Emily Likins-Ehlers knows how stressful pregnancy can be. A three-time survivor of Hyperemesis Gravidaram, Emily has had one surgical abortion and two empowered cesareans.

As a survivor of sexual and domestic violence, Emily joins reproductive health workers and advocates globally in making the connection between that trauma and how a birthing person’s body can react to pregnancy, labor, and the postpartum journey.

“I really do believe that my, quote-unquote, ‘failure to progress’ definitely had something to do with my sexual trauma,” Emily said. “ [And with] my unconscious clenching that I had been doing for years that my body had developed after years of being with a sexually abusive partner.”

Our cervix is a muscle, and it's a protective muscle,” they added.  “It’s a muscle that has evolved over millions of years to protect our babies and so when you are startled, or when you are in ‘fight or flight,’ that cervix clamps right up [as if to say] ‘I’m not dropping a baby here, it’s not safe!’”

Now a trauma-informed, full-spectrum doula based in Illinois, Emily works to support all pregnancy experiences and outcomes.

It’s important, Emily said, that midwives and doulas know a person’s history and that for those who have survived sexual or domestic violence that they be given the time and space to process their emotions, acknowledge their triggers and give birth without interference.

This, experts say, will help them deal with their trauma.

The World Health Organization (WHO) estimates that one in four birthing people experience some form of sexual violence. And when a birthing person becomes pregnant, they may experience an uptick in cues or triggers that recall painful memories because pregnancy, birth, and infant-feeding have aspects to them that the birthing person cannot control.

Midwives and doulas can be well-equipped to support survivors because the model of care is rooted in the birthing person’s rights to autonomy, self-determination, and informed consent or refusal. There are many ways to support survivors within the framework of the midwifery model of care.

“When people openly disclose abuse or assault, the very first thing that I do is ‘hands off’ because even a touch on the hand or a platonic hug can become very uncomfortable for someone who has been assaulted,” Emily said.

Emily also schedules additional prenatal appointments so they’ll have more time to build a rapport and get the client more comfortable with touch. Filling out an anatomy worksheet where the birthing person can list their preferred terms, Emily said, also helps to ensure the client isn’t triggered by terminology they may associate with a post-assault exam.

As they prepare for labor, Emily said they address the need for a birthing plan and a clear nursing care plan.

“A birth plan is obviously going to talk about your comfort measures and your refusals and your preferences for the immediate postpartum and all that, but your nursing care plan is going to sort of address other things like ‘when I am being cared for by the nurses postpartum, it’s important to me that no one remove the sheet from my body, I be the one who always takes the blankets off of me.’”

Here are some other points to consider with your client to help foster a successful labor experience:

• Have nurses and doctors introduce themselves beforehand--masks can be scary.
• For some clients, it’s important to avoid an epidural, or any intervention that might mean being "stuck" in a bed or restrained. For others, pain may be a trigger, and getting an epidural might be the relief they need.
• Hands and knees position can be extra triggering for survivors because it's hard to know if someone is coming up from behind.
• During a cesarean, unrestrained arms and other patient-centered cesarean measures can reduce the chance of triggering a past assault.
• Laboring people who have experienced sexual assault might want to be alone while they labor, or not be touched or talked to. Partners should do as much of the touching as they can, and whenever possible provide massage support over clothes.
• Coached pushing / pushing with stirrups can be especially triggering -- people telling you what to do while you're naked on a bed can be upsetting even for those who don't have a history of trauma!
• Bring extra sheets and curtains to births to create more privacy if it is lacking, or if you aren't sure there will be enough linens available to keep your client comfortably covered up.
• PTSD is often confused with postpartum depression (PPD), anxiety, and Obsessive-Compulsive Disorder (OCD). Trauma can cause obsessions with needing to feel in control and unreasonable fear of leaving the house, birth trauma can cause mothers to subconsciously assign the baby as "perpetrator" of the trauma re-experienced during childbirth, etc. PTSD and PPD are often co-morbidities.
• Chestfeeding aversion and Dysmorphic Let Down Syndrome are common with survivors of sexual abuse; bottles should be definitely considered if breast or chestfeeding is triggering. Lactation counselors should have models or demonstrate on their own bodies rather than touch the nursing person.

Survivors of sexual and domestic violence may be resilient but their reactions to the trauma may affect their ability to navigate pregnancy and childbirth. Access to trauma-informed midwives and doulas can be key in supporting their efforts to have a healthy pregnancy, a positive birthing experience, and ultimately a rewarding relationship with their baby.