Trauma-Informed Ob/Gyn Care: Awareness, Listening and Adapting to Patient Needs

Cleveland Clinic specialists who work in women’s healthcare are teaming up to share education and resources to help physicians deliver tailored care for patients with histories of sexual abuse, traumatizing medical or childbirth-related experiences and other traumas.

Daphne Spyropoulos, PhD, a psychologist who specializes in caring for women with gastrointestinal disorders, and ob/gyn Catherine Caponero, DO, share the goal of elevating conversations about the impact of trauma on patients’ ability to seek and receive necessary medical care. The two are collaborating to spread the word about ways to make medical care a better experience for this patient group.

“I know it's a cliche thing to say, but the body really does keep the score,” says Dr. Caponero. “If something traumatic has happened to a person, it can really affect them physically. In gynecology, we see people with vaginismus, for example, and it can often be related to past trauma. We work through that from a musculoskeletal standpoint and then also from a behavioral health standpoint. It’s so important for patients, not just to enable them to have a pelvic exam, but to ensure that they are living their fullest, healthiest lives. That’s why understanding trauma is important, and why it requires a multidisciplinary team.”

In a recent conversation with Consult QD, Drs. Caponero and Spyropoulos discuss the expanding understanding of the brain’s connection to gynecologic and gut issues and the importance of identifying patients with a history of trauma.

The interview

CQD: Dr. Spyropoulos, can you begin by explaining how your area of specialization intersects with the ob/gyn space?

DS: As a gastrointestinal psychologist, I work with people with inflammatory bowel diseases by supporting them through what we know about the gut-brain axis. Psychological factors can make an impact on patients’ symptoms and their progress by affecting whether they take medication or don’t take medication, or stick to a treatment plan, as well as other factors. We also know that there are behavioral interventions that can help reduce inflammation, maintain a healthy lifestyle and use the prescriptions provided by dietitians and their medical teams.

When I arrived at Cleveland Clinic, I saw an opportunity to bring a specialized focus on a psychological level to women's health. I founded a women's health and IBD clinic in GI. When I met Dr. Caponero, we discussed the need for specific interventions for women who struggle with fertility, contraception, high-risk pregnancies and menopause, in addition to all the medical conditions within GI. Our visions aligned.

CQD: Dr. Caponero, how can psychological expertise and knowledge of trauma improve outcomes for patients seeking gynecologic care?

CC: Some data shows that over 45% of women have some experience of birth trauma. In many cases, their expectations of the childbirth experience was not met in reality. Along with that birth trauma, there are also good data that show that one in four women have been sexually assaulted. Many women also have issues with anxiety and depression.

All of these patients need additional resources and support so that they are empowered in their decision making. So that's why it's so important that we give patients access to the kinds of resources that Dr. Spyropoulos provides.

CQD: Generally speaking, how can medical teams better serve women seeking care?

CC: Setting up people with the proper expectations is one of the biggest things that we can do as healthcare providers to help prevent these traumatic experiences from happening and to help patients who come in with a history of those experiences. For some patients, it’s also helpful to have someone available to work as a conduit or a translator, which is why I think psychology is so important. In the medical world, we're all trained to say things properly, but sometimes things get lost in translation. So having someone who isn’t as into the nitty-gritty details, such as a therapist or psychologist, can help us see a bigger, better picture so we can help patients feel comfortable and safe in what can be a scary environment.

DS: In addition, we need to take into consideration how feelings and emotions affect our behaviors and our adherence to medical care. People who have been through sexual trauma — as Dr. Caponero says, it's one in four women — are often patients who cancel necessary procedures or do not take their medication. In terms of medical trauma, we think about things like emergency C-sections or having one's child admitted to the NICU, miscarriages and stillbirths. A person who has gone through it will have feelings about the medical system and their care and the sense of control that we all want to have over our bodies and over our lives.

The other thing I'll say is when we get anxious, our heart rate increases and we sweat. Anxiety and cortisol levels can affect inflammation, which can affect our symptoms, depending on what we have.

CQD: How do you think healthcare is doing generally, in terms of understanding the needs of patients with trauma?
DS: The medical system generally has begun taking the steps to have multidisciplinary discussions addressing that patients who have been through trauma might get re-traumatized or triggered, which might not automatically occur to a medical provider who hasn’t had training in that. But thankfully at Cleveland Clinic, a lot of work has been going on in that direction, and fellows are being educated about it.

CC: So much of our training is oriented around having the advice we want to give the patient, but sometimes we just have to meet patients where they are. That's really challenging for a lot of healthcare providers, which is why this trauma-informed care is so important.

Just because we want to be able to do that exam today doesn't mean that the patient is ready. My agenda doesn't have to be the agenda that has to happen. It's got to be what the patient is confident in doing that day. Maybe instead of starting off in a cold gynecologist's office, we need to start off in our office space. Maybe we need to make sure that the patient is dressed before we have a conversation for the first time. There are a lot of little ways to make patients feel more comfortable if we're willing to give them time and space.

DS: Within GI, we prescreen for sexual trauma, for how long it took for them to get a diagnosis, for medical trauma and other factors. Then I ask patients — to normalize the conversation — if you were to avoid care, such as a colonoscopy, would you be open to getting an ultrasound? It's not the same as a colonoscopy or an endoscopy, but it's still something, and it can allow me to maintain that relationship with the patient. It makes the patient feel in control of their care instead of just being told what to do.

We also ask whether they prefer a male or female provider, because sometimes that plays a role. I ask whether there is something specific they would like me to tell their medical team, and whether they feel more comfortable with full sedation or no sedation. Offering the patients a buffet of options lets them know that we are open to having these conversations.

CQD: It sounds like the importance of clinicians remaining open-minded and open-hearted is an essential ingredient.
CC: We're all trained to look at things as right and wrong, and it can be really hard when a patient isn't able to take what you think is the right path. We just want to make sure that our patients are safe and everyone's being taken care of.

In OB/GYN, “healthy mom, healthy baby” is one of our favorite quotes, but the reality it is so much more than that. When I look back at my own birth experience, I'm a gynecologist and I still cried on the operating room table when I had my C-section. I knew exactly what was going to happen, and it wasn't even that unplanned, but I still cried. So everyone is susceptible, and these experiences are all part of the human experience.

DS: That’s such an important insight. Our patients can tell when we can actually understand what they're going through and we really care, because we've been in their shoes or a family member has been in their shoes. We do sometimes need a poker face, but we also need them to understand that we're human, and we're trying to figure this out together. It can make them feel less scared of being in a medical setting and the implications of that.

Additional resources

Cleveland Clinic has a variety of resources to address psychological issues that intersect with women’s healthcare, including:

• Cleveland Clinic’s M-Power program provides trauma-informed care to survivors of sexual assault and violence before, during and after childbirth.
• A pelvic pain psychologist works with medical teams treating patients with pelvic floor disorders to the address psychological components of chronic pelvic pain.
• Ayble Health. Because GI symptoms are significantly associated with chronic pelvic pain and endometriosis, clinicians in Cleveland Clinic’s Center for Endometriosis and Chronic Pelvic Pain are working with the health system’s Digestive Disease Institute to offer qualifying patients access to Ayble Health, an AI-powered health platform that provides those experiencing GI symptoms extra training in nutrition and behavioral skills as well as health coaching. Cleveland Clinic specialists co-developed the content, workflows and collaborative care model with Ayble, which is designed to work seamlessly alongside patients’ in-person care at Cleveland Clinic.