‘Not a normal part of the perinatal experience’: How to diagnose childbirth-related PTSD

About a third of Australian mothers experience a traumatic birth, research shows, and about one in eight of these women have symptoms of PTSD.

But University of Sydney researchers say childbirth-related PTSD — a phenomenon distinct from postpartum depression — remains overlooked.

The team, led by registered psychologist and PhD candidate Alysha-Leigh Fameli, recently validated the 29-item City Birth Trauma Scale adapted from the DSM-5 criteria for PTSD in a cohort of 29 Australian mothers.

She speaks to AusDoc about why the tool was developed, its role in antenatal and postpartum care, and the consequences of missed diagnoses for both mother and child.

AusDoc: What is childbirth-related PTSD and how does it differ from other forms of PTSD?  

Ms Fameli: PTSD in general is not really a uniform diagnosis — in that you can have multiple different presentations.   

With childbirth-related PTSD, the reason it is important to delineate is that the symptoms are likely to be different in perinatal populations.

In normal populations, we might see impulsive or reckless behaviour, like drinking, … but we don’t really see that in perinatal populations as much. 

We might see different hyperarousal presenters, inability to wind down, irritability, agitation, difficulty staying asleep, which sounds funny because people with babies are often waking up a lot.   

But if you combine waking up a lot to meet the needs of a baby with being unable to fall asleep because you have PTSD, you have this recipe for a sleep deprivation disaster, which exacerbates all the other symptoms of PTSD.   

So that is why it is so crucial to be screening for PTSD and not just other perinatal mental health conditions, like depression or anxiety, because the symptoms are different.  

AusDoc: How do you separate this phenomenon from postpartum depression?

Ms Fameli: That is a really interesting question. There is a need, I think, to delineate between postpartum depression and childbirth-related PTSD.

However, there is also an overlap between the symptoms.

Large components of PTSD are actually negative mood and cognitions, which are obviously the crux of what depression is.   

And also, traumatic childbirth can cause depressive symptoms; it can drastically impact a woman’s mood, her experience of or lack of joy and enjoyment, her ability to connect with others.   

I think they just need to be understood as potentially separate things that can occur but also things that are highly likely to occur together.   

In my study, there was a clear overlap between PTSD and symptoms of depression.   

The difference was the women in my study who had depression and childbirth-related PTSD felt that their symptoms came directly from their birth experience.

AusDoc: What are the consequences of missed diagnoses or undertreatment, for both mother and child? 

Ms Fameli: I think the biggest risk is that often women are told their symptoms are just a normal part of the postpartum experience.

They are feeling wound up or hyperaroused or are having some experience of the low mood negative effect, or they’re having flashbacks of the birth experience.

I think the difficulty is they are often told it is not [something wrong], and it can have such a ripple effect, affecting the bond with the baby.   

That is a really important part that needs to be considered when talking about maternal mental health: you are not just talking about the mother and the mother’s wellbeing.  

You are also talking about something that is drastically going to impact the infant and their development.   

We do have extensive research that tells us maternal mental health is a huge predictor of infant outcomes.   

Aside from mother and baby, it also impacts partner relationships, subsequent decisions to have more babies or future reproductive decisions.

Potentially, there could be really serious side effects, like a spiralling maternal mental health into other forms of psychopathology and things like that.   

It is important to screen to prevent things from getting out of control and to prevent those ripple effects, particularly for the infant.  

AusDoc: Are there certain types of births or situations that are more likely to result in childbirth-related PTSD?

Ms Fameli: Generally, in the literature, and certainly in my study, the two types of births that yielded the highest symptoms of birth trauma were emergency C-sections and instrumental vaginal births, including episiotomies and vacuum-assisted births. 

But the other thing that was consistent with traumatic births was induction of labour. 

Women who had had an induction were more likely to have symptoms of birth trauma in my study: the tricky thing here is that induction can lead to a cascade of other interventions because you are essentially speeding up the birth process. 

I think we have to start questioning how we manage labour and childbirth. 

AusDoc: What led to the development of a screening tool for childbirth-related PTSD?

Ms Fameli: The scale was developed by Susan Ayers and her colleagues in the UK in 2018.   

It was recognised that one of the biggest issues in research around birth trauma was that there was no consensus about what we could use to measure symptoms of childbirth-related PTSD.

There were a number of studies but all using different measures that were not comparable. 

Hence, Susan Ayers and colleagues developed the City Birth Trauma Scale or the BiTS and lined it up with the DSM-5 criteria for PTSD with modifications for perinatal populations. 

My study validated this scale in a cohort of Australian women.

As it stood, we did not have a measure of childbirth-related PTSD that could be used in routine healthcare with Australian women because nothing had been psychometrically tested or looked at in terms of appropriateness for use with Australian populations.  

It has also been measured and validated all over the world.  

I am currently conducting a follow-up observational study, with 90 participants so far, but I am looking for 150 in total.   

It will look at the way in which childbirth-related PTSD impacts the mother–infant relationship and will include clinical interviews with participants about their symptoms and experiences. 

From those observations, we can hopefully start developing helpful interventions for mothers and babies. 

AusDoc: Who do you think is responsible be diagnosing childbirth-related PTSD?

Ms Fameli: I think, practically, childbirth-related PTSD should be screened for in the antenatal period based on their previous birth experiences. 

Because if you have experienced a traumatic birth, there is a chance you may have difficulty with your next birth in that it might be re-traumatising or triggering.

I also think all women should be screened six weeks after birth and again between then and six months after birth because there can be a delayed onset of childbirth-related PTSD. 

In part, that is probably because the early postpartum period is all about surviving and keeping your baby well and recovering from birth. 

GPs tend to be the first point of contact for many women after birth, so they are best placed to do this. 

Antenatal midwives who do community outreach or child maternal health nurses should also be screening women in the postpartum period. 

AusDoc: Can you tell us more about the potential role of GPs here?

Ms Fameli: They can become familiar with the symptoms of childbirth-related PTSD.

We should not underestimate the important role GPs play in the postpartum period because they are often the first person a new mother goes to when she is struggling.

If that GP has an understanding about normal infant sleep, as well as the symptoms of childbirth-related PTSD, postpartum depression, postnatal anxiety, then they are in a powerful position. 

They can intervene at a vulnerable and early stage and really change the trajectory for that woman and her infant to stop that ripple effect from happening. 

They can use the City Birth Trauma Scale; it is an easy-to-use self-reported scale that maps onto DSM-5 criteria for PTSD. 

It is as simple to administer as the Edinburgh Postnatal Depression Scale, which is often administered by GPs. 

And if they can refer to psychologists, with the Better Access mental health treatment plan, then they are  going to offer women early intervention and early support, which is really crucial and hugely lacking in perinatal care.

AusDoc: Once a diagnosis is made, what is the ideal course of treatment?

Ms Fameli: There have not been enough studies about interventions that are effective.   

So far, there have been a few studies about well-known psychological interventions following trauma — specifically trauma-focused CBT and eye movement desensitisation reprocessing therapy — and those have been promising.   

In terms of birth trauma research, the sample sizes have not really been big enough for us to generalise those findings and say for definite what is the best course of action. 

But it does appear that an intervention is better than no intervention when compared with the control groups — there just is not a clear pathway forward as to what that should be.

Ms Fameli’s observational study looking at mother–infant relationships is still recruiting new mothers with symptoms of trauma. Find out more here.