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Trauma-Informed Care for Clinicians
Frameworks for practice
The definition of trauma and the reasons trauma-informed care is essential are on the introduction page. This section gives the frameworks you will use at the bedside.
What ACOG recommends
- Recognize how common trauma is and how it affects patients and the health care team, and use trauma-informed approaches to care.
- Become familiar with the trauma-informed model and implement it universally across all levels of practice, avoiding stigmatization and prioritizing resilience.
- Train clinicians and staff to be trauma-informed.
- Create a safe physical and emotional environment for patients and staff.
- Implement universal screening for current trauma and a history of trauma.
- In medical education, weigh the value of trainee experience against the risk of re-traumatizing patients through repeated interviews and examinations.
The Four Rs
the widespread impact of trauma and the potential paths for recovery.
the signs and symptoms of trauma in patients, families, staff and others in the system.
by integrating knowledge about trauma into policies, procedures and practices.
actively, for patients and for staff.
The six key principles
The Four Cs: skills for the visit
Notice how you feel while caring for the patient. Breathe and settle yourself, which models calm for the patient and protects you.
Ask only the level of trauma detail the patient can share while staying emotionally and physically safe, within the time of the visit.
Emphasize compassion and self-care, for the patient and for yourself.
Emphasize coping skills that build on strength, resilience and hope, for the patient and for yourself.
Signs that may point to trauma
Agitation; irritability or emotional swings; anxiety, depression or fear; outbursts of anger; being easily startled by noise or touch; sudden sweating or palpitations; flashbacks; difficulty concentrating; difficulty trusting; self-blame, guilt or shame; feeling disconnected or numb.1,2
Re-traumatization
Re-traumatization is a conscious or unconscious reminder of past trauma that causes the patient to re-experience it. A situation, an attitude or expression, or an environment that recreates a loss of power, control or safety can trigger it. Risk is higher with a clinician whose gender is distressing to the patient, with a power imbalance, and with repeated examinations by multiple trainees.1
Checklists by care setting
ACOG Committee Opinion 825 gives practices for examinations and procedures and does not give separate protocols for prenatal, labor or postpartum care. The prenatal, labor and postpartum lists below apply ACOG's general practices to those settings and are labeled that way.
Every visit (all settings)
- Screen every patient for current trauma and a history of trauma. Choose the timing, and whether to ask face to face or with a self-completed form; ACOG does not name one best method.
- Introduce screening with a framing statement (see Sample scripts). Respect a patient who does not want to discuss her experiences.
- Stay open at every visit. Patients may disclose months or years later.
- Ask what would make her more comfortable, and offer choices at every opportunity.
- Use compassionate, nonjudgmental language.
- If she discloses current violence, follow ACOG guidance on intimate partner violence (Committee Opinion 518) and sexual assault (Committee Opinion 777), and use your referral list.
Gynecologic and pelvic examinations
- Talk with the patient while she is dressed, before the examination.
- Ask permission before any physical contact.
- Describe each step before and during the examination.
- Offer to shift clothing rather than remove it.
- Agree on how she can stop the examination, and stop when she asks.
- Ask before trainees join, and avoid repeated examinations by multiple trainees.
- Consider whether the examiner's gender may be distressing to her, and ask.
Prenatal visits (applying ACOG's general practices)
- Screen early in prenatal care and stay open to later disclosure.
- Before a transvaginal ultrasound or a cervical examination, ask permission, explain the steps, offer to shift clothing rather than remove it, and agree on a stop signal.
- Invite her to share a care plan for labor and birth, and note it in the record with her permission.
- Be alert to conflicted feelings about the pregnancy, which ACOG lists among conditions that may be associated with trauma.
Labor and delivery (applying ACOG's general practices)
- Read her care plan on admission and tell the team who will care for her.
- Ask permission and explain the reason before each cervical examination. ACOG lists repeated unnecessary vaginal examinations as an example of obstetric violence.
- Ask before trainees examine her, and limit the number of examiners.
- In an emergency, keep explaining what is happening and why, as far as time allows. ACOG recognizes that obstetric emergencies, unexpected outcomes and neonatal complications can make birth itself traumatic.
- Avoid the other examples ACOG gives of obstetric violence: unindicated episiotomy, restricting activity or food during labor, and forced cesarean delivery. Watch for subtler forms: minimizing symptoms, or treating patients differently because of race, substance use or other characteristics.
Postpartum care and office procedures (applying ACOG's general practices)
- Before a postpartum examination, IUD insertion, colposcopy, endometrial biopsy or another office procedure: ask permission, explain each step and each instrument before using it, offer to shift clothing, and agree on a stop signal.
- Ask how the birth went for her. ACOG recognizes traumatic birth experiences.
- Be alert to difficulty with infant attachment, which ACOG lists among conditions that may be associated with trauma, and refer when needed.
- Review policies that penalize late or missed visits. Many survivors find it hard to schedule or attend appointments.
Sample scripts
The wording below is an example, not a quotation from ACOG. The first script follows the elements ACOG gives for a screening framing statement; the others put ACOG's examination practices into words. Adapt them to your patient and your own voice.
"Many people have been through hard or frightening experiences, and these can affect health. I ask all my patients about this. You only need to share what you are comfortable sharing, and it is completely fine if you would rather not talk about it."
"That's fine. If you ever want to talk about it, today or at a future visit, I'm here. Is there anything that would make today's exam easier for you?"
"Before we start, I'll explain what the exam involves. You can keep your top on, and we can move clothing aside rather than take it off. Is there anything that helps you feel more comfortable during an exam?"
"You are in charge of this exam. If you want me to pause or stop at any point, say 'stop' or raise your hand and I will stop right away."
"I'm going to touch your knee with the back of my hand now. Is that okay?"
"Next I'm going to insert the speculum. You'll feel some pressure. I'll tell you before I open it."
"I've stopped. Take your time. Would you like to sit up, try again in a moment, or finish another day?"
"I'd like to check your cervix to see how labor is progressing, because it will help us decide whether to [reason]. Is now okay, or would you like to wait until after this contraction?"
"A resident is working with me today. Would it be okay for her to be in the room? It's completely your choice, and your care won't change if you say no."
The whole team, and the team's own well-being
Everyone has a role
- Train the whole workforce, from the front desk to the examination room.
- Create a safe, calm, comfortable and clean environment.
- Review punitive policies on late or missed appointments.
- Use compassionate, nonjudgmental communication, and offer choices at every opportunity.
- Know which trauma-specific services the practice can and cannot provide.
- Keep a strong resource list and educational materials for referral.
Staff trauma and secondary traumatic stress
Clinicians and staff may have their own trauma histories. Secondary traumatic stress happens when staff are affected by hearing about others' trauma. ACOG advises that staff learn to balance compassion with not over-identifying with, or reliving, patients' experiences; recognize the signs of burnout; and prioritize self-care. Practices should have policies that support staff well-being.1
Self-check: five questions
Score: 0 of 5
Practice with AI role-play
Coming soon. Role-play scenarios on trauma-informed care, in which you practice these conversations with ChatGPT or Claude playing the patient and then receive a debrief, are being prepared and will be linked here.
Until then, use the sample scripts and the patient care plan on this page. Try the patient track yourself to see the plan your patients may bring.