childbirth, birth planSo many of you have asked about birth plans, your childbirth experience and postpartum depression, that I asked our fabulous Kate Kripke to write about how these things may or may not impact PPD or postpartum PTSD.

Oh, the pressure around childbirth!  Do we try for a natural, unmedicated birth or do we choose an epidural to relieve our pain when delivering our little ones?  Do we hire a doula to support us through our childbirth journey or do we rely on our doctor and nurses to support us throughout?  Do we choose to give birth in the comfort of our home with a trained home birth midwife, or do we plan to labor and deliver in a hospital surrounded by doctors and the option for pain medication?  Do we choose to attempt a VBAC or plan a second C-Section?  Do we lean towards waiting for natural contractions to begin, or do we get induced and, with that, have a clear idea of when that little face will enter this world?  Do we go forward towards childbirth with a birth plan, or do we enter the experience with an ease and flexibility about what the ultimate experience entails? These decisions can be endless, and I think it is fair to say that there is expectation, judgment, and pressure that come at us from every direction as we muddle through this laundry list of “choices.”

The woman and mother in me believe strongly that we should have a say in the process that is called birth.  I believe that each women should have the right to choose who her provider is, what positions she wants to labor in, and whether or not to receive pain relief.  Each one of us is, ultimately, the best judge of what our body needs under best-case scenarios.  However, the clinician in me also knows that sometimes deep hopes and expectations can lead to emotional challenges postpartum if and when they are not met as desired.  And the research buff, experienced therapist, and perinatal mood disorder expert in me knows that it is actually not the specifics of one’s birth that can lead to a postpartum mood disorder like postpartum depression, anxiety, or postpartum PTSD, but a mom’s perceptions of those experiences.

Let me explain with some examples:

I am talking about the mom whose birth, on paper was “perfect.”  She gave birth in a hospital with a nurse midwife.  Her labor was moderate in length and she delivered vaginally with no medication for pain relief.  Her baby was born with an Apgar score of nine.  Her husband was encouraging of her throughout.  And, still, this mom arrived in my office several weeks later in deep despair.  In her memory, her birth was “traumatic.” She remembers intense pain and little relief from this and, while her husband and midwife had cheered her on because they “knew” that she had wanted to give birth naturally, what she remembers wanting most desperately was for it all to just stop.  She cried when recalling that she felt unheard, torn apart, and vulnerable. She was terrified throughout her birth process and, despite the loving people around her, she felt alone.  Because it had all gone as planned, this mom felt ashamed for her despair and guilty for “not being happy” about all of it.  She had, until coming to my office, not talked to anyone about how she felt.

I am talking about the mom who wanted desperately to give birth “naturally” but who, after 30 hours of labor and six hours of pushing, was rushed into the operating room for an emergency C-Section.  A nurse held her hand all the way down the hall and explained to her what was happening.  She remembers her OB, masked and ready for surgery, talking to her over the curtain as he explained his process in removing her son from her body.  She remembers seeing her son whisked away after being born and being left, only momentarily, until a second nurse who she had never met before came and sat with her and described her baby in detail until her husband returned.  When asked about her birth experience, this mom smiled and became tearful with pride. “It was as it was meant to be,” she said.  “ My baby and I were surrounded by people who cared about us and I could not have asked for anything more.”

I am talking about the mom who is terrified of pain and who, leading up to her birth, knew that she wanted an epidural at the moment her contractions began.  Her friends all discouraged her from this as most of them had given birth naturally without intervention, but this mom knew what was best for her and remained committed to this.  Her epidural was followed by the typical cascade of interventions: pitocin, heart monitor, and an ultimate vacuum delivery.  She gave birth to a beautiful baby girl, with an OB who she had never met, and with nurses who she never got to know because of a shift change during her labor.  “It was amazing,” this mom says of her birth.  It was all that I hoped and expected.

There are such opinions, such camps of thought, and such differing ideas about what it means to give birth, so many, in fact, that it is unrealistic and unfair to assume that any of us know what the “right way to give birth” is.  What truly matters most in the connection between birth experience and whether or not a mom develops postpartum depression, postpartum PTSD or any other mood disorder is whether or not she felt heard, seen, and supported, and whether or not that mom had the chance to process her experience and talk about what it means to her, both empowering and difficult.  Truly.  Even a mom who is disappointed by the loss of expectation around a hoped childbirth may not develop symptoms of depression or anxiety if she is given the chance to discuss and mourn her losses.

There is no doubt, however, that every woman should have the chance to think about what she would like, ideally, and have the opportunity to express this to her care providers and her support people.  One OB who I work closely with here in Boulder (and who I trust, admire, and respect deeply) speaks openly about how, if a mom does not express a desire to give birth without intervention, she will assume that an epidural and pitocin will be part of the equation. And if a mom does not reject this, she will push on. Because, yes, in western medicine this seems to be the culture these days.  And so, I imagine that because of similar situations across the globe, we are led to believe that OB’s don’t care what a mom wants (sure, there may be those out there too, I know) and that a mom really has to fight for the kind of birth that she desires.

And fighting is draining.  And heart wrenching.  And leaves us feeling angry and let down and vulnerable even if we end up with what we want.

So, write your birth plan if it’s something you’d like to do.  Interview providers and find someone to work with whom, ideally, supports your ultimate goals in childbirth if/whenever possible.  Make sure that if you are working with an OB in a practice with rotating providers that you meet each one and spread your hopes around so that those doctors know who you are and what your ultimate wishes are in delivery care.  Talk to your partner, your doula if you have one, and your doctor or midwife about your hopes and fears around childbirth and make sure that THEY know what kind of emotional support you desire.  If you plan on delivering in a hospital, request a nurse who has experience supporting moms through natural childbirth if this is a goal (yes, you can request this).   You can most certainly do your part ahead of time to set yourself up for the most supported experience possible.

And then, of course, know that it doesn’t always go as planned. Know that there are those times when your wishes won’t be granted and your goals won’t be met because birth tends to happen the way it happens both because of and despite our positive thinking, hard work, and determination.  Sometimes we are pleasantly surprised, and often we find that our expectations result in a bit of loss.  And if this is you, please find support- from your partner, family members, friends, doula, doctor, or therapist … wherever you can.

Our birth experiences tend to determine the lens from which we look into early motherhood, and if it doesn’t feel right — if this lens is dusted with anger, disappointment, sadness, loss, or fear — you might be at a higher risk for developing postpartum depression, anxiety or PTSD.  The sooner you get support around this, the sooner you will be able to look towards being a mom with clarity and understanding.

Updated Author’s Note:  

Please understand that my intention of this post is not to judge any one type of birth plan nor is it to criticize any one’s ultimate experience.  Although I did not include such an example here, there are certainly many many women out there who give birth naturally- without intervention- who leave that experience feeling fulfilled and empowered (and some of these women may NOT have intended to give birth this way).  These women, however, are also most likely those who felt supported, heard, and validated along the way.  The goal of this post is to bring light to that, particular, part of the birth process and to call attention to the fact that it is not the experience that brings the positive feelings about childbirth that we all hope for, but each mom’s feelings about her ultimate experience- did she feel heard?  Did she feel prepared?  Did she feel a sense of control?  So many folks out there in the blog world have written about ways in which they believe that “natural” childbirth is the only way to feel empowered and fulfilled, and this is simply a closer look at whether or not that is true.  Would love, as always, to hear thoughts around this…

~ Kate Kripke, LCSW

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