Ryding 1998.

Methods	Design: RCT
Participants	Setting: hospital obstetrics and gynaecology department Type of trauma exposure: EmCS Inclusion criteria: Swedish‐speaking women, subjected to an EmCS delivering a live infant. Exclusion criteria: no additional criteria specified. Sample size: 111 patients screened; 106 randomised and 105 agreed to take part. Mean age: 30 (SD not reported) years Gender: 99 (100%) women Ethnicity: not reported Country: Sweden
Interventions	Group 1: counselling: n = 53 Intervention delivered by an obstetrician with a primary psychotherapy qualification. After informed consent, the counsellor booked the participant for a consultation at the maternity ward as soon as practicable. First, the participant was asked to tell her own story about the delivery including the EmCS. Then her thoughts and feelings during 6 phases of the delivery experience (arrival at the unit to sight of the infant for the first time) were explored. The aim of the first consultation was to establish contact and to collect relevant information. The participant was asked what she needed help with. A second consultation took place before the woman was discharged from hospital. The participant was encouraged to talk about her worst memories of and feelings about the delivery. Questions about risks to the life or health of the woman or her baby were dealt with. Existential issues, such as the insecurity of life, were discussed if relevant. The participant was assured that her possible symptoms of post‐traumatic stress reactions were normal under the circumstances. She was instructed how to 'dose' frightening memories when at home. She was encouraged in her role as a new mother. During the third consultation about 2 weeks after delivery, the participant discussed her situation at home and her contact with her baby, her partner and others. Any post‐traumatic stress reactions were again considered. She was given a copy of her complete record, which was examined in detail and explained. Possible feelings of shame or guilt about her performance during or after delivery were discussed, as well as possible feelings of anger or disappointment with the staff. The consultation ended by focusing on a positive memory in relation to the delivery. The fourth consultation took place about 3 weeks after delivery. Thoughts and feelings concerning the delivery experience were again examined. The meaning of the recent EmCS for the individual woman, and what she had learnt from the experience, was discussed. The possibility of another pregnancy was discussed, as well as hopes and misgivings about a future delivery. The participant was given medical advice concerning a possible pregnancy and delivery to come. The first consultation took ≥ 1 hour. The second to fourth meetings were limited to about 45 min. Group 2: TAU: n = 52 A member of the research team contacted participants on the maternity ward. The women completed 3 questionnaires intended to measure the cognitive appraisal of the experienced delivery, the possible presence of post‐traumatic stress reactions and general mental distress. If they had questions regarding the recent delivery or expressed distress of any type, they were encouraged to contact the ward staff.
Outcomes	PTSD: IES Other: Symptoms Check List (SCL); Wijma‐Expectancy/Experience Questionnaire Follow‐up: 1 and 6 months' postpartum
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Every second EmCS patient, according to the delivery ward register, was selected for counselling, the remainder being selected for the comparison group.
Allocation concealment (selection bias)	High risk	Every second EmCS patient, according to the delivery ward register, was selected for counselling, the remainder being selected for the comparison group.
Blinding of outcome assessment (detection bias) All outcomes	Low risk	All measures where self‐report which participants completed by post.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Dropout from both groups was low and about equivalent.
Selective reporting (reporting bias)	Unclear risk	No study protocol identified.
Other bias	Unclear risk	The study therapist was also the research leader and the study report acknowledges that participant gratitude may have contributed to participant responses. Treatment adherence was not reported.