Trauma-Informed Care Practice Guideline

Summer 2018
Atoosa Benji

All midwives and staff members of Labor with Love, Inc. strive to provide trauma-informed care
to the clients we serve. All staff and care providers have attended training in trauma-informed
care through the National Center for Trauma-Informed Care (NCTIC). It is our goal to create
an atmosphere of safety within our practice. This includes providing security, comfort, having
an information-sharing policy as well as priorities in place when working with survivors of
trauma. We uphold the highest standard of privacy and confidentiality and we hold cultural
respect a fundamental component of all the services we provide.
MISSION STATEMENT:
Definition of Trauma:
“Trauma is an emotional response to a terrible event like an accident, rape or natural disaster.
Immediately after the event, shock and denial are typical. Longer term reactions include
unpredictable emotions, flashbacks, strained relationships and even physical symptoms like
headaches or nausea. While these feelings are normal, some people have difficulty moving on
with their lives” (www.apa.org). Traumatic events may involve sexual violation that took place
anytime from childhood to adulthood. This includes but is not limited to molestation, sexual
coercion, non-consensual sexual acts, and rape.
There is a deep connection between trauma, oppression and other forms of victimization. For
example, reproductive coercion is a form of oppression and victimization that causes trauma, but
may or may or not have obvious physical symptoms. The victim will suffer from the effects of
trauma, but may not even register it as abuse until give the space to share and process with a
trained care-provider.
We are keenly aware that both the perception and the acceptance of trauma as well as the
understanding and acceptance of repercussions thereafter, vary by culture. Both our staff and our
midwives have been trained in both cultural competence and cultural humility. We make it our
highest priority to support our client as they process trauma while simultaneously holding deep
respect and honor for the client’s cultural and spiritual beliefs.

Cultural Respect Mission Statement:

According to the National Institute of Health (NIH), “Cultural respect is critical to reducing
health disparities and improving access to high-quality health care, health care that is respectful
of and responsive to the needs of diverse patients. When developed and implemented as a
framework, cultural respect enables systems, agencies, and groups of professionals to function
effectively to understand the needs of groups accessing health information and health care—or
participating in research-in an inclusive partnership where the provider and the user of the
information meet on common ground”. We acknowledge and appreciate the differences in
beliefs and ideology in the people with whom we work. This includes: age or generation,
gender, sexual orientation, occupation and socioeconomic status, ethnic origin or migrant
experience, religious or spiritual belief, disability.
Principles of Trauma-Informed Care: According to the Substance Abuse and Mental Health
Services Administration (SAMHSA), “a trauma-informed approach reflects adherence to six key
principles rather than a prescribed set of practices or procedures. These principles may be
generalizable across multiple types of settings, although terminology and application may be
setting- or sector-specific”: (www.samhsa.gov).

1. Safety
2. Trustworthiness and Transparency
3. Peer support
4. Collaboration and mutuality
5. Empowerment, voice and choice
6. Cultural, Historical, and Gender Issues

Rationale for Trauma-Informed Midwifery Care:

Midwives have the unique role of providing services at a time of extreme excitement,
anticipation, anxiety, and vulnerability. They hold space at a time when the client may be
experiencing a plethora of changes both emotionally and physically. The ever-changing body,
coupled with pressures that the birth of a child may bring, can trigger past traumas, some
consciously, some subconsciously. Additionally, physical exams that may be performed on
breasts and the genital area, may trigger traumas from past sexual violations, as may the
challenges of labor, birth and the postpartum period. The body carries a heavy toll from past
trauma and this toll may present with physical ailments and maladies in the birthing person,
causing the person to be higher risk antenatally, during labor, birth and postpartum.

For these reasons, it is paramount to complete midwifery care that midwives and staff members
be trained in trauma-informed care so there can be a higher degree of trust and rapport between
provider and client. In this model, potential triggers may be prophylactically addressed and
prepared for, and possible physical and emotional manifestations of abuse may be treated with
proper care and referral, whenever possible.

TRAUMA INFORMED PRINCIPLES

Screening Protocol

Every client signing on to care with our practice will be sent a digital intake form including a
complete medical, psychological, and social history questionnaire. Clients must complete the
form prior to the first appointment. If the client is faced with questions that they do not feel safe
answering, a private, one on one may be made with the care-provider with complete
confidentiality. While partners are welcome at all visits, we understand that there are times that
a client may feel they need to spend time alone with their care-provider. All clients will be
screened for past trauma history, including physical, and emotional abuse and well as for
intimate partner violence. Typically, we use the “Immediate Safety Screening Questions” from
the Family Violence Prevention Fund, as well as American Medical Association (AMA) “Abuse
Assessment Screening”. There will be follow up care and support provided if client discloses
abuse or trauma. The screening will be completed every trimester and again at the 1-week and 6-
week postpartum visit for every client.

Disclosure Support

When a client shares a history or current case of abuse or endangerment, as midwives we

embrace the client with a supportive and companionate. This care includes but is not limited to:

Accepting the information

Providing empathy and care
Clarifying confidentiality
Acknowledging the prevalence of abuse
Validating the disclosure
Addressing Time limitations
Offering reassurance
Collaboration and Planning for Self-Care
Asking about previous disclosure
Discussion of Referral for Collaborative Care with a Counselor, Social Worker, Therapist or
Psychiatrist.
Communication and Self-Care Plan *
Midwives will communicate the importance of self-care with relation to trauma and provide
continuity of care to assure client is using tools provided. These tools may include but not be
limited to:
Breathing Exercises Prayer and Spiritual and/or Religious Rituals (if desired by
the client)
Learning to practice Containment Physical Exercise and Stretching
Writing Essential Oils
Alone-Time Taking Baths
Using music and poetry Helpful books and readings
Guided Imagery and Meditation

Warm Referral:
According to SAMHSA, “The “warm-handoff referral” is the action by which the clinician
directly introduces the patient to the treatment provider at the time of the patient’s medical visit.
The reasons behind the warm-handoff referral are to establish an initial direct contact between
the patient and the treatment counselor and to confer the trust and rapport. Evidence strongly
indicates that warm handoffs are dramatically more successful than passive referrals”
(www.samhsa.gov)
In our practice, should a warm-referral be deemed necessary, care-provider will be directly
involved in introducing client to collaborative care specialist which may include but not be
limited to social workers, support groups, psychologists, counselors, and/or medical doctors.
CHILDHOOD TRAUMA
Definition of Toxic Stress:
“Strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic
neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the
accumulated burdens of family economic hardship—without adequate adult support. This
kind of prolonged activation of the stress response systems can disrupt the development of
brain architecture and other organ systems, and increase the risk for stress-related disease and
cognitive impairment, well into the adult. “(www.mentalhealthamerica,net)

Emotional and Behavioral Impact of Trauma

• poorer mental health and a lower health-related quality of life

• drug and alcohol use, self-mutilation, suicide, and disordered eating
• adult onset of mood, anxiety, and substance use disorders
 • higher rates of childhood mental disorders, personality disorders, anxiety disorders, and
major affective disorders such as Borderline Personality Disorder
• mistrust of adults or authority figures, including medical care-providers
• over-attachment and clinging to caring adults and providers
• delayed emotional and mental development- stunted growth
• Increased likelihood of being abused as an adult and forming harmful relationships
• Increased likelihood of the perception of harm, where harm is not actually being inflicted

Physical Impact of Trauma

• chronic pelvic pain

• gastrointestinal disorders
• intractable low back pain
• chronic headache
• greater functional disability, more physical symptoms, more physician-coded diagnoses,
and more health risk behaviors, including driving while intoxicated, unsafe sex, and
obesity
• ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease
• greater use of medical services

Children and adolescents must be given the time, space and care to identify their feelings and
wishes about their own wellbeing. When children are not taught that they are autonomous agents
and their opinions and wishes for their own care matter, they are in more danger of being abused
as adults. A culture of listening to the needs of children is deeply honored in our practice, as we
believe that children must learn to use their voices and be taught to speak up until they are heard.

Documentation

All documentation must

a) accurately reflect the patient's condition
b) use photos or body maps
c) use direct and/or specific quotes
Care provider must review safest form of future communication with client so as not to cause
potential further harm from abuser.
Mandated Reporting Laws
In California mandatory reporting is required for
a) Child- a person under the age of 18
and for
b) Elder- any person over the age of 65 living in CA
and
c) Dependent Adult- "

 any person between the ages of 18 and 64 years who resides in California and who has
physical or mental limitations that restrict his or her ability to carry out normal activities or to
protect his or her rights, including, but not limited to, persons who have physical or
developmental disabilities, or whose physical or mental abilities have diminished because of
age; and
 any person between the ages of 18 and 64 years who is admitted as an inpatient to a 24-hour
health facility.
 www.apps.rainn.org

Transfer/Transport Protocol
During a transfer, it may not be necessary to transfer every section of the medical chart, if it not
pertinent to imminent medical care. Parts of the client’s chart including but not limited to social
history may not be shared with provider taking over care unless medically necessary. This may
include not disclosing information on a chart, but rather sharing it verbally with the care-provider
taking over care. Again, only if it pertinent to the client's emotional, mental and/or physical
well-being.
Client will be prepared during prenatal visits on situations that may warrant transfer. Scenarios
will be clearly discussed and client will have the chance to meet back up physician and get a tour
of transfer hospital (wherever possible).
INTIMATE PARTNER VIOLENCE (IPV)

Social Impact of IPV

 Homelessness
 Social isolation
 Problems with accessing social services
 Problems with employers
 Problems with health providers

Somatic Impact of IPV

Inflammatory issues in the body that may result in:

 Gastro-Intestinal Issues
 Joint pain
 Headaches
 Chronic pain syndromes
 Heart Disease
 Asthma
 Circulatory problems

Impact of IPV on Health Behaviors

 Eating Disorders
 Using Harmful Substances i.e.: drugs, cigarettes, alcohol misuse
 Engaging in High Risk Sexual Behavior
 Overusing Health Services

Impact of IPV in Childbearing Year

For the Mother:

• Anemia
• Poor weigh gain
• Pelvic damage
• Placental abruption
• Infection
• Substance use
• Postpartum Complications
 Impact on Fetus or Neonate
• Stillbirth
• Premature Delivery
• Low Birth Weight
• Fetal Injury

Triggers and Management

“Historical Trauma” refers to the cumulative effects of trauma on an individual or group.

Victims of historical trauma are at higher risk for maladaptive coping techniques, as well as
physical and mental illnesses.

As providers, we are keenly aware of the deep-rooted effects of historical trauma both at the
individual and the multi-generational level and will provide trauma-informed care as needed for
the client’s wellbeing.

“A trigger is something that sets off a memory tape or flashback transporting the person back to
the event of her/his original trauma. Triggers are very personal; different things trigger different
people. The survivor may begin to avoid situations and stimuli that she/he thinks triggered the
flashback. She/he will react to this flashback, trigger with an emotional intensity similar to that at
the time of the trauma. A person’s triggers are activated through one or more of the five senses:
sight, sound, touch, smell and taste”. (psychcentral.com)

Midwives and staff have been trained on how to identify and mediate triggers in a client. This
may include physical and or/emotional responses of a client to a particular event or interaction
while in care with the practice- whether in or out of the office. Such care may involve grounding
techniques, preventing client from self-harm, offering a meal or a warm drink, breathing
exercises etc.…When the care-provider is involved in helping survivors manage their feelings,
the chances that crisis will occur may be minimized.

Care Plan and Resilience

Midwives will provide care to help client identify and implement a self-care plan* (see self-care
plan in above section) to promote wellbeing and resiliency, and to promote healthy coping;
pursuing goals, maintaining healthy communication and having the ability to live in the present.
Safety Plan

Care-provider will collaborate with client to create a safety plan. The basis of a safety plan is to
help come up with several ways to enable the victim to stay safe, helping to avoid chances of
future harm. It involves brainstorming on ways to plan a future episode of harm, considering the
options at hand, and making suitable decisions about what next steps might be. It is important
that those involved in making a safety plan be cognizant that a safety plan will not increase the
chances of the victim being further traumatized and that a safety plan, is in-fact a way to allow
the victim to feel safer and heal.

Documenting IPV Protocol:

All documentation must
b) accurately reflect the patient's condition
b) use photos or body maps
c) use direct and/or specific quotes
Care provider must review safest form of future communication with client so as not to cause
potential further harm from abuser.

Transfer/Transport Protocol
During a transfer, it may not be necessary to transfer every section of the medical chart, if it not
pertinent to imminent medical care. Parts of the client’s chart including but not limited to social
history may not be shared with provider taking over care unless medically necessary. This may
include not disclosing information on a chart, but rather sharing it verbally with the care-provider
taking over care, again, only if it pertinent to the client's emotional, mental and/or physical well-
being.
Client will be prepared during prenatal visits on reasons at any point during care that may
warrant transfer. Scenarios will be clearly discussed and client will have the chance to meet
back up physician and get a tour of transfer hospital (wherever possible).
BEREAVEMENT
Inherent to the practice of midwifery is the understanding that no one is immune to tragedy and
loss. While we are well aware that “life on life’s terms” happens, we are grateful that tragedies
and unexpected outcomes are few and far between, all staff and care-providers are trained in
supporting people who are faced with situations including but not limited to:
Miscarriage
Stillbirth
Abortion
Sudden Infant Death
Unexpected Outcome for Birthing Person or Baby

Clients will remain in care until with the midwife as care continues to be needed. Care will
include holding of space for parties involved and continued emotional medical care (within the
midwife’s scope of practice). Warm referrals will be made as deemed necessary for the
complete well-being of the client. Holistic support may be provided including nutrition and
herbal support, essential oil use, referrals to alternative care practitioners such as acupuncturists
and energy workers, as well as to mental health professionals, as needs warrant.

OUR CARE-PROVIDERS
All our care-providers engage in regular peer-review sessions and strive to maintain close bonds
with fellow midwives. Giving and receiving support from peers is integral in our work. As
midwives we are responsible for our own maintenance of self-care, continued education, case
processing, and maintenance of healthy boundaries both with our clients and our peers. Peer
review sessions allow midwives to discuss cases (with no identifying information given) in an
arena of support, learning, support and non-judgement.
 References
Addressing Intimate Partner Violence, Reproductive and Sexual Coercion. (2014, August 28).
Retrieved August 2, 2018, from https://www.futureswithoutviolence.org/addressing-intimate-
partner-violence/

Principles of Trauma-Informed Care. (n.d.). Retrieved August 11, 2018, from

https://www.samhsa.gov/
Schachter, C.L., Stalker, C.A., Teram, E., Lasiuk, G.C., Danilkewich, A. (2009). Handbook on
sensitive practice for health care practitioner: Lessons from adult survivors of childhood
sexual abuse. Ottawa: Public Health Agency of Canada.
Simkin, Penny & Klaus, Phyllis, When Survivors Give Birth: Understanding and Healing the
Effects of Early Sexual Abuse on Childbearing Women, Classic Day Publishing, 2004
State Law Database. (n.d.). Retrieved August 11, 2018, from https://apps.rainn.org/policy/
Toxic Stress. (n.d.). Retrieved August 11, 2018, from http://www.mentalhealthamerica.net/
Trauma. (n.d.). Retrieved August 11, 2018, from http://www.apa.org/
Violence Prevention. (2017, August 22). Retrieved August 2, 2018, from
https://www.cdc.gov/violenceprevention/intimatepartnerviolence/consequences.html

What is a Trigger? (n.d.). Retrieved August 11, 2018, from https://psychcentral.com/

Women's Health Care Physicians. (n.d.). Retrieved August 2, 2018, from
https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-
on-Health-Care-for-Underserved-Women/Intimate-Partner-Violence
to violence, and/or the accumulated burdens of
family economic hardship—without adequate
adult support. This kind of prolonged activation
of the stress response systems can disrupt the
development of brain architecture and other
organ systems, and increase the risk for stress-
related disease and cognitive impairment, well
into the adult.