREE Preview Chapter of my course on Powerful Prenatal Relationships. It includes copies of depression, anxiety and trauma assessment scales that I recommend for doulas.
If you want to learn more about trauma and the brain, I highly recommend my online course, Recognizing the Previously Traumatized Patient In Labor.
If you enjoy learning more about how our brains work and how that can enrich your relationships, check out my course on Virtual Visits and The Social Brain.
(I'll upload the MP3 in a few weeks. Sorry for the delay!)