| Obstetrically focused response to disclosure of past sexual abuse or assault |
- Offer mental health referral.
- Create obstetric care plan (trigger avoidance and preparation for unavoidable stressors at delivery).
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| Preparation for delivery stressors |
| Generate plan to address intrapartum triggers |
- Involve multidisciplinary team for birth planning and counseling early in pregnancy (including but not limited to trauma-trained nurse educators, certified nurse midwives, psychologists, social workers, and clergy when appropriate).
- If team not available, consider nurse educator trained in trauma-informed birth planning to assist the woman in identifying triggers and generating a feasible birth plan.
- Final coordination and collaboration between the obstetrician, the woman, and the trauma-trained multidisciplinary team or educator in preparation for delivery.
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| A few common triggers and possible modifications |
| Triggers identified antepartum | Intrapartum modifications | Postpartum modifications |
- Undressing, genital exposure.
| - Drape adequately during examinations and at delivery.
- Limit spectator cheering/sensitive photos at delivery.
- Avoid shining bright light directly at perineum.
| - Cover breasts adequately when examining or assisting with breast feeding.
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- Feeling of fluid escaping from vagina, loss of bowel/bladder control.
| - Attend to keeping perineum clean during labor and at delivery.
| - Encourage staff to warn a woman before touching her and explain why they are doing so.
- Pay close attention to perineal care.
|
| | - Always ask before touching.
- Limit vaginal examinations and caregivers performing internal examination when possible.
- Avoid rushing.
- Encourage woman to bring calming music and/or support persons.
| - Avoid pressure to breastfeed if triggers unwanted memories.
|
- Feeling powerless, limited mobility.
| - Avoid overpowering words/behaviors (eg, command to relax).
- Avoid leaning over patient for vaginal examinations.
- Consider intermittent monitoring to allow greater mobility.
- Discuss epidural timing with emphasis on the loss of mobility and improved pain control.
| - Encourage postpartum social work or multidisciplinary team involvement.
- Consider home visitation program.
- Ask about stressors at postpartum visit.
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| Special issues to consider |
| Timing of abuse disclosure |
- Disclosure of past abuse may occur at any time, often later in pregnancy when trust is established. Allow the woman to control the timing of her own disclosure.
- Consider repeating abuse inquiry later in pregnancy if anxiety behaviors or comments lead you to suspect an abuse history, but respect her boundaries if she denies such a history.
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| Patient privacy, perception of safety, and control |
- Seek permission before sharing the woman's past abuse history with the obstetrical care team, other providers, and especially family members who may be unaware of this history.
- Avoid unrealistic promises (eg, "Don't worry, you'll be fine"), which can undermine trust.
- Emphasize realistic goals (eg, "We'll try to follow the delivery plan as much as possible, and if we have to change the plan because of concerns for you or the baby, we will discuss it with you").
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| Suspected ongoing abuse |
- Goal of safety planning takes precedence.
- Offer crisis hotline number, safety card, or educational material (National Domestic Violence Hotline 1-800-799-SAFE
![]( "Call: 1-800-799-SAFE") ). - Offer community resources (shelters, law enforcement contacts, mental health services, referral to social worker or multidisciplinary team if available to assist with safety planning).
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| Special safety issues when screening adolescents |
- Disclosure of childhood abuse for adolescent patients may suggest ongoing abuse. If ongoing abuse is suspected, state-specific mandatory reporting requirements apply.
- An immediate and coordinated response (including law enforcement involvement) is needed to assist the young woman in securing a safe environment.
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| Reimbursement and office time concerns |
- Consider using CPT codes for extended counseling.
- Involve nurse educator or experienced certified nurse midwives if appropriately trained to address trauma-related issues. This may alleviate office time concerns for birth planning and counseling.
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| Coordinating care with labor and delivery staff and postpartum staff |
- Obtain the patient's permission first before discussing her unique birth plan with labor and delivery staff and explain the reasons for sharing the plan.
- The delivery team will need to be aware of specific triggers and planned modifications upfront.
- Postpartum nurses will also need to be aware of specific triggers and planned modifications.
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| Obstetrical emergencies |
- Discuss the possibility of obstetrical emergencies during birth planning.
- Encourage the presence of support persons during labor, especially a trained labor coach or doula to facilitate adaptive stress coping.
- When unplanned obstetrical interventions are necessary to expedite delivery, discuss the labor course with the woman after delivery and encourage her to describe her feelings about the birth experience.
- Consider referral for postpartum birth counseling for abuse survivors who describe an unsettling birth experience or desire such counseling.
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