FRCA Notes

Trauma-Informed Care in Obstetric Anaesthesia

Curriculum

This topic is included owing to a recent BJA Education article; there are some relevant curriculum items too:

"The particular sensitivity of patient choice even when this is not in line with accepted evidence based best practice e.g., choice of birth plan"

"Demonstrates ability to communicate a balanced view of the advantages, disadvantages, risks and benefits of various forms of analgesia and anaesthesia appropriate to individual patients"

Resources


Why it matters

  • Over 70% of adults have experienced a traumatic event; physical and sexual assault are the most common
  • Perinatal mood and anxiety disorders affect 1 in 5 mothers
  • Childbirth itself can be traumatic: childbirth-related PTSD affects ~5%; up to 17% have post-traumatic symptoms
  • Mental health disorders and suicide are a leading cause of maternal death in the UK; ~40% of deaths between 6 weeks and 1 year postpartum

Features of PTSD

  • Hyperarousal: irritability, excessive vigilance about the baby
  • Intrusion: flashbacks, nightmares
  • Negative cognition: low mood, guilt, shame, fear of death
  • Avoidance: of people, places and things associated with the trauma; including healthcare

Sources of childbirth trauma

  • 'Sensitive procedures': examination, palpation and instrumentation of the genital area
  • Repeated examinations by multiple staff; loss of bodily autonomy
  • Emergencies: e.g. cord prolapse, shoulder dystocia

Psychological Procedure-related Situational
Verbal abuse Unexplained procedures Preterm labour
Dismissive attitudes Forced interventions Rushed decision-making
Miscommunication Invasive monitoring Emergency surgery
Emotional neglect Invasive positioning


Definition

  • A framework that shifts the question from "what is wrong with the patient?" to "what has happened to the patient?"
  • Also considers "what is happening now?": intrapartum events can themselves cause trauma
  • Assumes a patient is more likely than not to have a history of trauma

Six key principles

  • Safety
  • Trustworthiness and transparency
  • Peer support
  • Collaboration and mutuality
  • Empowerment and choice
  • Cultural, historical and gender issues

The three Es

  • Event; experience of the event; effects of the experience
  • Anaesthetists usually only see the effects: e.g. declining an epidural through mistrust or fear

The four Rs


Step Meaning
Realise The widespread prevalence and impact of trauma
Recognise Signs and symptoms of trauma in patients, families and staff
Respond Integrate knowledge of trauma into policies, procedures and practice
Resist Retraumatisation; avoid immediate debriefing

Recognising trauma

  • Withdrawn; poor eye contact; flat affect
  • Dissociation: feeling disconnected, conversation halts
  • Protective body language; e.g. pulling blankets around self
  • Avoidance of healthcare; scant antenatal care
  • Declining analgesia or requesting specific staff not be involved

Retraumatisation

  • Re-experiencing past trauma as if it were new; triggered by people, places, situations or environments
  • Behaviour may be misread as immaturity, disengagement or neglect, leading to reduced empathy
  • Staff defensiveness may shorten consent and interactions; care suffers

Higher risk groups

  • History of sexual abuse or interpersonal violence
  • Previous traumatic birth; e.g. failed neuraxial block with conversion to GA
  • Transgender, non-binary and gender-expansive patients: use correct pronouns and gender-neutral terminology
  • Pre-existing mental health disorders

Applying trauma-informed care in obstetric anaesthesia


Antenatal

  • Information on analgesic options during pregnancy; ideally introduced by the obstetric team
  • Encourage birth plans
  • Anaesthetic antenatal consultation for those with previous traumatic birth or anaesthesia-related fears
  • Written trauma-informed care plan shared between obstetric, anaesthetic and paediatric teams
  • Screening for past trauma and referral to perinatal mental health services

Consent

  • Build trust and transparency; introduce your role
  • Open questions: "What is your birth plan?", "What questions do you have?"
  • Ask about previous deliveries and how this experience could be better
  • Realistic expectations of neuraxial and general anaesthesia
  • Respect choice: including declining neuraxial analgesia or choosing its timing
  • Consider culture and values

Neuraxial placement

  • Ask the patient privately whether they want a support person present
  • Comfortable environment: lighting, music, mindfulness techniques
  • Allow the patient to open their own gown; explain why exposure is needed; keep clothed as far as possible
  • Ask permission before palpation and each step
  • Agree that the patient can say "stop" at any point
  • Watch body language and hand positioning
  • Consider low dose regimens to preserve lower limb mobility

Caesarean section

  • Coaching and positive reinforcement; may avoid the need for sedation
  • Explain what is happening throughout
  • Avoid arm restraints; keep drapes away from the face
  • Attend to comfort and temperature
  • Offer to lower the drapes at delivery; support early skin-to-skin contact
  • Sedation after delivery is optional: ask first

Emergencies and inadequate block

  • Unplanned GA is traumatic for most mothers
  • Keep the patient informed of the problem and the plan, however brief
  • Calm, reassuring communication

  • Follow up: ask about the experience of labour and delivery
  • Explain the clinical reasons behind distressing events
  • Address any complications of neuraxial techniques
  • Offer a later debrief with the patient, support persons and team; not immediately after the event
  • Refer to perinatal mental health services where needed