"Big T, Little t": Exploring the Spectrum of Birth Trauma and How to Heal

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In the weeks before my second child was due, I met with my doula to plan for my upcoming labor and delivery. She asked me to share a bit about my experience during my first delivery, which I had only recently (due to the nature of my graduate studies and interest in maternal mental health) realized had been traumatic. 

Even now, it can be hard to reference my “birth trauma” because of the very normal hesitancy I share with my clients to brand an experience as a “trauma” when I worry that it doesn’t fit neatly into the definition of what others might call traumatic. After all, my delivery ended with a healthy baby, no intense medical interventions, and no NICU stay. How traumatic could it have been, really? 

Here’s where I find it helpful to employ the terminology of “Big T” and “Little t” trauma. “Big T” traumas are major, life-threatening, or deeply disturbing events that overwhelm a person’s ability to cope and often lead to PTSD or other significant psychological effects. “Big T” traumas might include experiencing physical or sexual assault, surviving natural disasters or war, or facing a life-threatening illness. No one would argue with you if you called any of those experiences “traumatic.” 

Where it gets tricky is recognizing that even “Little t” traumas can be deeply distressing and impactful to a person’s emotional and psychological well-being. For “Little t” traumas, you might find yourself dismissing the experience as “not that bad compared to…” or “not traumatic enough.” When you go through an experience that is distressing, even though you’re not actually fleeing a warzone but instead, say, experiencing public humiliation at a work meeting, your body might still experience the impact as fundamentally disruptive and, therefore, traumatic, especially if the experiences occur repeatedly or during important developmental stages. “Little t” trauma might include experiences like being bullied in school, experiencing a financial loss, witnessing tension in your family life, or being marginalized for your identity.

Birth trauma can involve both “Big T” and “Little T” trauma, depending on your experience and perception of the event. The American Psychiatric Organization defines birth trauma as “a perceived or life-threatening series of events that result in severe injury or death of the infant or mother”; birth trauma leads to birth-related PTSD in approximately 17% of postpartum parents and symptoms of posttraumatic stress that doesn’t meet clinical criteria for PTSD in many other parents (link). This definition seems to align with the “Big T” traumas we may associate with life-threatening childbirth experiences, like emergency c-sections due to fetal distress or a postpartum hemorrhage. For parents who experience these traumas, it is so important to access adequate resources to help support recovery and healing so as to alleviate the risk of developing PTSD. Even in these cases of “Big T” traumas involving life-threatening experiences, parents often feel that they are overreacting or should just focus on gratitude that “everything is okay now.” Trauma therapy like EMDR can be extremely effective at helping process and metabolize these experiences, but without proper support and recognition this kind of birth trauma is often unresolved. 

When it comes to “Little t” traumas, parents are even less likely to recognize that their experiences deserve compassionate acknowledgement and care. And while “Big T” birth traumas are generally unavoidable, research conducted by the Birth Trauma Association shows that most cases of “Little t” birth traumas can be prevented “simply by treating women with dignity and respect during labor.” This could mean healthcare providers exhibiting sympathy when women are upset, obtaining informed consent for vaginal exams, actively listening to women when they express concern, and providing as much choice and explanation to women as possible (link). Even in scenarios where so much is happening so quickly and very little might be a “choice” at all, providers can mitigate the trauma of the experience by engaging directly and compassionately with the laboring mother. 

For many of my clients, when we discuss their birth stories I find myself considering the various ways they felt unheard or that their choice was taken away from them. With deep respect for the medical expertise and training of OBGYNs, nurses, and midwives - particularly those who are working to incorporate trauma-informed care into their practice - we can also recognize that there is much that can be improved about the way women are treated during childbirth. 

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If you’ve ever questioned whether your birth was traumatic (“Big T” or “Little t”!), consider the following: 

• Did you feel dismissed, unheard, or pressured into decisions during labor?

• Do you have unresolved emotions - sadness, disappointment, guilt, or anger - about your birth? 

• Have you struggled to talk about your birth experience without feeling emotional or triggered?

• Did your birth leave you feeling disconnected from your body, your baby, or your sense of self?

If any of these resonate with you, it may be worth exploring your birth experience more deeply. Acknowledging your feelings is not about placing blame - it’s about recognizing your needs and giving yourself permission to heal.

And while we cannot control the way others treat us, we can advocate for ourselves in the context of our childbirth experience. While processing with my doula, I remembered the way the nurse had immediately handed the baby to me for “skin-to-skin,” an evidence-based practice the World Health Organization recommends to support breastfeeding, regulate the baby’s temperature, reduce stress levels in both mother and baby, and encourage bonding. Something it took me years to realize- in fact, until that moment just weeks from the birth of my second child, with the help of my doula, I hadn’t even considered it - was that all I had really wanted in the immediate aftermath of my difficult birth experience was the opportunity to be alone with my body and my thoughts, responsible for no one but myself and focused on recovering from the physically taxing ordeal I had just undergone. Of course, I couldn’t have known that then and the nurse was absolutely only doing what she believed was best for me and my baby. 

Honestly, it felt uncomfortable recognizing that this time around I didn’t want to hold my baby the minute she was born. And even after I decided that I would request that the nurse hand my husband the baby first, a part of me wondered: Did it mean something was wrong with me? What kind of mom was I to pass up this sacred moment? Thanks to the safe and nonjudgmental space my doula offered me, I was able to recognize that choosing to take those moments after my second baby was born was a way to compassionately listen to my own needs and make choices that did not in any way risk my baby’s well-being (it’s not like I didn’t spend the next few years holding her tight!) but rather offered me the opportunity to take care of my own mental well-being and help prevent a “Little t” birth trauma. In my own way, postponing the immediate skin-to-skin experience actually enabled me to be open to the bonding experience with my daughter when I felt ready to embrace her.

In my work as a reproductive mental health therapist, I seek to center my client’s experience by working with her to recognize opportunities for choices that support her well-being and resilience, even when those choices may not be traditional. We can often choose our OBGYN, but we can’t know exactly what their bedside manner will be or how trauma-informed the on-call nurses will be. Again, with gratitude for their expertise, we need to also recognize that exploring choices we can make to help the experience of childbirth feel as safe and supportive as possible can go a long way. 

I encourage my clients to honor their experiences, explore ways to advocate for themselves, and make choices that support their mental and emotional well-being - before, during, and after birth. While we can’t always control the circumstances of childbirth, we can take steps to feel more empowered in our experiences. For me, that meant recognizing my need for space in those immediate postpartum moments before holding my baby. This choice allowed me to tap into my strength and resilience so that I could embark on my postpartum journey in a more grounded way.

If you’re still processing your birth experience, know that you don’t have to do it alone. Whether through therapy, support groups, or conversations with loved ones, you deserve a space to make sense of what happened and find healing. 

The key is knowing that your needs are valid and that prioritizing your well-being is more than okay.

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