A few weeks ago, I was working at a high-volume abortion clinic and was handed a chart for a 32-year-old woman, Alice*, with a history of one previous miscarriage and a previous medication abortion, who was here for an abortion at 13 weeks’ gestational age. Nothing in her history or intake stood out to me or the staff. She was very pleasant and chatty, with blonde hair tied back in a ponytail and nails bitten down to the quick. As we started the exam, she became increasingly anxious and jittery. She found the pain of every movement almost impossible to bear, and her eyes would glaze over as she writhed and pushed back against the footrests. I stopped, offered her more pain medication (which she accepted), let her know that she could reschedule to another day (which she declined – she wanted to get it over with), and asked her a little more about herself. I learned that she had recently moved to California to get away from a controlling and physically abusive partner in New York, had no local support system, and was currently making money doing live webcam porn. With her trauma history in mind, we proceeded.
The private and invasive nature of abortion care can be triggering to patients with trauma histories. Alice was fine and calm when we were talking, but with every dilation, she became very uncomfortable and fearful, retreating up the exam table and not responding well to instructions. Emotionally, she felt very far away. In these situations, our job is to help our patient come back into herself and find her way out of the trauma groove. My first impulse with Alice was to assertively try to pull her back into reality. But Allison Briscoe-Smith, a psychologist specializing in mental health programs for children experiencing trauma, suggests the opposite. When children become triggered through therapy or in school, she recommends backing up, giving space, and attending to basic needs, like food, water, and warmth, instead of approaching aggressively or even rationally. This tactic may not seem feasible during an abortion, but, with a creative approach, it can be. If you are at a safe place in the procedure, you can stop what you’re doing and give the patient space and time to calm down. If it’s safe with her level of sedation, offer her a sip of water. Let the patient control the pace by developing a signal that lets her indicate that she wants a break or that she’s ready for the next step of the procedure. Give the patient permission to experience all emotions, including pain, fear, sadness, frustration, and/or relief, and remind her that you respect her and will help her through this. Remind her to wiggle her toes and fingers to release tension. Give her tools to control her breathing. Most importantly, listen to and remain present for the patient, regardless of what she is going through.
With the amazing support of my medical assistant, we allowed Alice to control the pace of the procedure, giving her time to recover her composure and breath between steps. I safely finished the procedure and let the nurse in the recovery area know that Alice might need a little extra support. We made sure that she had information about Exhale and All Options (formerly Backline), talk-lines that provide nonjudgmental emotional support around an abortion. While my care for Alice was based on a trauma-informed perspective, even women who have not experienced trauma may experience having an abortion as stressful and invasive. We can take what we’ve learned from trauma-informed care and apply it to patient-centered care for all women, in all aspects of sexual and reproductive health care.
*The patient’s name and some details have been changed to protect her privacy