Transcript

[00:00:35] Nicole : Hi everybody. And welcome to the woman centered health podcast. Today we are interviewing Allison tinker, a midwife who has a particular interest in expertise in trauma informed care. Trauma informed care is a topic that we have briefly discussed in a few of our podcasts and it is something that we have wanted to have a dedicated podcast episode about.

[00:00:54] Nicole : Allison was actually referred to us by Dr. Kalin Klie, our guest, who spoke about perinatal substance use, and we are very excited to speak with her today about such an important topic. And for our listeners who are new to the show, you can get a PDF of our show notes or be notified of upcoming guests so that you can submit your questions to our guests by becoming a patron of the woman-centered health podcast. By going to www.womancenteredhealth.com.

[00:01:29] Stephanie: Allison, thanks for joining us today. We’d like to give our listeners a brief background about our guests. So we would like you to talk a little bit about yourself. Please tell our listeners about your background, your education and training and where you currently practice, like the types of patients you serve and what area of the country you’re in.

[00:01:52] Alison Tinker: Oh, great. Thank you so much for having me. It’s a pleasure to be here before we begin, though. If it’s all right, I’d like to put some soft parameters around today’s discussion, given that we will be focusing on women’s health and given that sexual abuse has a particular effect on women’s health, we will be touching on sexual abuse often during our discuss.

[00:02:10] Alison Tinker: However I wanted to assure your listeners that we will not include any graphic descriptions of abuse or trauma. Our discussion today will include types of trauma and ways that trauma can manifest itself. So there is some potential for triggering, but my goal is to provide information in a manner that’s thoughtful and informative and not difficult to hear.

[00:02:30] Alison Tinker: The reason I set this out ahead of time is that one in four women in America are the victims of childhood sexual abuse. So the odds are pretty good that some of your listeners might have this history and even though we’re providers, we’re still people and it’s hard to listen to learn. If you are scared that someone’s gonna surprise you with an emotional trigger at any moment.

[00:02:49] Alison Tinker: So I just wanted to set that out ahead of time to just kind of keep this a safe place for people. Thank you. That being said, I am a certified nurse midwife and I provide full scope care to women, uh, from adolescence through menopause, including pregnancy and childbirth. I’m also a doctoral student and I focus on the effects of prior sexual trauma on women during their childbearing year.

[00:03:10] Alison Tinker: And I’m also an international and national presenter and trainer on trauma effects and trauma informed care specifically aimed to teach healthcare providers how to provide trauma informed care.

[00:03:20] Stephanie: The other question we like to ask all of our guests is what informs your perspective or your practice. So in other words, why do you do what you do? What is most valuable to you or what’s your philosophy of practice?

[00:03:35] Alison Tinker: Well, I’ll tell you what I know for sure. And what the research is showing, and that is that women, even with a history of trauma can be transformed by a positive birth experience. What I also know. And what many of your listeners know as well I’m sure is that there is a dearth of information for providers on what to do when they have a patient who declares a history of trauma, or even when you suspect that a patient has a history of trauma.

[00:03:58] Alison Tinker: So my goal is to help providers to feel confident in knowing what their next steps are when faced with a disclosure of trauma or when helping a survivor during labor or during an exam. So what sparked your interest in focusing on trauma-informed care? So when I, uh, was becoming a new mom, I had a very, very transformative experience during my childbirth.

[00:04:20] Alison Tinker: And it just occurred to me that if childbirth can be such a change making event in women’s lives, there’s got to be a way that we can take this individualized experience and then transform it into a larger picture. So as I was going through my training to become a midwife, this was always just an extra interest of mine is looking at women that had a history of sexual trauma.

[00:04:40] Alison Tinker: And then what does the literature should I say? What does our evidence based practice say about providing care for trauma survivors and what I found and what I’m sure, like I said, a lot of your listeners have found also is that when you start digging into the research, there’s nothing out. There’s nothing that says, okay, when you get a positive screen, do this, it’s not like we have a patient that has a history of an MI.

[00:05:01] Alison Tinker: Everybody gets a beta blocker. We don’t have that protocol yet for trauma survivors, which is surprising when you think that it’s one in four women have this history. So that sort of started, it was thinking, oh my gosh, we need to be doing something about this.

[00:05:17] Nicole: Okay. So like we said, we’re gonna discuss trauma informed care. So let’s jump right. So for our listeners who may be finding us for the first time, we have talked a lot on other episodes, very briefly about trauma informed care, but could you define and discuss what is trauma-informed care?

[00:05:33] Alison Tinker: Absolutely. So I think one of the best definitions comes from SAMSA, which is a department of health and human services branch.

[00:05:40] Alison Tinker: It’s the substance abuse and mental health services administration. Their definition of trauma informed care has four RS. So it’s realizing the prevalence of trauma, recognizing the signs of trauma, responding by integrating our knowledge of trauma into policies and procedures and seeking to avoid retraumatizing underneath all of this is really this understanding that trauma informed care underscores the importance of physical, psychological, and emotional safety of patients and providers with the goal of empowering survivors of trauma towards resiliency and recovery.

[00:06:13] Alison Tinker: It’s a, a very proper definition. So I’d like to break it down just a little bit and acknowledge some really key aspects of that sentence. And then I’ll make sure that we touch on all of them as we sort of talk today. One of the parts that that sentence talks about is the interconnectedness of our physical, our psychological and our emotional health.

[00:06:31] Alison Tinker: The other very important word is safety, not just for our patients, but for providers as well. And I’ll get into that a little more empowerment, which is really just a sense of control and resiliency, which has to do with our coping skills and our coping mechanism. In addition recovery, which is ongoing and defined by the woman and includes her physical, psychological, and emotional components.

[00:06:51] Alison Tinker: So can you talk about why trauma informed care is important and relevant to today’s care providers? Sure. So, as I mentioned, one in four American women has a history of childhood sexual trauma. The world health organization estimates that 35% of women globally. Has experienced either intimate partner violence or sexual violence by a non-partner.

[00:07:13] Alison Tinker: But we know that this number is actually limited by the women who have historically been willing to raise their hands and say, me too. So it’s safe to assume that these numbers are an underestimation. In addition, there was the large research study that was done, the Ace’s trauma study. And so Ace’s trauma study looked at adverse childhood events.

[00:07:33] Alison Tinker: This could be physical trauma, emotional trauma, sexual trauma, but included other things such as, did you have a parent that was mentally ill or used drugs or was incarcerated? So some of the research now is also finding that any adverse childhood event, which includes all these traumatic events really has a long term outcome on our health.

[00:07:52] Alison Tinker: So even though we’re gonna be talking about sexual trauma in particular today, because of its effect of women and their interactions with the healthcare system, I just wanted to remind everyone that it’s not just sexual trauma that we’ll be talking about, but that all types of trauma can be managed through a trauma informed lens.

[00:08:09] Stephanie: So one thing that I’ve noticed in my own research with providers and also with patients is that some women may have experienced sexual trauma as a provider or the academic setting has defined it, whereas the patient doesn’t recognize it as trauma or vice versa where we wouldn’t necessarily recognize it as trauma and the patient would, could you just for our listeners give a little bit of a brief definition about what is considered trauma?

[00:08:43] Alison Tinker: Sure. That’s a really great question. And there’s a few different ways I’d like to answer it. One is the definition of trauma by DSM four, actually classified it as an event that’s outside of normal occurrences. They changed this slightly with the DSM five to incorporate things like chronic stress trauma.

[00:08:59] Alison Tinker: So having longer term effects from an event that happened in the past. So there’s really a broad definition of trauma. I think from a provider standpoint, the best way to think of trauma is based on the woman’s perception of trauma. If. Occurred. She feels was traumatic. We should therefore consider it traumatic as well.

[00:09:17] Alison Tinker: It’s like pain. It’s very subjective. We can’t understand a woman’s pain. Just the way we can’t understand the way an event has become traumatic for her. As far as the definition of sexual trauma, it’s a very, very wide and broad umbrella that classifies this sexual trauma. So there doesn’t need to be penetration.

[00:09:34] Alison Tinker: It can be even exposure or exposure to materials that were sexual in nature. So there’s a very large umbrella for things that fall under trauma. I think when we think about trauma, we think about how trauma gets imbibed in the body. So it’s like a story of the tiger. So if we were way, way, way back in human history, and we were walking along a path one day and around a corner comes a tiger.

[00:09:58] Alison Tinker: The human body is amazing. The human body knows that it needs to try to survive this tiger attack or this tiger encounter. So what the body does is it switches over into this mode immediately where every sensory input, every piece of information we can get to use to help us escape from this tiger. Our body will memorize that because if we were successful in escaping from this tiger, our body wants to be able to escape another tiger if it ever had to again, in the future.

[00:10:25] Alison Tinker: So what happens when we experience trauma is that it gets integrated into our bodies on the deepest levels possible so that our autonomic nervous system can respond to this. Traumatic event again, should it occur? So unfortunately, because in society today, we are often exposed to things that could potentially be retriggering.

[00:10:46] Alison Tinker: Survivors of trauma tend to live in this hyper vigilant state of stress at all times. So even though we might not be having a tiger encounter, our body experiences daily living as though it were about to encounter a tiger at any moment. So one of the things we see with trauma is that trauma actually has really long term impacts on the body.

[00:11:10] Alison Tinker: For example, the correlation between having a history of trauma and cardiovascular disease is astronomical. Some the other health impacts we see from a history of trauma are increased levels of asthma, of diabetes, of gastrointestinal issues. Like IBS, gallbladder issues, digestive issues, insomnia, chronic pain, such as fibromyalgia or difficulty controlling pain, or idiopathic pain pain.

[00:11:35] Alison Tinker: We just can’t really explain. In addition, women who, particularly who have a history of sexual trauma tend to have a lot of gynecologic issues like fibroids, endometriosis, abnormal, uterine bleeding, ovarian cysts. Oftentimes you’ll have a patient too that might have a substantial medical or surgical history, including a history of plastic surgery.

[00:11:54] Alison Tinker: We’ll also see that people that have a history of trauma have a real increased use of emergency services. And I think when we start looking back on the neurobiologic level of this, it makes sense a lot of these diseases and a lot of these things are really connected to those high levels of cortisol that our body then has to process at all times.

[00:12:12] Alison Tinker: And so we’re really finding that it’s that heightened stress response. That’s really leading to some of these long term health impacts. So when you talk about how you embody this experience, and you’re always living in this hypervigilant state as a provider, when a patient comes in, how might those manifest themselves in an exam room?

[00:12:30] Alison Tinker: Like what might a woman do or say, or what might be the triggers for them? So I think we need to, again, keep a very broad lens when we’re thinking about how a woman with trauma might present themselves again, because we don’t know what was traumatic for her, and we don’t know what is being retried. I think one of the things that I find helpful to think about is a basket of symptoms.

[00:12:52] Alison Tinker: So I think it might help your listeners if I give a few more examples, too, some of the other things that we might see, particularly within the OB GYN setting for trauma survivors. I think as we’re talking with our patients and we have a sense of their history, if we start getting a whole bunch of different red flags, I think you can start thinking, huh?

[00:13:12] Alison Tinker: I wonder if I should have a high suspicion of a history of trauma with this patient. So we’ve talked about the cardiovascular disease, asthma diabetes, the GI issues is very prevalent, chronic pain, the gynecologic issues. In addition, when a woman comes in, who’s pregnant, she might have some negative associations between her past abuse and the current pregnancy.

[00:13:30] Alison Tinker: So having some feelings or some questions that just are a little bit different in her initial OB appointment, oftentimes women that have a history of sexual trauma have very strong feelings one way or the other about the baby’s gender. Sometimes we see fertility issues as well. Some women who have a history of trauma have resistance to certain types of birth.

 

[00:13:47] Alison Tinker: Whether it’s an implanted device or not wanting to have chemicals in her system, a history of painful sex, more pregnancy discomfort than the usual patient, more ultrasounds, more unscheduled clinic visits. Maybe this patient will also have a greater desire for either a natural delivery or for certain types of pain management or in fact, a desire for a cesarean delivery.

[00:14:09] Alison Tinker: Also, I think one of the things to keep in mind too, when we’re thinking about this basket of symptoms is a lot of the ways that survivors have managed their symptoms of anxiety and depression is through coping mechanisms, which we all have coping mechanisms that we utilize. To manage our anxiety on a day to day basis.

[00:14:27] Alison Tinker: Some of us might choose cupcakes. Others might choose heroin, really the way the body processes. It is the same. It’s gonna hit the same neurotransmitters and relieve our anxiety, whether it’s chocolate or smoking a cigarette. So a lot of times some of the coping mechanisms that we’ll see in people that have a history of trauma includes drug use alcohol use smoking, disordered eating is a very common thing to find with the history of trauma, bulimia, anorexia.

[00:14:52] Alison Tinker: There’s a link to a particular. Eating habits. So whether it’s vegan or vegetarianism, excessive exercise, O C D we also see a lot of history of self mutilation, whether it’s cutting, but in addition, excessive tattooing, it hits the same level of the body that cutting does. And so it releases the same neurotransmitters in the body.

[00:15:11] Alison Tinker: So I’m not saying that every patient that comes into your office that has a sleeve full of tattoos and looks painfully underweight and has a history of IBS, definitely has a history of trauma. But I think if she’s also describing a real aversion to getting a birth control implant in her arm, or an I U D and she’s particularly afraid of becoming pregnant, then you start thinking, you know, this is a basket of symptoms I’m seeing here.

[00:15:35] Alison Tinker: I think it’s just a way that we can sort of identify these patients in our. The truth is, is we don’t need a disclosure. We never really need our patients to disclose a history of trauma. I think there’s one sentence that I think we, as providers could ask ourselves in this moment. And that is if, what I’m seeing and hearing from my patient, if I knew that she had a history of trauma, would it make everything make sense?

[00:15:58] Alison Tinker: Really is the only question we need to ask ourselves. And if the answer is, yes, gosh, that would explain a lot. Then we can just move forward with an assumption that this woman has a history of trauma and we can treat her with a trauma informed lens.

[00:16:23] Nicole: So you talk about having this possible basket of symptoms and also that maybe you don’t really need to ask, but maybe you’re a curious provider and you want to ask, or you wanna screen or, or know what’s going on.
Do you have a way that you recommend for providers to go about screening for trauma?

[00:16:42] Alison Tinker: Absolutely. And I think one of the things the research is also showing is that survivors of trauma do want to be asked. They do want to be screened for this, with their medical providers, because it acknowledges that this is an important part of their history.
So I certainly don’t wanna give the impression that we shouldn’t be screening. I think we should, 100%, as far as screening goes, though, proper screening really needs to be done in writing. So often this is an initial intake. You’d go into an initial OB visit and you’re filling out the paperwork in the waiting room.

[00:16:59] Alison Tinker: And there’s usually one type of question there that says, do you have a history of sexual trauma? Oftentimes that question is actually phrased from a perspective of intimate partner violence. You know, are you safe in your home? That type of question. And that’s, I feel like that question is fine. I don’t think it gets to the full picture if we’re only asking about her current safety, but certainly it’s connected.

[00:17:20] Alison Tinker: So I think asking and writing is appropriate. The thing is though, and as we know in an initial OB visit, I may or may not have ever met this provider before. Yeah. I don’t even know if the smile goes all the way to their eyes, basically. I don’t know if they’re trustworthy. So the odds of us getting a positive screen on an initial intake is very small.

[00:17:38] Alison Tinker: So what we need to be doing, I think is asking more than. So we’ll do it at initial intake, but if there’s a way that we can work it into the course of a woman’s encounters with her provider, that that will increase our chances of getting a positive screen, because really trust and establishing trust with your provider is the Linch pin of establishing trust.

[00:18:00] Alison Tinker: And making sure that you have a good relationship with your provider and until, you know, you can trust them. I’m not really sure that they’re gonna answer affirmatively. In addition, oftentimes in our initial screening, we’ll ask some type of question about history of trauma, but it’s usually phrased as a yes or no question.

[00:18:15] Alison Tinker: One of the things that I could encourage practices to do is to include a third option one when it says maybe I’m not sure. The reason why I include that is a lot of times women are unsure if what they experienced as trauma would qualify as a traumatic event. So for example, let’s say a woman says, no, I I’ve never had any sort of, uh, sexual trauma.

[00:18:36] Alison Tinker: I mean, I never really liked the way that my uncle hugged me at Thanksgiving when I was a kid. But does that count or maybe a woman says, well, you know, this guy and I we’ve been going out a few times. And then there was that one night we had sex and I was really drunk. Does that count? For example, I also had a patient once who had had a laparoscopic procedure, uh, for ovarian cysts, but her provider didn’t tell her that they were always gonna have to have vaginal access in order to complete the procedure.

[00:19:03] Alison Tinker: And so when she woke up and she was sore and inquired about it, and then found out that they had had to use vaginal access at the same time. She felt very traumatized, but would she have told me at the beginning that she had a history of sexual trauma? No. So oftentimes I think if we can allow women to have a larger umbrella, then the issue isn’t really whether or not somebody had a history of sexual trauma, it’s how they feel when they’re engaging with their medical provider.

[00:19:26] Alison Tinker: Now isn’t it. So that’s kind of the in writing screening part, some of the other things I’d like to include in that though, is that when we are inquiring about a history of trauma, I would always recommend that a patient is fully clothed. Why don’t we do this? One of the things I think that survivors often think is that somewhere on their body, they must be defective somewhere.

[00:19:47] Alison Tinker: It must show on them that they have this history. And if we’re doing this while either undressed or in a gown, and then a provider’s asking about trauma, I think it just lends to a really weird dynamic where she thinks, oh my gosh, you can see it on me. You’re certainly never gonna ask this question while doing any sort of.

[00:20:05] Alison Tinker: I think one of the things though, uh, some offices don’t screen for trauma at all. And I think I can understand why this occurs though, too. Our body has this really amazing functionality, uh, called mirror neurons. It’s the thing where if I watch you eating a lovely, delicious chocolate cupcake with lots of frosting, my salady glands are actually gonna start watering it’s because I can imagine what it must taste like as you’re biting into that delicious cupcake.

[00:20:31] Alison Tinker: So on the flip side of that, when we hear somebody describing something traumatic, we can actually kind of feel that in our body, we can envision that in our minds. So sometimes I feel. Providers are hesitant to screen because we’re afraid it might open this floodgate of information that we’re not prepared as humans to take in.

[00:20:51] Alison Tinker: I don’t necessarily want to hear you describe in detail your sexual trauma. So I’m not gonna ask about it. I can understand where this comes from completely. So I think as providers, we just need to be aware of our humanity when we’re talking about providing trauma informed care. In addition, some of our self-protection mechanisms, when we hear scary stories, when we hear things we weren’t prepared to hear, we tend to withdraw a little bit.

[00:21:16] Alison Tinker: So a lot of times survivors will come away from a medical experience. Feeling like they’re caregiver was just really removed. Very distant. Didn’t ask any follow up questions, disregarded their disclosure. And again, from a human perspective, I can understand this. It’s hard to hear this information. That doesn’t mean we shouldn’t screen because we should be screening patients for a history of trauma, knowing how much it affects health outcomes.

[00:21:38] Stephanie: That’s a really good point. We talked about this on another podcast top. I can’t remember, but somebody said, don’t ask if you’re not ready to help someone. Oh, is human trafficking. So don’t ask if you don’t have any knowledge of how to help someone through that. And so that was kind of my assumption is that sometimes for providers didn’t ask because they just don’t even know what to do.

[00:22:01] Stephanie: Like you said, at the beginning, if someone discloses that to you, what do I say? What kinda help do I offer them? That kind of thing. So there could be some of that going on too. So I guess that sort of leads to my next question on, if you do screen as a provider, how do you deal with your own discomfort, hearing those stories and experiences or even your own discomfort on not knowing exactly what to say.

[00:22:27] Alison Tinker: Yeah. It’s such a great question. And I think you’re absolutely right. And as we talked at the very beginning, there is absolutely a lack of protocol for what to do when we have this patient who is a history of trauma. And so again, it does beg that question of if we have no change in plan, what’s the point in screening for something, if I’m not going to adjust my plan of care in any way, regardless of the answer.

[00:22:51] Alison Tinker: So I hear that argument too. So when we do have a patient who discloses a history of trauma, I mean, this is the hard moment, isn’t it? And really it’s gonna boil down to a few key things and a few keyword. The first thing is we’re gonna have a pause point. We’re gonna stop. And we’re just going to acknowledge this moment.

[00:23:09] Alison Tinker: So whatever you were talking about, whatever your plan was for the next 15 seconds, you’re just gonna pause because really it’s gonna take a lot for your patient to disclose this to you. You want to acknowledge the weight of the information they’re giving you and you wanna pause, and then you’re gonna make eye contact because eye contact says, I see you as a human.

[00:23:28] Alison Tinker: I hear the words you’ve told me. And then the words that you can say in response are, man, that’s hard. Thank you for trusting me with that information and how can I support you? Right. I think as providers, we tend to think that with a disclosure, we need to take responsibility for this information that somehow we are now in control of the outcome of this person’s life, because they’ve told me this information, and again, that’s such an understandable human response, but the truth is is that this woman sitting in front of us has made it all the way through her lifetime, got herself up this morning, got herself dressed, somehow transported herself to your office and sat down in front of you with whatever question or problem brought her to you today.

[00:24:11] Alison Tinker: So she clearly knows how to cross streets safely without you. She knows how to drive a car without you. We don’t have to take ownership of the outcome of her life. From this point, we need to remember that survivors are resilient. People they’re coping skills may or may not be fantastic. It might range from cupcakes to heroin, but she does have coping skills.

[00:24:29] Alison Tinker: She is resilient, right? So when we get that disclosure, we don’t have to take ownership and responsibility of the entire event. All we have to do is make eye contact, pause and say, man, that’s hard. Thank you for trusting me with that information. And how can I support you right now? Because really, I don’t know what my patient needs the most.

[00:24:48] Alison Tinker: Maybe it’s the fact that she has to take three buses across town at rush hour to get here for our last appointment of the day, which is at five. Maybe what she needs most is extended hours. Maybe this patient absolutely will not give up smoking. That’s what I’d like to convince her to do. But maybe smoking is her one coping skill that she has maintaining.

[00:25:06] Alison Tinker: She quit drinking when she got pregnant. But Laura, don’t ask her to give up cigarettes, right? I don’t know what her needs are today. So I’m gonna ask her, what does she need? That being said. We don’t need to be mental health professionals, either. There is a role for mental health support currently. That’s really, all the protocol says is after a disclosure, make sure that you refer to mental health.

[00:25:26] Alison Tinker: So I think one of the things we can ask a person who’s made a disclosure is how far along are you in your recovery? Trying to get a sense of how much mental health support they have current. If they have none, then let’s help get her connected to some mental health. If she has a therapist she’s been seeing for 15 years, awesome.

[00:25:43] Alison Tinker: Is that working? We know that peer support is incredibly useful for people that have a history of trauma. A lot of the trauma research is really coming out of soldiers, coming back with PTSD. And we know that peer support is very helpful. So we do wanna know what sort of resources our community has to offer, but there’s some other things that might come up too.

[00:26:01] Alison Tinker: We’ve talked about intimate partner violence and women that have a history of sexual trauma are actually seven times more likely to experience intimate partner violence in her lifetime than someone that did not have a history of trauma. So maybe it’s that she’s not safe at home. Maybe that is her biggest need right now.

[00:26:18] Nicole: This is a lot. I feel like I’m just digesting all of this.

[00:26:23] Stephanie: I know me too.

[00:26:27] Nicole: Like what, what million question am I gonna ask now? I
know usually I’m like snappy, snappy, you got all these questions. I’m just like, whoa. Like this is good stuff, really sitting with it. And I, I think you’ve just made some really good points is, well, just recently we had a podcast about infertility and then that too was just about giving ’em space and yeah.

[00:26:46] Alison Tinker: And what do you need? This is great. I think one of the other interesting things that happens with trauma. Especially childhood trauma, whether it was sexual or physical or emotional when our traumatic event happened as a child, often, not always, but often the perpetrator of that trauma was an adult. And so they were in a position of power.

[00:27:04] Alison Tinker: The child was in a position of helplessness. So often when we experienced the healthcare system, we’ve also encountered the same sort of power dynamic, where we have an adult who has information and power and knowledge that, that we as patient do not have. And so it sets up this power dynamic that is particularly troublesome to someone that has a history of trauma.

[00:27:27] Alison Tinker: So one of the ways that we can manage that as a provider is to acknowledge. And to really try to equal the playing field as often as possible. So I wanna make sure we get to, how do we provide trauma informed care in an exam room, et cetera. But I think the, the key things, if I could say two things right now that the two things that survivors want most is safety and control of their body and their environment, survivors of trauma are not looking to detail the way they want their medical care to be provided to them.

[00:27:56] Alison Tinker: What I mean is they’re not trying to make their own medical decisions. Oftentimes. The questions they’re asking. And the things that they’re demanding is really just an effort to regain safety and control of their body and the environment. We are still the medical providers and we still make the medical decisions and we can still guide care in the best way we feel.

[00:28:15] Alison Tinker: But if we can do it with a lens of, Hey, my patients really just asking all these questions and coming to me with this giant birth plan, because she’s trying to establish safety and control of her body and her environment. Well, then I guess we’ll just jump right into that question. What does a trauma informed exam look like?

[00:28:32] Alison Tinker: Again, keeping that lens of trauma informed care. We’re gonna use all the information we have. So we’re gonna use whatever intake information we got from the intake questionnaire. We’re gonna take any information we’re getting from a birth plan. We’re also gonna be looking at our patient and looking at their behavior.

[00:28:46] Alison Tinker: Listening to their words, listening to the what’s, the music behind their words. What is it they’re trying to say with all of their questions, et cetera. And again, we’re gonna ask ourselves as provider would everything I’m seeing and with everything that she is saying and doing, would it make more sense?

[00:29:01] Alison Tinker: If I knew that this patient had a history of trauma, we don’t need that disclosure and then we can move forward. So I think we all have had that patient that has a million questions that needs additional time in their appointments. That seems to be calling us all the time out of hours. We’re getting the pages over the weekend from them.

[00:29:18] Alison Tinker: So we’re just gonna try to think to ourselves that she has a very good reason for saying the things she’s doing a good reason for asking the questions that she’s asking and trying to keep us ourselves in that empathetic frame of mind. As far as the exams, there are a couple of different things that we can do as part of a, an exam with a woman.

[00:29:36] Alison Tinker: And really these, again, just focus on providing safety and control of her body and her environment. So the number one rule, which I think should be just the number one rule for living in general, but number one rule for providing trauma informed care is consent for every contact. So every time I go to touch a patient, I’m gonna get consent for it.

[00:29:53] Alison Tinker: So whether it’s taking a blood pressure, I’m gonna ask consent. Is it all right if I put this cuff on your arm and take your blood pressure, is it all right? If we do the pelvic exam, now we we’re gonna ask these questions in the course of a woman’s labor in the hospital. She might have consented to a cervical examination four hours ago, but that doesn’t necessarily mean she’s gonna consent for this cervical examination.

[00:30:13] Alison Tinker: So we just need to be asking consent for every contact as far as a clinic appointment. Allowing our patients to remain as closed as they feel comfortable for as long as they need to be. We don’t necessarily need our patients to walk into a room, take off all their clothes, put the gown on and the drap on there’s a lot of things we could do with our patients, still fully dressed, explaining the events and the reasons and the interventions that we’re doing.

[00:30:35] Alison Tinker: This is why we’re doing ’em. This is what an information I’m hoping to get from it. This is how long I anticipate this to last. And then also allowing that woman to have some sort of voice. So while I’m doing this exam, if at any point in time, you’re feeling uncomfortable, please let me know if you want me to stop, I will stop.

[00:30:51] Alison Tinker: And then living up to your words. So if you say, I’ll stop, if you tell me to, well, then you have to stop. When, when she says, so we can do things such as allowing women to insert their own speculum. There’s no reason why I have to insert that a woman can insert that herself. If she chooses, in addition, women can do a lot of the swabbing, the vaginal swabbing by themselves.

[00:31:10] Alison Tinker: I don’t necessarily need to do that. We can also refrain from doing any unnecessary exams. So the rules just sort of changed on doing a clinical breast exam. We don’t necessarily need to do it at every annual appointment anymore. So really staying abreast of what the recommendations are for different types of exams.

[00:31:26] Alison Tinker: And if we don’t need to do one, then let’s not do it. One other thing that comes up a lot is pronouns. And I think using people’s preferred pronouns in any sort of exam setting is a really wonderful way to go. So as we’re going through an exam, making sure that you’re using the person’s preferred pronouns.

[00:31:43] Alison Tinker: Another thing that comes up often is if we’re doing an exam, a pelvic exam, do we need to have another attendant in the room, a second person? And I think what I would like to suggest with this is that we ask our patient what would be your preference? The reason that we would have someone in the room is for your comfort and to maintain the integrity of the experience.

[00:32:02] Alison Tinker: But if this would make you feel more uncomfortable, then we don’t need to have this person, but really asking about that ahead of time. And then often, like I said, because of this power dynamic. It also puts us as providers into this really interesting position too, where we could also put on the rescuer hat.

[00:32:17] Alison Tinker: And I think we need to refrain from putting on a rescuer hat. The key thing to recovering from trauma is to create empowered women who feel like they have a sense of agency about their bodies and their lives in general. And no one’s gonna feel empowered if we are just, uh, reinforcing their helplessness.

[00:32:34] Alison Tinker: So as we’re dealing with patients, let’s make sure that we refrain from rescuing or attempting to control our patient. And by demonstrating healthy boundaries, my history of trauma means that at some point, somewhere along the line did not have good boundaries with you. And so if we as providers. Can demonstrate healthy boundaries that will go very far in helping women to understand what healthy boundaries look like and how to request them for themselves.

[00:32:57] Nicole: Another thing that some other providers have talked about when we’ve touched on this topic of trauma informed care is physical space and how a room could be set up. What would a trauma informed lens on physical space look like?

[00:33:19] Alison Tinker: I think it, honestly, if you were setting up an exam room and you put yourself in the position of the patient, how would I feel if the bed or the exam table was angled in this way?
What is the lighting like? Where’s the door, what instruments are going to be used today? I think often when we have that mysterious drawer, that’s down between our legs somewhere and not knowing what that clingy metal thing is that you’re pulling out of the drawer and then there’s a lamp and all of it is just really disconcerting to a survivor.

[00:33:38] Alison Tinker: So setting up a room in a way that keeps everything in the open, remember, we’re all about trying to provide safety and control of the body and the environment. So not keeping things hidden, not keeping them in drawers, having everything. In advance showing women ahead of time. This is a speculum, and this is a tool that I will use to look at your cervix.

[00:33:58] Alison Tinker: We’ll need to insert it into your vagina to do so. It opens this way. It’ll be open about this much and it’ll end up being inside your vagina for about this amount of time. Right? You can see how that really gives a lot more information about a pelvic exam than just the weird cl metal thing coming up from between your legs.

[00:34:16] Nicole: Well, I know some have talked about is their back towards the door. Are they able to have it against a firm surface like a wall?

[00:34:39] Alison Tinker: And I can understand wanting hard and fast. I totally understand, wanting to know where do I put the bed, how many inches and it’s because we don’t want to cause trauma, we don’t wanna do something inadvertently that’s gonna cause a woman to feel triggered.
And, and I think that’s a really normal human response. And again, I would like to remind providers that that’s not our responsibility to own her experience and to own what is triggering and what is not triggering for her. As long as we attempt to not retraumatize in the course of our actions, that’s really as much responsibility as we need to take control over.

[00:35:03] Alison Tinker: We could ask if we felt the need to, we could ask, would you be more comfortable if the bed were placed this way or this way, but let’s be honest. The truth is most exam rooms don’t have the flexibility of that movement. And so then we’re gonna feel limited in the trauma informed care we provide instead.

[00:35:19] Alison Tinker: If we keep things in the open and we keep that communication with our patient, we’re gonna be able to work around a bed. That’s in an awkward position. Remember, survivors are more resilient than we give ’em credit for. Yeah.

[00:35:30] Stephanie: Thank you. Yeah. I really like that. I did wanna go back to a couple things that you said mm-hmm one of ’em was about a chaperone mm-hmm and giving women that choice. I know as part of the organization that I work for and other ones that I’ve heard about, that’s sort of not a choice based on policies, particularly if the provider is male. Do you have any thoughts on that or how to deal with maybe if you, as a provider or sort of forced by the organization that you work for to include a chaperone in that visit?

[00:36:03] Alison Tinker: Sure. And I think, again, that’s a conversation with our patient saying part of our company’s policy is to have a chaperone in the room during all pelvic examinations. So this person will step in at that time. And again, you’re gonna have to work within the scope of the policy itself, but perhaps there’s some leeway as to where that chaperone stands.

[00:36:21] Alison Tinker: Maybe can they stand at the head of the bed? Do they have to stand at the foot of the bed? Is it okay if they’re just leaning up against the door because they’re physically in the room? What is our leeway there? Because it might be more comfortable for the patient to have them at the head of the bed instead of the foot of the bed.

[00:36:36] Alison Tinker: if it’s really just having a second person in the room, that’s the important part.

[00:36:39] Stephanie: And do you have any advice on sort of, I know that I personally have been chaperone to exams before and sometimes providers almost don’t even acknowledge my presence. So do you do you have any advice for those people on how do you sort of address the, the chaperone or introduce the chaperone?

[00:37:00] Alison Tinker: Absolutely. Great question again. I think it would be any way that you would want to know what is that cling metal thing you would say? This is my chaperone. Her name is Samantha. She is an ma in our office and I have worked with her for a long time and I trust her very much while I’m doing your pelvic exams.

[00:37:18] Alison Tinker: Samantha’s gonna be in the room with us, but she can stand near the head of the bed or she can stand near the door. What would be your preference? right. So I’ve explained who she is, why she’s there, how long she’ll be there. And my relationship with her, I think anytime you’re gonna have someone else in the room, you should be explaining who they are and why they’re there, which is a great segue into what did we do for women who’s in labor, because really here’s where the rubber hits the road.

[00:37:43] Alison Tinker: And so that is very important is explaining all the people in the room for a survivor who is giving birth. And so it, like I said, it can be as simple as that. The person’s name, what their role is, my experience with them and what their purpose is for being in that room. I think one of the most terrifying things for providers is the patient that comes in, who has not disclosed a history of trauma.

[00:38:05] Alison Tinker: And now is in active labor and is all of a sudden just losing their minds. And then maybe even worse says, well, Anna was raped three years ago or whatever. And so now we have no time to build a relationship to build trust with this person. And now here they are in full blown labor. So I have a couple of hints for providers for that moment when you’ve got an actively triggered person and, and it could be in a clinic environment as well, but for how to manage an actively triggered patient, the first thing that you have to do is you have to match her.

[00:38:35] Alison Tinker: So I’ll just give an example. You have a patient who is kind of hyperventilating and kind of freaking out. The key thing you wanna do is again, the eye contact and you wanna get her attention. So I’m just gonna use Nicole as a name. So I would say Nicole, Nicole, Look at me here. I am. I’m with you. You’re okay.

[00:38:53] Alison Tinker: So I I’ve gotten your attention somehow, but I need to go to the rhythm that she’s at. So if she’s hyperventilating and freaking out, I can’t come in and be like Nicole, Nicole deer. Right. Cuz that’s totally matching the wrong energy level. So I’m gonna match her energy initially just to get her attention and to match her.

[00:39:11] Alison Tinker: But then what I wanna do is I wanna give some rhythm to this encounter because rhythm is control. So when you think about it, when you think about rhythm, when you think about music, it’s nothing. If not a controlled environment. So I’m gonna come in now and I’m gonna go low and I’m gonna go slow and I’m going to start putting some control and some rhythm to this encounter.

[00:39:32] Alison Tinker: So you can tell, I actually changed my voice just now, even in speaking with you. So Nicole, Nicole, I’m here with you. I’m Allie. I’m your midwife. You’re safe. You’re fine. Look at me, Nicole. Okay. Good job. Now take a breath. Good. Good. Right. So I then have control of the environment and I’m gonna bring control.

[00:39:53] Alison Tinker: Some of the other ways we can induce rhythm is with tapping. So even just a hand on an arm or a hand on a leg, your viewers cannot see me tapping my own knee or your listeners can’t, but I’m tapping my own knee in rhythm because I can be tapping her on her knee or her arm and just giving a rhythm because rhythm is in control and how she was before is out of control.

[00:40:17] Alison Tinker: Another really great tidbit for contractions, cuz oftentimes that’s when we start to lose control is during a contraction. So as a provider, we all kind of have a sense of when a contraction is peaking and as it’s gonna start ebbing. So what I can do is I can say to the patient, Nicole, so this contraction is gonna be ending, okay, you ready?

[00:40:38] Alison Tinker: It’s gonna end 5, 4, 3. To see, and it’s going now. I cannot feel what’s going on inside your body. I don’t know if that contraction is actually about to end or not, but I know when they’re about to ebb and I can put some control to that by counting it down and then it will be going away whether it’s fully gone or not, that that point, the patient will know that it’s going.

[00:41:01] Alison Tinker: And it gives that patient that sense that we’ve got some control to what’s feeling out of control. Cause remember in that moment, that’s really what we’re doing is we’re trying to provide safety and control of her body and her environment. Something that also comes up during labor sometimes is a discussion about dissociation is dissociation.

[00:41:19] Alison Tinker: Okay. Should we let her dissociate, not disassociate? Is this a good thing or a bad thing? And I think if possible, having a conversation beforehand about dissociation. So if we have a, a. Patient who’s disclosed a history of trauma. This is a lovely conversation to have in a prenatal appointment. Is do you tend to dissociate?

[00:41:35] Alison Tinker: If you’re triggered dissociation can be a lovely coping skill. If a woman needs to dissociate and to escape from the pain or to escape from the moment and that works for her and she’s not afraid of dissociation. Well, good. Gosh, let’s let you do what you need to do to get through your moment. One suggestion I might make though, is that during the actual delivery that perhaps dissociation is not the greatest.

[00:41:59] Alison Tinker: That time. So bringing a woman back into her body for that moment, because that’s really where that power comes from, that we’ve talked about with that transformative experience and in an ideal world, I would love for that trauma survivor to be present at that moment when she’s successful, when she’s crossing that finish line, I’d like her to be present for that.

[00:42:19] Alison Tinker: So she can really integrate that feeling into her body. But if that’s not possible, well, that’s not gonna cause the worst harm in the world. Some ways that we can bring women back from a dissociated state, again, is physical touch. Again, drawing her out of that by calling her name, making eye contact, reminding her where she is and bringing her senses back into the room can often pull someone out of a dissociated state before we’re attempting to do that in the.

[00:42:44] Alison Tinker: Often though, remember, we’re not gonna know what’s a trigger and not a trigger for survivors. They might not even know themselves. They might think that the biggest trigger for them is gonna have the insertion of the epidural for her. That’s the thing that she’s most freaked out about, but the truth is it wasn’t, it’s pushing or the sense of being afraid that she’s pooping at the same time, she might not know ahead of time that that’s actually a giant trigger. So we need to just stay engaged with our patients and really just be watching their faces, watching their responses. Do they get glazed over? Are they not making eye contact anymore? And really just staying engaged in that moment and then coming back to them with that really empathetic response.

[00:43:22] Alison Tinker: And the other thing too, that I would like to point out is that all women, whether we are survivors or not are going to have positive and negative experiences in childbirth, there are going to be parts of it that were absolutely wonderful and fantastic. And when exactly according to your plan, and then there’s gonna be the parts you’re like, oh, well that, wasn’t what I thought.

[00:43:41] Alison Tinker: For example, I remember getting into the tub the first time with my son and I was expecting it to be really warm and to just, I just was gonna lay there and labor and the water was like Luke warm and, and it didn’t matter. I was in there for six pushes and my son came out, but later I thought. Oh, man, that would’ve been so much nicer.

[00:44:01] Alison Tinker: If the water had been actually warm, you know, so no matter what we’re gonna have these positive and these negatives, and we don’t know which part’s gonna be positive and negative. So we don’t need to take control of that as a provider, we don’t have to own every single part of her birth.

[00:44:16] Stephanie: So you mentioned specifically during labor and delivery, there are a lot of different people in the room, especially in an academic medical center, like where I have worked. Are there tips for our listeners on how do you manage other staff who are in the room that maybe aren’t being so trauma informed or trauma sensitive?

[00:44:38] Alison Tinker: Gosh, wouldn’t it be great if we could just wave a magic wand and control all the situations cause there’s just so many ways that that can play out.

[00:44:49] Alison Tinker: In an ideal world, I would love to be able to have a conversation in the hallway with whatever other learners are gonna be coming in and watching this delivery. And what I would like to do is I would like to explain ahead of time that this woman has a history of trauma. Really. I don’t need to go into any descriptions, just we, we don’t need a disclosure and I don’t need a storyline.

[00:45:09] Alison Tinker: All we need to know is that she’s a history of trauma and that it’s gonna be imperative, that we maintain her body and environmental safety and control. And I’m gonna introduce you in who you are and your purpose in the. and I’m going to be talking a lot and explaining a lot about what it is I’m doing before I actually do it.

[00:45:26] Alison Tinker: And that consent for every contact is what I’m going to insist on. So in an ideal world, I’d have that conversation, but I know your listeners are thinking about their own situations and already found 15 flaws in what I said, because it just won’t work in their situation. So it is a difficult situation to manage.

[00:45:45] Alison Tinker: But as the provider in the room, we can really do a lot about controlling the environment and setting some real boundaries and ground rules.

[00:46:02] Nicole: You know, the trauma lens aside, having given birth twice now, and one at the learning facility that would’ve been really nice to just have done anyways.
See my first one, I have the whole entire audience. It was the resident, the, a attendee, someone else, like three nursing students, the nurse. I mean, I was like, whatever, it’s not a big deal cuz I understand that. But yeah, even in general, I mean, I couldn’t have told you whose name was what or anything like that. So I, in some ways I feel like that might be a nice practice just in general.

[00:46:23] Stephanie: mm-hmm, including with C-sections because I think I had a very planned C-section with my last one, other than the anesthesiologist and the surgeon who I was my OB couldn’t tell you who all else was in the, yeah.

[00:46:36] Alison Tinker: And, and I think when we, again, keep that trauma informed lens on, and we just remember that whenever this trauma occurred, especially if it happened in childhood, there was a real sense for that person of being helpless and being out of control and not having a voice and not knowing what was happening, why and when.

[00:46:53] Alison Tinker: And so if we can answer those questions. Ahead of time introducing people. This is what I’m doing. This is how long it will take. This is how long they’ll be here. This is their name. I think it’s just gonna go a long way towards making the environment safer. I cannot control her response to the environment, but I can control how I present the environment to her.

[00:47:13] Stephanie: I have a off topic question, or I guess it’s on topic, but not necessarily related to what we’re currently talking about. And this is sort of a personal professional question, but maybe other people have it. So in my current role, I refer a lot of patients to OBS and other nurses. And I have talked about disclosing when we know someone has a personal history of trauma.Do we disclose that to the provider who we’re referring to or do we allow the patient. To disclose that on their own. And I wanted to get your thoughts about that.

[00:47:49] Alison Tinker: I think it, again, in an ideal world, I would ask the patient, her preference on this beforehand. Sure. It, it is her information and again, it might have taken her 24 weeks to even disclose this information to me.

[00:48:02] Alison Tinker: I might be the only person she’s ever told this to. And that just because she told me doesn’t mean that she wants everyone to know. So in an ideal world, I would ask her permission to share that information or not, or, you know, would she like me to share it? Would she like to share it? There are some situations though, where I can envision transferring care in active labor. And you’ve been with the woman for hours and hours and know that she has this history and that she responds very well to some things and, and has some real fears of being triggered by others. In that situation. I could see how it would be understandable to share the information that you have about what’s working and what’s not working.

[00:48:40] Alison Tinker: And then why she has a history of trauma. Again, it doesn’t need any more information than that. We don’t have to tell this story and it doesn’t have to be a description of what kind of trauma. It could just be a history of trauma, but if it’s going to assist care in that moment, I don’t think there’s harm in sharing that.

[00:48:56] Stephanie: Thank you. Okay. So Allison, we always ask our guests the final question about what are the most important communication tips for listeners. So you’ve said a lot along the way, but just kind of a summary on what you would recommend for providers when providing trauma informed

[00:49:14] Alison Tinker: care. I think the real thing to take away from this is consent for every contact mean really that’s, that’s the key of things and that keeping a trauma informed lens involves asking yourself would everything I’m seeing everything this patient’s doing.

[00:49:27] Alison Tinker: Would it make more sense if I knew they had a history of trauma or not? And if you think to yourself, gosh, yes, that would explain a lot. Just go ahead and assume there’s a history of trauma, but remember too, that. Survivors are much more resilient than we give them credit for. And that she’s made it this far in.

[00:49:44] Alison Tinker: So we don’t need to own and take responsibility for every part of this. What we do have control of though is the way that we behave. So even though I know she has a history of trauma, we’re not gonna necessarily know what’s going to be triggering and not triggering for her. But what I can control is that I can maintain my myself with her in a way that I do not create any additional trauma.

[00:50:06] Alison Tinker: I do not create any new trauma for her. One thing I’d like to also say, though, because working with patients that have a history of trauma, it can be very taxing. And so as providers, we do need the support of our other. Provider network to help us in dealing with these patients. We are still human and hearing these stories and seeing people’s reactions.

[00:50:28] Alison Tinker: It is normal and completely understandable that that will have an emotional impact on us as well. And to remember that we have support systems where we can talk about this and why this was a difficult patient and why this patient just, gosh, I don’t know why, but they just get under my skin and that maintaining and demonstrating healthy boundaries is really an important part of recovery for survivors.

[00:50:50] Alison Tinker: And if part of that is setting firmer boundaries with this patient, for them and for ourselves, then that’s okay as well. Even if that includes stepping away from providing care for that patient and safely transferring them to somebody else.

[00:51:03] Stephanie: Yeah. Thank you so much for mentioning that secondary trauma. I know that has been another topic that we would like to talk about on women’s centered health podcast, because I think it’s really important that as care providers, that we are getting care.

[00:51:19] Yeah, absolutely. For ourselves. Absolutely. Because really we’re all in this because we want to provide empathetic care to people. And if we find ourselves in a position unable to do that, then we do need to step back and let someone else step in who can do so.

Nicole: And Allison, where can providers go to learn more or get more training on providing trauma informed care?

[00:51:38] Alison Tinker: So again, the SAMSA website through the department of health and human services, it’s a M H S a substance abuse and mental health services administration has some very good information on providing trauma informed care. The pivotal book that has been written about, uh, survivors and childbirth is when survivors give birth by Penny Simkin and Phyllis Klaus.

[00:51:58] Alison Tinker: There’s some really good podcasts and websites out there of other midwives and providers that are providing trauma informed care. And there’s been a lot of really exciting research in the last 10 years or so. So the evidence base is really growing as far as you know, what the impacts are of trauma, the ways that trauma manifests itself, and then what providers can do. So there’s a lot more out there than there was just a few years ago.

[00:52:17] Nicole I actually have another question. Might be a little bit rabbit hole, so we don’t have to go there, but I’m just gonna throw it out there. So we actually kind of touched on this in another podcast, but we do have a growing number of women who are tuning into our podcasts, who aren’t providers. And I’m just curious, do you have any advice if one of our listeners has experienced trauma, do you have advice for them as they would approach their provider or seek care for any sexual reproductive, health, prenatal, whatever, any advice for them?

[00:53:09] Alison Tinker: Yeah, absolutely. And that might be a lovely podcast. so I would say to your listener that has a history of trauma, that she has a very good reason for thinking the things she does.
She has a very good reason for acting the way she does. And she’s a very good reason for requesting the types of care that she requests trauma is subjective. And our responses to it are unique to ourselves. And when a woman feels comfortable to disclose this, that’s really a gift that she’s giving to whoever that person is, whether it’s a loved one, a friend or a provider, I would encourage them to watch that person’s response to them, especially a provider.

[00:53:37] Alison Tinker: And if they feel that that provider is hearing them and seeing them as a person who has a history, but who’s also a strong and resilient person. Then you found a provider that you can trust to care for you. I would encourage them to ask lots of questions. A lot of providers don’t necessarily know the right things to do the right things to ask.

[00:53:57] Alison Tinker: And so fortunately, or unfortunately, sometimes we have to direct our care. And by that, I mean, seeing things like dear doctor or midwife, I would prefer, if you could explain to me all of the things you’re doing and the steps you’re gonna take before you do them, sometimes we have to request things for ourself. Would it be okay if I left my gown on it until we had to do a pelvic exam, a provider that’s willing to hear you and hear your requests is one that’s worth keeping. I would suggest for a survivor of trauma who is pregnant to really access some of the resources that are out there, whether it’s books or support groups or peer groups finding a counselor, because there are things that are gonna come up.

[00:54:35] Alison Tinker: That you can’t foresee will be a triggering issue. And it doesn’t mean that you are going to fail as a mom. And it doesn’t mean that you’re gonna be the worst at pregnancy and the worst at childbirth ever. It’s just that you might need a little more information than your average Joe. And so to really sort of look for some information on that peer support groups are fantastic for managing trauma.

[00:54:56] Alison Tinker: I would encourage this woman to think about what she does well already to manage and to cope with stress. What do we do sitting at a red light when we are late for an appointment? What are some of the things that I do? Well, not the things I don’t do well, there’s plenty of things I don’t do well sitting at that red light, but what are the things that I do well that help me manage those uncomfortable moments?

[00:55:21] Alison Tinker: What do I do when things don’t go my way? What are the, the good things I do when things don’t go my way and to start really thinking about what are my really positive coping skills, because those are gonna be useful to you. In your labor in your delivery. Heroin might be one of my coping skills, but in delivery, it’s not gonna be the one I can fall back on, same with cupcakes and then I would just remind all survivors that this trauma does not define who they are.

[00:55:48] It is a part of their history, and it has informed the way they look and interact with the world. But it does not mean that they are defective and it does not define who they are and that they can continue to do anything and define a provider that supports them in that.

[00:56:05] Nicole: Well, thank you. I’m guess I’m glad I went down that rabbit hole because yeah, I hope that resonates even with providers. I think that that was a great response.
Alison Tinker: Thank you. I tried to keep it a shallow rabbit hole.

[00:56:16] Stephanie: and that was a good question, Nicole. I think that was important.

[00:56:20] Alison Tinker: Yeah. And, and likely we probably could do a whole entire podcast then, but since we are getting to the end of the times, Stephanie and I would both like to thank you so much for your time and commitment to advancing sexual and reproductive health through communication.

[00:56:31] Stephanie: Do you have any last thoughts you’d like to add before we end.

[00:56:53] Alison Tinker: So one of the other things, sometimes that comes up with survivors, particularly after delivery is with breastfeeding. And this can be surprising for some women, for some survivors. It’s not at all surprising, but if a woman’s breasts were sexualized as part of her trauma, sometimes the act of breastfeeding and the sensations involved with breastfeeding can be overwhelming.

So a woman let’s say had a history of trauma and made it all the way through pregnancy and childbirth, fine managed her triggers. And now it comes time to breastfeed. And of course, in the hospital and everywhere we just push breastfeeding, cuz we know all the benefits to it. But if we have a woman who finds breastfeeding to be particularly triggering, I think we really need to remain empathetic to that because really what matters most in the end is that a baby is fed.

[00:57:15] Alison Tinker: And if by forcing a woman to breastfeed and to manage her triggers. Constantly what eight to 10 times a day for the next, however many months, that might be just more than her system can manage. And I would like to keep her head in a good head space, especially postpartum. And so let’s just keep that in mind, too, as we’re helping women postpartum who have a history of trauma, in addition, oftentimes bonding can become difficult.

[00:57:41] Alison Tinker: Cortisol really messes with our oxytocin. And if we’re in a really heightened state, our oxytocin and our bonding really is gonna get decreased. So sometimes it might take women a little while to warm up to their children. And this is okay if childbirth was a particularly traumatizing event for her, her cortisol levels are gonna be really through the roof, which could also be affecting her milk production.

[00:58:04] Alison Tinker: But we need to just remind her that she’s gonna be okay, what we’re gonna talk through that traumatic childbirth with her, but just to keep these things in mind postpartum, oftentimes I feel like the survivors, once we get through the delivery part of things, we kind of forget that. A postpartum to being a trauma survivor as well.

[00:58:21] Alison Tinker: And just to be keeping an eye on that because particularly women that have a history of trauma are more likely to develop postpartum depression and anxiety than women that don’t have a history of trauma. So just keeping them on our radar postpartum, maybe increasing the number of appointments we see her postpartum would be helpful in touch base with her.

[00:58:38] Nicole: Actually, and since you bring up breastfeeding, there’s also a fair amount of bleeding that comes with after like vaginal deliveries. I can’t speak to c-section cause I’ve not had one, but is that ever a trigger or how do you manage that?

[00:59:12] Alison Tinker: Yeah, certainly. And, and it’s not always bleeding in and of itself. It’s not necessarily blood, but it’s the sensation often sensations are really the thing that can get to trauma survivors, warm and wet is often just like a trigger that could even include baby immediately after delivery being placed, skin to skin still covered in vernix and amniotic fluid.

So I think just being aware of the sensational side of labor and delivery and how that might be affecting a woman, again, you can learn a lot just by looking at someone in the eyes, looking at their responses. Do they look present? Do they look like they’ve zoned out? Do they look not okay with what’s going on right now?

[00:59:31] Alison Tinker: And then asking questions because we don’t know what her experience is. So just asking the question and then I just want to remind everyone out there that childbirth has this potential to be a really empowering and transformative moment in women’s lives. And that as providers, we can do a lot to creating an environment that a woman comes out of saying, wow, if I can do that, I can do anything.

[00:59:57] Nicole: Love that. This makes me think after like epidurals and freaking out being, I can’t do all. No, just kidding.

[01:00:11] Alison Tinker: A you did, but you did, but you did. Yes, I did. Well, thank you so much, Allison. Yeah. Thank you. Thank you so much for having me. It was a pleasure.