Very little research has thus far been published involving pregnant women with PTSD following childbirth. From a theoretical point of view, treatment can result in increased stress, with unknown consequences for the fetus. Both trauma-focused CBT and EMDR require women to direct their attention to the traumatic event, which can be stress provoking. A key element for consideration is therefore the level of current distress that a woman is experiencing. For example, if a woman is exhausted because she keeps waking up after 2 h of sleep with disturbing dreams and she is too fearful to go back to sleep, she is already highly stressed. While the safety of interventions during pregnancy is not well established, we should assume a potential harm of ongoing stress during pregnancy, which may even increase as the due date draws closer. This may have therapists and women decide together that treatment during pregnancy is desired. An alternative approach, with emerging evidence that does not require reliving, is a metacognitive therapy [37]. This involves understanding how we think about and respond to our distress and symptoms of PTSD, rather than focusing on the traumatic event itself. So this intervention is not about what images or thoughts we have in response to a traumatic situation but how we think about our thoughts. The premise is that certain patterns of response maintain symptoms rather than allowing natural processing and resolution. So it is what we make of the fact that we have distressing images and thoughts, rather than their existence that exacerbates problems and prevents natural resolution. Identifying, understanding, and challenging these patterns of response to symptoms and developing alternatives have shown promise. These alternative approaches and their implications need to be discussed with the woman so she can indicate her own preferences and provide informed consent.

Traumatic experiences and PTSD can never be completely avoided, because complications and interventions are sometimes inevitable, and some women are more vulnerable to psychopathology than others. However, if women feel well supported throughout childbirth and experience a sufficient degree of autonomy and communication between woman, partner, and obstetric staff is optimal, the risks of experiencing even an obstetrically complex birth as traumatic will be very significantly reduced [38]. It is important to be aware of symptoms of mental disorders during pregnancy and offer adequate counseling, support and/or intervention, and careful preparation for the next birth.

Many women report having felt a complete loss of autonomy and control during the traumatic delivery, and providing tools for them to feel prepared, heard, and in charge may help. These may include things such as discussing pain relief options, agreeing on scheduling or avoiding induction of labor, offering elective caesarean section in some cases, agreeing to avoid instrumental deliveries unless for fetal distress, etc. It may help for women to write down general birth preferences for how they are supported and wish to be cared for in childbirth, rather than rigid plans in order for the professionals attending their delivery to be aware of their background. Psychoeducation should help women to understand and prepare for the need for flexibility in response to the course of labor and the fact that aspects of childbirth are not all a function of their preparation and efforts but are also affected by unpredictable factors. Whether a traumatic experience or fear of childbirth is a legitimate reason for obstetricians to consent to an elective caesarean (in the absence of a medical necessity) is a topic of debate, and guidelines vary between countries. Aside from the medical risks associated with major abdominal surgery, for some women a successful vaginal delivery with adequate staff and partner support is incredibly empowering. On the other hand, for other women the decision not to go through the labor and delivery process again, but to opt for a controlled and planned caesarean section instead, provides them with a sense of autonomy that they felt lacking during the previous (traumatic) delivery and leads to tremendous stress reduction.

The simplest answer is that we do not know, meaning that no good quality research with well-designed prevention strategies have been published. However, Slade’s model [13], through providing a conceptual etiological framework that focuses on understanding how (1) predisposing factors (preexisting attributes or patterns of relating that a woman brings with her into the pregnancy), (2) precipitating factors (what actually happens in the events of childbirth), and (3) maintaining factors (how a woman responds to her early postpartum experiences) interact to determine whether a woman develops PTSD, provides testable hypotheses that future research can explore. Based on extrapolation of other studies and the experience of many experts in this field, a number of suggestions can be made. Obviously, healthcare professionals should strive to minimize the number of emergency situations, unnecessary interventions, and obstetric complications. Whether screening for and treating anxiety and depression during pregnancy leads to fewer cases of PTSD postpartum has never been studied, although this would benefit women’s general well-being.

There is ample evidence that the degree and quality of perceived support during labor is associated with women’s appraisal of the delivery, having a traumatic experience, and developing PTSD. This works both ways: positive support during birth is associated with reduced PTSD, especially in case of interventions and in women with a history of trauma [38], partly by improving women’s perceived control [39]. Conversely, many women point to a lack of (perceived) support, feeling ignored and abandoned, and uncaring staff as crucial factors in their traumatic experience [40]. It is known from general childbirth literature that continuous one-on-one support influences a variety of factors, such as the duration of labor and the incidence of caesarean section, instrumental deliveries, and epidural anesthesia [41]. It seems that the quantity and quality of staff interaction and communication during labor and delivery also affect the development of PTSD, and hence improved support should theoretically be useful.

Negative, bad, or traumatic experiences are often associated with a discrepancy between expectations and reality. Therefore, it is crucial that women are prepared (by healthcare professionals, antenatal classes, reading, or otherwise) for what to expect during labor and delivery. All too often, usually with good intentions, women end up being educated on all the possibilities and benefits of natural, drug-free labor, but know very little about what to expect in terms of pain, duration of labor, induction, and chances of having a caesarean section or postpartum hemorrhage. In their preparation, having or developing a reasonable degree of cognitive flexibility is imperative. Rather than focusing on a birth plan with a single well-defined outcome (usually an idealistic picture of childbirth), women should be encouraged to consider their wishes in the light of different possible scenarios (e.g., induction, preterm birth, caesarean section) and may call this a birth flow chart instead of a birth plan [42].

Certainly early postpartum identification of women at risk and intervention can theoretically have the potential to prevent posttraumatic stress disorder, although definitive evidence is awaited. There is some evidence to suggest that a “childbirth review”—a meeting to discuss the birth with a professional who can clarify and answer queries—may help women to make sense of their experiences. However, neither universal debriefing nor critical incident debriefing is indicated by the literature [43].

Approximately 3 % of women meet the DSM-5 diagnostic criteria for PTSD, a larger proportion reports and suffers from sub-diagnostic PTSD symptoms, and at least one-third of women report having experienced the delivery as traumatic. There is increasing recognition for the occurrence and consequences of traumatic delivery experiences and PTSD following childbirth. Some women are more prone to develop postpartum PTSD, based on their psychological vulnerability and previous trauma, the (objective) nature of the course of their labor and delivery, and maintaining factors after birth. Early identification of these women at risk is crucial for timely intervention/treatment. Obstetric staff should be(come) aware of their role in women’s appraisal of labor and delivery, both positively and negatively. Future research should include further investigating prevention strategies to reduce the likelihood of women reporting childbirth to be traumatic, which may lead to the development of postpartum PTSD.