Trauma-Informed Care

Safer, calmer care for every patient: what it is, how to practice it, and a care plan you can bring to your next visit.

For patientsI am a patientLearn what to expect and make your care plan For cliniciansI am a clinicianObGyns, midwives, nurses and staff

What it is · Why it is essential · Choose your track · Sources

ACOG recommends a trauma-informed approach in every obstetric and gynecologic practice.¹ This page explains what it is and why it matters, for patients and for the clinicians and staff who care for them. Choose your track above or at the end of the page.

What is trauma?

The definition used by the Substance Abuse and Mental Health Services Administration (SAMHSA), and adopted by the American College of Obstetricians and Gynecologists (ACOG), states that "individual trauma results from an event, series of events, or set of circumstances" that a person experiences as physically or emotionally harmful or life-threatening, and that has lasting adverse effects on her functioning and well-being.^1,2

The definition has three parts: what happened, how the person experienced it, and the lasting effect it has. Two people can go through the same event and be affected differently.² Trauma can lie far in the past or be happening now.¹

Examples ACOG lists include intimate partner violence, sexual assault (including military sexual trauma), violence based on race or sexual orientation, childhood neglect, combat, natural disasters, community violence, immigration-related trauma and family separation. ACOG also recognizes that birth itself can be traumatic, through unexpected outcomes, procedures, obstetric emergencies and complications in the newborn.¹

What is trauma-informed care?

Trauma-informed care is a way of organizing a practice, and every visit within it, around one assumption: any patient, and any member of staff, may have lived through trauma. Instead of waiting for a patient to disclose, the whole team gives care in a way that is safe for everyone.^1,2

SAMHSA describes a trauma-informed practice by four actions, the "Four Rs." It realizes how widespread trauma is and that recovery is possible; recognizes the signs of trauma in patients, families and staff; responds by building that knowledge into its policies, procedures and daily practice; and actively resists re-traumatization.^1,2 It rests on six principles: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; and attention to cultural, historical and gender issues.²

What it is

An approach for the whole practice, from the front desk to the delivery room, used with every patient.¹

What it is not

It is not therapy. Treatments for the effects of trauma are "trauma-specific services," which are different, and most are not routinely offered in ObGyn practice.¹

No one has to tell their story

Patients are asked about difficult experiences, and share only what they are comfortable sharing.¹

What it looks like

Asking permission before touch, explaining each step, moving clothing aside rather than removing it, stopping when asked, and offering choices.¹

Why it is essential

Trauma is common. In the original Adverse Childhood Experiences study (a mostly NH-White sample with some college education), about 64% reported at least one adverse childhood experience and 12.5% reported four or more. In a more diverse Philadelphia survey, about 83% of adults reported at least one adversity and about 37% four or more. In a 2009-2011 survey, 41% of female veterans reported military sexual trauma.¹

Trauma affects health and how people use care. It is linked to anxiety, depression, post-traumatic stress disorder, substance use and chronic diseases of the heart, lungs and liver, and to autoimmune disease. Survivors tend to use more emergency care and less preventive care, and trauma can affect a person's ability to follow health recommendations.¹

ObGyn care carries a high risk of re-traumatization. Personal questions, touch, undressing, pelvic examinations and exposed positions can recreate a loss of power, control or safety. The risk rises with a clinician whose gender is distressing to the patient, with a power imbalance, and with repeated examinations by several trainees.¹

Trauma shows up in ObGyn conditions. Chronic pelvic pain, sexually transmitted infections, unintended pregnancy, conflicted feelings about pregnancy and sexuality, and difficulty with infant attachment after birth may all be associated with trauma.¹

You cannot tell who has been affected. Many patients do not disclose, and some disclose months or years later. That is why ACOG recommends universal screening and a trauma-informed approach for every patient, not only for those who share their history.¹

Care itself can cause harm. ACOG describes obstetric violence, such as repeated unnecessary vaginal examinations, an unindicated episiotomy or a forced cesarean delivery, as disrespect that can take away a woman's control over her own care.¹

It protects the team too. Clinicians and staff may have their own trauma histories, and hearing about patients' trauma can cause secondary traumatic stress. A safe environment is for staff as well as patients.¹

ACOG's position. Obstetrician-gynecologists should become familiar with the trauma-informed model and implement it universally, across all levels of their practice, with close attention to avoiding stigmatization and prioritizing resilience.¹

Choose your track

Patients can learn what to expect and make a one-page care plan to print or show their clinician. Clinicians get frameworks, checklists by care setting, sample wording, a section for the whole team and a short self-check quiz. Nothing you type is saved or sent anywhere.

For patientsI am a patientLearn what to expect and make your care plan For cliniciansI am a clinicianObGyns, midwives, nurses and staff