by KMom
Copyright © 1998-2001 KMom@Vireday.Com. All rights reserved.
DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider.
CONTENTS
"Your pain matters, it is your guide to healing." Lynn Madsen, Rebounding From Childbirth
Women who experience a cesarean respond in different ways. For some women, the experience is no big deal, and they quickly move on with their lives. Some women even experience a cesarean as a relief, as freedom from a long difficult labor, a 'rescue' from a life-threatening situation, or an emotional 'escape-hatch' when the idea of normal labor pain and/or vaginal birth is extremely distressing for some reason.
Other women find a cesarean difficult to deal with emotionally. They are happy to have their children with them, but just can't see the method of their birth as 'no big deal'. For some, the lost dream of the way they had wanted to birth takes real grieving, and for others, the pain of the physical recovery (from what is after all MAJOR surgery) is difficult emotionally too. Still other women experience their birth and cesarean as a deeply traumatic event, even akin to rape.
A woman's response to a cesarean depends on a great number of factors, including how she was treated by medical staff, the respect and dignity she was accorded, factors involved in the actual surgery, how labor went, the response of her loved ones, the fantasy birth she had dreamed of beforehand, the fears and emotions she brought to labor and birth, prior experiences with the medical establishment, and her own emotional background and personal history. Because of all of these variables, it is only logical that different women would experience and interpret a similar event----surgical birth----differently. This is completely normal.
This particular FAQ is about the emotional recovery after a c-section. It discusses what women may experience emotionally, the wide range of responses that can happen, the validity of these responses, and ideas that other women have used to help themselves heal and grow after a cesarean. Because many women find that their future choices about birth and parenthood can be affected by their cesareans, this FAQ also briefly addresses the emotional aspects of choosing more children and birth choices in future pregnancies.
Since women who 'love' their cesareans or have no problems recovering emotionally from them tend not to need a great deal of validation of that experience in our society, this FAQ does emphasize those women who found their cesarean emotionally disappointing or traumatic. However, this is not meant as a judgment of those who were not distressed by their cesarean. It is simply a validation to those who found the experience difficult and distressing, and a way to share steps that other women have found to be emotionally healing afterwards.
It is important that women who read this FAQ not judge women whose experience of cesarean was different from theirs. No response is 'right' or 'wrong', and no one's experience is 'more valid' than anyone else's. Emotions are just that-----simply EMOTIONS. They don't need to be justified, they just are. This is not the place for judgment of other people's choices or responses. Instead, this is the place to try and understand where someone else is coming from and why they feel that way, to empathize with those feelings, and to find validation for your own feelings, whether they are the same or different from others' feelings here.
If you would like to share your own experience about emotional recovery from a cesarean, feel free to email Kmom about that experience. If you would like it shared here, please keep it reasonably brief, send it by email (no attachments please), and give permission for your story to be published. See below for more information.
Ideas for emotional healing and recovery in this FAQ are drawn from many resources. Rebounding From Childbirth: Toward Emotional Recovery by Lynn Madsen is a primary source, and Kmom highly recommends this book. Other useful books included Birth As A Healing Experience by Lois Halzel Freedman, Transformation Through Birth by Claudia Panuthos, Silent Knife by Nancy Wainer Cohen and Lois Estner, Trust Your Body! Trust Your Baby! Childbirth Wisdom and Cesarean Prevention edited by Andrea Frank Henkart, and Ended Beginnings: Healing Childbearing Losses by Cathy Romeo and Claudia Panuthos. Further information on these books and where to find them can be found in the references section.
Other resources include Healing and Grieving Workshops given by Nancy Wainer, grieving exercises from the Birth Works childbirth education program, an ICAN workshop on "The Emotional Scars of Cesarean Birth" by Nicette Jukelevics, workshops by Penny Simkin, the writings of Gloria Lemay and Leilah McCracken, and suggestions from the ICAN mailing list.
Enormous thanks are due to the women who have dealt with these issues and shared what worked for them, and especially to those who have actively worked towards helping other women heal their birthing experiences. Bless you for breaking the silence and talking about an issue that few people took seriously. And bless you for lighting a candle for others to use as a guide towards healing. You will never know how many women you have helped.
Note: Since most women will not read this FAQ in its entirety at one time, a number of important points are repeated throughout the text to make the FAQ more user-friendly.
Emotional Recovery After Cesarean: A Variety of Responses
Women have a wide range of emotional responses after a cesarean. Some are devastated by it, some love it, some are disappointed but okay with it, some feel 'rescued' by it, and some seem fine at first only to experience delayed grieving later. There are many factors that can influence how a woman experiences and interprets a cesarean emotionally.
Planned Cesarean vs. Unplanned Cesarean
Whether or not the cesarean was planned is often (but not always) a factor in how a woman experiences her cesarean.
Women whose cesareans were planned ahead of time usually have the easiest time recovering emotionally, since they knew ahead of time that it would happen and more or less what to expect. They had time to grieve their lost ideal birth ahead of time, and were able to prepare themselves mentally for the rigors of surgery and recovery. They did not have to go through the pain of labor and the pain of surgery too.
However, not all women who have planned cesareans have an easy time emotionally; some have planned cesareans because of unavoidable physical factors and/or unenlightened medical policies. Because they did not want the cesarean but were forced to have one anyway, the emotional recovery in these cases can be difficult and painful.
Women who do not plan to have a cesarean but who go through labor and still end up with a cesarean anyway generally have a hard time adjusting emotionally too. To go through the intensity of labor and then have to endure the pain of surgical recovery too is a double physical burden. To give up your fantasy of how you wanted your birth to go and face a totally unexpected outcome is a difficult emotional adjustment for many.
Those who unconsciously believed that 'this won't happen to me' (and conversely, those who were especially afraid of having a cesarean) often face the most difficult emotional adjustments of all. Rigid expectations of birth, denial of the unpredictable nature of birth, or extreme avoidance fears of possible surgery make a cesarean that much harder to deal with if it does occur.
Experience of Labor
Another factor that strongly influences a woman's experience of cesarean birth is how her labor went.
If a woman experienced a relatively easy labor but a situation suddenly occurred where a cesarean became necessary, some women feel bereft and robbed of the culmination of what they had been working towards. These women tend to adjust fairly quickly and are often able to navigate recovery easily enough. They usually do not face future pregnancies or births with much fear of labor, just the fear of the recurrence of the complication recurring. Once they get past the stage where the complication occurred, they generally do very well. Sometimes they do experience the complication recurring, but with a more favorable resolution, and then they are fine.
On the other hand, sometimes women who have had a sudden cesarean due to an emergency during labor are traumatized by the suddenness of how things changed, the unpredictable nature of labor, and a sense of fear over this volatility. The quick action that sometimes must be taken because of complications often does not leave time for women to adjust emotionally; they may feel like their bodies and emotions have been hijacked. In subsequent labors, even if everything is going well, they may fear another sudden 'hijacking' by a complication, and often need a lot of reassurance that all is going well. Again, once they are past the point where the previous complication occurred, they can often relax a bit more.
Women who experienced a very difficult and painful labor before their cesarean occurred often see the cesarean as a welcome release from the pain they experienced. These are often the women who 'loved' their cesareans, as to them it was a release or a rescue from a difficult situation. To go from an immense amount of pain with little or no progress to the numbness of cesarean anesthesia may feel like a real blessing, and to have the immediate gratification of having it all over and holding that precious little one in their arms sooner rather than later is an understandable joy.
Many women in this position logically therefore see their anesthesiologist or OB as rescuer and hero. Ironically, many of these difficult labors were actually caused by the labor management policies of the doctors, who were then able to ride in on their white horse to 'rescue' the woman from the problem the doctors had created in the first place! Women in this situation usually divide into two camps---those who staunchly keep seeing their doctors as white knight rescuers, and those whose heroes get knocked from the pedestals when they find out that the actions of their doctors may have caused their cesareans in the first place.
This is a particularly difficult emotional transition. A woman may be 'fine' with her cesarean at first because she saw it as a rescue from a difficult situation or a lifesaving measure for herself or her baby. If she finds out later that the doctor actually caused or greatly added to the problem that she had to be rescued from (or even worse, put her baby's life in danger through his actions), that transition from loving the cesarean to feeling betrayed by it can be particularly bumpy. If she idolized her doctor/hero only to have him fall from the pedestal in a big way later on, then all of her beliefs about medicine and childbirth get shaken to their core. These women often start out 'fine' with their cesarean but have a very difficult time healing emotionally once they truly understand their prior labor and birth.
Women who are induced, have a long and painful labor, and end in an unanticipated cesarean can also have a particularly hard emotional recovery. A cesarean after a long difficult induction can be particularly challenging physically, and induction drugs often have long-term physical effects too. Pitocin, for example, can cause significant swelling and edema in the mother, which may impact breastfeeding supply, make it difficult and painful to walk, and be very uncomfortable to deal with. Women who have been induced with Cytotec (misoprostol) often report that their labors were extremely painful and difficult to deal with. Babies who have experienced labors with lots of drugs and pain medications often are jaundiced, drowsy, and 'out of it' at first, then fussy later on. All of these physical factors tend to make emotional recovery much more difficult as well.
Adding to the difficulty of physical and emotional recovery after a difficult induction is the fear factor. Some inductions are so difficult that women develop a tremendous fear about labor. They can feel traumatized by how hard it was and how much pain they went through. Many have great anxiety about going through labor again because their only experience of labor was such an unnaturally strong and painful one. As a result, many choose an elective cesarean for their next birth in order to avoid a recurrence of such a difficult labor, not knowing (or not being able to trust) that labor doesn't have to be that painful and hard.
Experience of Surgery and Recovery
What happens during surgery and recovery also influences a woman's perception about her cesarean.
If the surgery was experienced as a blessed relief after a long and very difficult labor, many women feel 'rescued' by it, and may always want to have a cesarean in the future. If they have never experienced an uncomplicated vaginal birth and have no comparison of how much easier a vaginal birth is to recover from, then they have no standard by which to measure a surgical recovery. Therefore, if their surgical recovery was unremarkable, these women are inclined to think of a cesarean as 'no big deal'.
On the other hand, if surgery was difficult or traumatic in any way, a woman's perception of her cesarean is understandably going to be more negative, and her emotional recovery afterwards more difficult. For example, some women have experienced a lack of complete anesthesia coverage during their cesareans, which can be absolutely devastating emotionally and physically. This type of experience has long-term effects on feelings and fears about birth and surgery, and is a very difficult issue to heal from. It also can involve Post-Traumatic Stress Disorder. True recovery often involves going back and revisiting and reprocessing the experience, and the difficulty of doing that can keep women from healing for a long time. However, emotional recovery is possible, and the experience can often be a potent healing influence.
If a woman's physical recovery is difficult or involved after a cesarean, then her emotional recovery will also likely be affected. Since larger women are more at risk for infections and wound separations after a cesarean, this can be an issue for them (although it should be noted that average-sized women can encounter problems too!). If a woman's incision site will not close, develops an infection or pockets of fluid, then she may need long-term nursing care. Sometimes women even need to be re-admitted to the hospital for additional surgery on the site. Cesareans also increase the risk for postpartum health problems like gallstones, appendicitis, ectopic pregnancy, painful scar adhesions, and possibly infertility. If you experienced problems like this, it's understandable not appreciating the cesarean, or having difficulty recovering emotionally afterwards!
Treatment by Staff
How a woman was treated by the medical staff during her labor, during her cesarean, and during her recovery also influences her opinions about cesareans and her emotional recovery from them.
If the staff were consistently helpful, nurturing, empathetic and considerate towards her feelings, this goes a long way towards helping a woman towards physical and emotional healing. She may still experience disappointment over her cesarean but probably won't be as deeply traumatized by it.
On the other hand, if staff were uncaring, cold, distant, judgmental, or abusive during labor, the cesarean, or recovery, then a woman is highly likely to find her cesarean traumatic and have great difficulty recovering emotionally. Although we would like to think that all hospital staff is caring and considerate, some staff can be chillingly cruel or even sadistic. This may be particularly true if the staff is fat-phobic.
If you read a few of the stories in the BBW Cesarean Birth Stories, you will understand better how some women can find their cesareans deeply traumatic, and carry long-term emotional wounds from them. Emotional healing is of course still possible; often these terrible experiences are a call to action and create great empowerment for these women if they are able to marshal their anger and channel it into action and reform.
Necessity of Surgery
How necessary the surgery was is also a very important factor in how women perceive a cesarean.
If the surgery truly saved the life of the mother or the baby, her feelings about it will be different from a woman who was bullied into surgery unnecessarily. For some women, knowing their surgery was necessary helps them recover emotionally without a great deal of regret. Their disappointment about the cesarean may be overshadowed by gratitude that surgery was possible and available, and that they and their child are alive to tell about the experience.
However, even when surgery is truly necessary or life-saving, some women still mourn the loss of their ideal birth and the changes that had to occur due to circumstances. These women are often told "at least you have a healthy baby" and that they should be thankful for the life-saving surgery, but often find this an extremely frustrating and disempowering statement. Guest columnist Gretchen Humphries writes about this statement in her powerful essay, "You Should Be Grateful."
Of course it is true that a healthy baby is the top priority, and if the c-section was truly necessary, then we can be grateful intellectually for the procedure. It is insulting to suggest otherwise. However, even when the surgery was necessary, a woman often needs to mourn the birth she wished she could have or was not allowed to have, and to acknowledge the difficulty of having major surgery. Having major abdominal surgery right before taking care of a needy and high-maintenance newborn is not easy! Most women would not choose to adopt a baby and bring it home on the day they had their gallbladders out, yet people routinely dismiss the physical impact of cesarean surgery on the mother. And for some women, to be told that they have no right to mourn the loss of their ideal birth in addition to the physical invasiveness and burden of surgery is insult added to injury.
If women who truly needed a cesarean can still find it distressing, imagine the bitterness and intensity of mourning in women who find out that their cesarean was unnecessary! About half of all cesareans in this country have been estimated to be 'unnecessary', and as previously noted, are often caused by the management policies of the doctors themselves. When a woman realizes this difficult and invasive experience could have been avoided, the anger and bitterness she experiences often makes it emotional healing difficult. On the other hand, if she is able to channel this anger into empowerment, this may also propel her into great action and healing in birth issues and in life.
Beliefs, Dreams, and Fears About Birth
A lot of how a woman experiences a cesarean emotionally has to do with her own beliefs about birth, the fears and dreams and beliefs she brings to labor and birth.
If a woman believes that birth is high-risk, if she doesn't trust her body to 'work right', if she uses technology as a talisman to ward off bad luck or bad outcomes, then she is much more likely to fear birth and see a cesarean as a rescue. Women who 'love' their cesareans are often those who prefer a high-tech approach to birth, those who have prior miscarriages or stillbirths and feel 'safer' with a cesarean, or those who have deeply rooted fears of birth that cause them to view a cesarean with relief and anticipation.
Women who prefer cesareans can also include those who fear labor pain very strongly, those who dislike the messiness and unpredictability of birth, and those who prefer the convenience and predictability of scheduled elective cesareans. Women who are uncomfortable with their bodies because of past abuse also sometimes prefer cesareans because it allows them to circumvent "that" part of their bodies, to avoid uncomfortable feelings and procedures that may remind them of the abuse, or to prevent themselves from 'losing control' or feeling too much during labor. It offers them a feeling of control over the process, and control is often an important issue to these women.
There are also women who really don't care how their babies arrive in the world, who see cesarean birth and vaginal birth as truly interchangeable, and simply do not see a cesarean as any big deal. They are often able to adapt and 'go with the flow' easily and don't care how they give birth, or just don't see a birth experience as important and would just as soon get it over with. Some of these women have had a difficult time imagining themselves actually giving birth vaginally, and so are not disappointed if it does not happen. To them, it doesn't really make much difference either way.
On the other hand, if a woman strongly believes that birth is a natural occurrence and dreams of a birth that is totally natural and medication-free, a complication that ends in a cesarean often shakes her belief in the safety and naturalness of birth, and shakes her trust in her body. Women who strongly desire a totally natural birth yet experience a cesarean often have a difficult time integrating that experience.
Women who had a strong ideal of birth beforehand that was not fulfilled in reality also often have a hard time mourning the birth that they wanted and didn't get. There is nothing wrong with a strong vision of birth, but it is important to be able to be flexible and adapt because birth is not always predictable. These women have to find a way to maintain their vision of birth but be able to 'go with the flow' if things happen differently, and to encompass into their vision a way to have a good birth if a problem makes different choices necessary. Mourning their cesarean often helps these women find that compromise of vision with flexibility.
Some women see birth as a pass/fail test. They are often perfectionists and high achievers who place a high priority on 'doing things right' and doing a good job at all times. Being 'out of control' during the most intense part of labor may frighten them, and the thought of 'failing' at labor may have them petrified. Experiencing a cesarean is often devastating to these women, but if they let it, the experience can help them find the ability to release control and embrace the uncertainty of life.
Women who have co-dependency issues also often have a strong need for control, and the unpredictability of birth is often difficult for them too. They may have highly detailed birth plans that specify what is to happen under what circumstances, and may encounter difficulties with providers that are impatient or inflexible about hospital policies. The uncontrollable, roller coaster nature of labor (especially one that leads to an unplanned cesarean) is often very difficult for these women to deal with. They frequently find their cesareans very threatening, and may carefully research and analyze things for their next birth in an attempt to control it better. Their emotional healing from a cesarean often involves nurturing the ability to 'let go' of trying to control the outcome.
Women who have been abused sometimes experience a cesarean as a rescue as noted above, but can also experience it instead as a terrible violation, as almost akin to another rape. A cesarean is by its nature a very intrusive procedure, and it is only natural for a woman to want to protect her body and her baby. To be laid bare in front of room of strangers, placed in a position that resembles a crucifixion, and tied down while being 'violated' often triggers memories of abuse, and can be extremely traumatic for some. These women often become very determined to find a different way of birthing next time, and the trauma of their cesarean can create a very powerful impulse towards healing of their unresolved trauma. These women also often become birth pioneers if they can actively transform their trauma into a force for healing in the world.
Conclusion
Women experience their cesareans in vastly different ways, depending on the beliefs and fears they brought to the birth, how well they were treated during labor and birth, how the surgery and recovery went for them, and how necessary the surgery really was. Although these generalizations about women's experiences are obviously a bit over-simplified, they do contain many truths about how and why women respond so differently to what seems on the surface to be the same experience. Remember, no judgments are implied here; these are simply observations that may help explain why different people experience the same incident so differently.
Did you find yourself, your beliefs, or your situation described at all above? Did you recognize Kmom in any of the entries? [She's there in a lot of them!] Many women who read these observations will see themselves, perhaps in multiple ways. Other women may not see themselves at all.
Take some time to consider to yourself how you have responded to your cesarean, and what factors might have influenced that response. Don't be judgmental; simply observe your influences and reflect on them. This may contain some of the keys to help you towards healing.
The Response of Friends and Relatives To Our Grief
"A woman faces everyone else's denial when she attempts to say how a traumatic birth has affected her. An uncomfortable sense of isolation and a fear of being crazy results, as loved ones, friends, and co-workers do not acknowledge her pain or how her world has changed. This separation from others in viewpoint and experience is often more difficult to heal than the physical wounds of birth." Lynn Madsen, Rebounding From Childbirth
Women who have had cesareans often find that their providers, spouses, siblings, friends, and parents are less than sympathetic to their grief over their cesarean. People surrounding the mother may dismiss her disappointment at having a surgical 'birth,' be cavalier about her physical pain, or even be derisive about the trauma she may have suffered. This lack of understanding from friends and family is often very painful, and women may feel isolated and depressed because no one seems to understand her suffering or value her experience of birth. She may begin to question the validity of her own feelings and even her own sanity.
Years later, as women plan further children, they may be further disparaged for wanting a Vaginal Birth After Cesarean next time; the mother may be told she is being selfish and putting her own self-centered need for a 'good birth experience' ahead of her baby's health (completely ignoring the data that shows that cesareans are actually more risky than vaginal birth!). Or friends and family may otherwise criticize and deride the plans the woman has made to make a better birth experience for herself, denying that how a woman experiences birth matters at all. As long as you get a healthy baby out of it, they say, who cares?
It can be very difficult to deal with friends, relatives, and even spouses who "don't get" why we are upset over our birth experiences, don't agree with our assessment of what happened, or find the birth plans we have made for future children threatening to their belief systems.
Dealing With Relatives and Friends
Friends and relatives can be difficult to deal with after a cesarean in many ways. Although the majority of problems are due to dismissal of a mother's emotional pain over her cesarean, in a few cases women are disparaged for having had a cesarean instead of a vaginal birth. In some cultures, for example, a woman may be looked down on for needing a cesarean. She may be viewed as 'defective' because some health concern necessitated the cesarean, or seen as 'less' of a woman. Some are disparaged for 'taking the easy way out.' This is nonsense, of course; vaginal birth is not a requirement for being a 'real' mother, and needing a cesarean does not mean you are 'defective.' And certainly, having major surgery is NOT the 'easy' way out of birth!
However, this scenario is unusual in our society. Instead, most of the problems cesarean mothers have with friends and relatives is caused by denial of the mother's grief over her cesarean. Many people today believe that a cesarean is basically interchangeable with vaginal birth, that an elective cesarean is great because then the mom doesn't have to go through labor, or that a cesarean is 'easier' on mother and baby. There is a lack of understanding about the true scope of cesarean surgery; some people seem to think it's kind of like unzipping a zipper and taking the baby out----maybe a little more complicated, but not that difficult. They do not fully understand just how invasive it is and do not equate it with other similar major abdominal surgeries. Nowadays, most people just see it as 'no big deal,' and so they find it hard to understand why the mother is upset about it.
Some relatives may be less-than-sympathetic because they come from an age of extreme intervention in childbirth and may have little interest in more natural childbirth. Many older women come from a time when they were completely unconscious during the birth of their child, suffered through huge episiotomies that often left long-term damage, and were routinely separated from their children for long periods after birth. To them, unconsciousness or semi-consciousness at birth, pain, suffering, and separation may seem totally normal and unremarkable. Even women who gave birth in less interventive times often have unresolved birth grief to deal with, legacies of still-potent drugs, 'purple pushing', episiotomies, and routine separations from their babies.
It should be noted that some relatives may be less than attentive to the mother's grief because they are concentrating on their joy in the new baby. Perhaps they cannot bear to acknowledge any shadows from such a wondrous blessing as a baby, and so brush aside any mention of problems. Oftentimes, friends and relatives may simply be swept up in the thrill of getting to know their new grandchild/godchild, and in their happiness they may be unable to understand less-than-total joy at its birth.
Friends and siblings may also find it difficult to relate to your pain because they often have unresolved grief from the births of their own children to deal with, even with seemingly normal births. Because they have their own birth beliefs and fears, they may impose these beliefs on your experience too. If they fear labor pain greatly, they may not emotionally be able to see that epidurals can bring risks and intervention along with pain relief. If they had a cesarean and felt 'rescued' by that experience, this may not allow them to understand that someone else could feel traumatized by their cesarean.
Conversely, others may have had such easy and uncomplicated births that they 'don't see what the big deal is' and simply cannot understand that someone else's birth might not have been as simple and easy as theirs was. More than one grieving woman has been brushed off by women who birth easily and can't understand that not every birth is like that.
Some therapists feel that many people are unconsciously dealing with grief over the way they were born so many years ago. If a baby really is a fully feeling, sentient being at birth, how must he or she feel at some of the more violent interventions of birth, from forceps or vacuum extractors dragging them out, being taken away from the mother and isolated, to all the routine shots, blood tests, circumcisions, and other interventions that babies are subjected to immediately upon entering a new world? There are therapists who feel that those who experienced particularly difficult births were traumatized by the experience and carry that trauma with them into life.
Many women feel acute pain when they are not able to share their grief over their birth experience with their mothers. Here is the one person in the world who should be able to empathize with you, yet she is often the person who has the least understanding. The reasons are often complex. For her, the joy of becoming a grandmother may supercede her ability to hear your emotional pain, or the unacknowledged grief of her own birthing experiences may keep her from being able acknowledge yours. Perhaps the difficulty of seeing her beloved daughter in pain may have caused her to see the medical system as having 'rescued ' you from terrible pain or even from danger. Or she may have boundary issues with you that makes her want to control your life, to discount your feelings and desires, and to 'fix' things for you.
The often-strained relationship between many mothers and daughters makes communication about basic issues difficult enough, let alone emotion-laden issues such as birthing experiences. And communication may be hampered by unresolved tensions in the relationship, such as control or co-dependence issues. Often, the mother's reaction to her daughter's birth grief reflects her own life issues, and the underlying issues of tension in their relationship.
Summary
The sad truth is that many women are never able to find sufficient understanding about birth grief with their own mothers, friends, or relatives, and must learn to find the support they need elsewhere. It's possible that eventually you may be able to get them to understand or at least acknowledge your pain, but it may also be that you need to concentrate on the things you do have in common and learn to accept that this may never include sharing your birth grief. This is a significant loss and you should mourn it, but eventually try to find a way to move on and honor the things that you can share.
The people in our lives that have the most violent and denying reactions against our grief may be those who have the most birth grief themselves, either from their own births or from the births of their children. How other people react may not really be a reflection of your experience but of their own fears and beliefs that get imposed on your situation. The only way to deal with such people is to realize that their reaction is not really about you, but about their own needs.
With less extreme reactions, the answer often lies in our culture's inability to deal with grief. People in our society have a difficult time dealing with another person's pain and grief, whatever the source, and tend to avoid or minimize it rather than acknowledge it. We are trained to avoid other people's grief, to look away from pain, to deny illness and death, and leave people to deal with these things in private. Sharing another person's pain is simply not a skill many of us have developed or are comfortable with, and grief is still taboo in our society. Grieving death is hard enough; grieving anything less than a death is often seen as indulgent, self-involved, and neurotic.
But birth is a major rite of passage in a woman's life, and a woman's experience of this does matter. It is normal to grieve if this rite of passage was difficult or traumatic or even 'just' less-than-ideal. It is part of our devaluing of women and their experiences in our society for people to imply that only the end product matters, and that how a woman experiences birth does not matter. It DOES matter, and it is normal to grieve and need to work through that grief.
You are not wrong or crazy or neurotic or wimpy or selfish for feeling the way that you feel. As Madsen writes, "It is important to realize that other have their own reactions to a birth; a woman's personal reaction is right for her regardless of others'." Your feelings are simply your feelings, and they are neither right nor wrong----they just ARE. If you look closely at them, they are your clues to why this birth has such meaning for you, what life issues they are resonating with, and what you can do to help heal yourself. If others have a problem with your feelings, then that is THEIR problem. You have every right to your feeling, and you need to tell people so. Madsen writes further:
Each time a woman is confronted with someone else's minimization, placation, or denial, she is tempted to take this craziness into herself rather than acknowledge that the situation is crazy. She becomes stronger as she learns to trust herself and name what is going on inside, to separate out which thoughts are her responsibility and which are others', and to rebuild bridges with people she cares about.
You cannot expect every person around you to understand your feelings completely, but you can ask them to acknowledge and respect the fact that you have these feelings. You can't expect everyone around you to be in constant mourning with you over your birth, but you should be able to expect them to acknowledge that you were hurt, that you have the right to your feelings, and to give you space for the mourning and healing that you need to do.
Sometimes, you simply have to tell friends that they may not fully understand why you are so upset over your birth experience, but they do need to understand that you ARE upset by it, and that they need to respect that. Sometimes, you have to instruct them on what you need----a listening but non-judgmental ear, someone to bounce ideas off of, a helper to take the baby for an hour or two so you can take time to really grieve, or whatever. Sometimes, strong or repeated conflict is an indication that you are having boundary issues with someone, and that you need to become more assertive and set more strict limits with that person. Occasionally, you simply have to declare the subject off-limits with certain people, and if necessary get up and leave.
On the other hand, it's important to understand and respect that other people have different views of birth. You don't need to convert everyone around you into your point of view about birth; if you want them to respect your point of view, you have to respect that they may completely disagree with you. As Madsen notes, "With the emotionally loaded subject of birth, differences in philosophy and practice make for volatile encounters. Without the agreement to disagree with respect, primary relationships such as marriage, parent-daughter, and friendships can be torn apart." Remember, their beliefs in different birth values than yours does NOT invalidate your beliefs. Don't be threatened by someone else's beliefs, just agree to disagree.
Don't randomly seek support from people around you; seek out the people you can get support from and find a way to deal with the rest without denying your feelings or going crazy. When you encounter a person who simply cannot acknowledge your grief or empathize with your birth choices, you may need to minimize contact with that person, or if you value their place in your life, you may need to honor the relationship by concentrating on the things that you do share and agreeing to disagree on the others.
You may be able to help some friends to understand your feelings better by giving them a copy of one of the following essays:
Sometimes, reading essays such as these can help people 'get' our pain, or at least acknowledge that we are having pain, whether they fully understand it or not. You may have been saying the same things all along, but hearing it in another person's voice may be the key to getting a friend or loved one to be more empathetic.
However, some people may never 'get it.' They may have too much of their own 'stuff' in the way, they may have their own agendas about birth, or they may not be willing or able to really acknowledge and deal with someone else's pain. Madsen urges women to seek support for their healing journey from sources where they will get it. Don't keep looking for understanding from people who are not capable of giving it; instead seek out sources where you are more likely to find understanding or a sympathetic ear. Seek out many different types of resources, as one may not be able to provide you with all the support you need. Combine resources as needed in order to meet all of your various requirements. As Madsen states:
Support will come from a variety of places and people, not just one or two sources. Some sources will provide emotional understanding, others will offer practical advice [on the baby], and other may offer financial support. The challenge is to accept what is offered and to piece together within oneself a coherent and loving sense of self.
And of course, don't forget that your primary resource is yourself; you are the key to your own healing.
"Spouses' birth experiences and expectations are intrinsically different from a birthing woman's...Yet often spouses are the ones women first turn to for support, and the kind of understanding sought may be unrealistic. Spouses give support, but it won't be totally what a woman needs. They are too close to the situation, and have their own reactions and investments...Having witnessed the birth, spouses have their own trauma to heal. Because of this, their ability to listen to and support the birthing woman is conceivable, but not always possible." Lynn Madsen, Rebounding from Childbirth
Many women also have great difficulty in dealing with their spouses after a traumatic birth. Spouses in particular tend to pressure a woman to "just get over it already" because of their own difficulty dealing with emotional issues, their own birth beliefs and birth issues, their difficulty in questioning medical authority, their distaste for dealing with women's intimate issues, and a reluctance to revisit the difficult emotions and memories of the birth itself.
Reluctance to validate a wife's grief over her birth may reflect the husband's discomfort with how the birth progressed. Supporting a woman through a difficult labor and subsequent surgical birth is extremely trying emotionally, and many spouses feel inadequate, frightened, and powerless in the process. It is very hard to watch someone you love be in pain, and most men are trained culturally to want 'to do something;' Therefore, having the surgeon take over and 'get it all over with' is frequently a relief to them. Thus, to them, the cesarean may actually have seemed like a really good thing to them.
Men also have their own birth beliefs and issues that interfere with their ability to support the mother emotionally. Men may need to resolve their own difficult births, or they may have issues with their own parents that tend to resurface as they become parents themselves. Dealing with the reality of their wife's pregnancy and birth of their child may remind men of these issues and make them uncomfortable if they are not ready to deal with them yet.
Furthermore, men are trained to be very uncomfortable with 'women's stuff'; frank talk about body fluids and their partner's anatomy tends to make most men ill at ease, so they avoid it whenever possible. In addition, seeing their intimate partner during birth in a such a clinical way can make men uneasy; they may prefer to return to their perception of their partner as a sexual intimate instead. Men's profound discomfort with 'women's stuff' is often a powerful barrier to helping their partners heal.
Issues of response to authority may also arise. Many men are very reluctant to question doctors, and want to simply assume that 'doctors always know best.' Many men become co-opted into the medical model of childbirth by the doctors, and doctors often talk past the mother and to the father during labor, forming a male coalition to 'handle' the woman during birth. Other men would prefer to keep birth on an intellectual level, easily analyzed with data charts and dealt with through black-and-white decisions made by an all-knowing authority figure. To be forced into questioning whether this authority figure actually made the right decisions is very threatening to some men. Madsen notes that, "Spouses may need to hang onto their faith with the medical practitioners for their own various reasons."
Furthermore, fathers may not be very responsive to the mother's birth grief because they may be working through their own emotional issues about becoming a parent about the time the mother is most in need of support. While mothers start dealing with parenthood issues earlier because of the physical reality of pregnancy, fathers often are dealing with it more during the first few months after birth. They may be so overwhelmed by the new baby in the house and the realities of their new role as parent that they just do not want to discuss the birth or wish to simply put it in the past. Thus the mother may feel abandoned at the time when she needs support the most, and the father may feel put-upon trying to deal with all of the mother's issues while simultaneously trying to grapple with his own issues.
Fathers go through a grieving process, too, but they may show it differently, or they may be in a different stage at a different time than their wives. Nancy Wainer Cohen writes in Silent Knife, "Often, the father and mother are at different stages of grieving. This is understandable and appropriate, considering that their experiences and perceptions about the baby and birth are different. However, the difference can complicate matters, especially if understanding, patience, and acceptance are scarce. The character of the marital relationship and the degree of communication and support present will influence the patterns and expediency of grieving."
Witnessing your loved one being cut open while you are present can also be deeply distressing. Cesareans are the only surgery where your loved ones are permitted to be present and watch the surgery. While men generally want to be present to support their wives and see their babies right away, many are unnerved by the surgery part. It is far too real a lesson in anatomy for most people, let alone a disturbing reminder of the mortality of their partners, and many men would prefer not to be reminded of that experience afterwards. If the surgery was in any way especially traumatic, men tend to especially shut down and not want to deal with remembering it at all because it may be so disturbing to recall.
On the other hand, it must also be noted that often-times, a cesarean is more father-friendly than mother-friendly. The baby is often given to Dad to bond with while the mother is still being operated on, and he may even get to give the baby its first feeding. So while the mother may get a glance at her baby or a kiss or two, the father usually gets extended access in those precious newborn minutes. Many mothers are deeply envious of this time------this was supposed to have been their bonding time with baby after all!-----while fathers naturally enjoy this private time. Because cesareans can be very rewarding in this way for fathers, and because an elective cesarean does not require the father to go through the emotional pressure of trying to coach and support the mom through labor, some men prefer elective cesareans and pressure their wives to have them for all future births.
Because many spouses are distressed by the feelings of helplessness they felt during the birth, disturbed at the idea of questioning medical authority, out of their comfort zone in dealing with intimate anatomical processes, dealing with their own emotional issues, and may be overwhelmed with the reality of a new baby and their new role as a father, they are often just relieved that it's all over with and don't want to deal with it anymore afterwards. As a result, many fathers find it difficult to empathize or deal with the mother's emotional needs after a cesarean and simply want to move on.
This conflicts deeply with the mothers' need to deal with the reality of what happened to them, to integrate and understand the experience, and find a way to live with the wild array of emotions the birth has brought to them. If other friends and relatives are less than supportive of her need to grieve, the mother may also unrealistically place all her need for support and healing upon her partner, adding even more pressure to their relationship.
One of the most common areas of tension with spouses is the mother's need to re-tell the birth. Most postpartum women feel the need to go over and over the birth, especially if the birth was traumatic in any way. This need to discuss the birth repeatedly can create a great deal of tension with the spouse, who generally wants to forget the experience or is ready to move on sooner than the mother is. It is completely normal for mothers to need to re-live the births of their babies however it went, but this need is often markedly stronger in women who had difficult or traumatic births.
It is your job to emphasize to your partner that it is a very important (and normal) part of the healing process to need to review the birth again and again. He needs to understand that his job is to listen, help you recall, sympathize, comfort, and hold you, but it is not to help you solve anything or get you to move on. Men tend to be programmed to do this when trying to help, and it's the opposite of what most women need after birth.
Many men tend to listen, offer a course of action to solve the problem, and then move on. That's fine; it works for them. However, they need to understand that YOUR course of healing may be different, and that what most women usually need is a sympathetic ear, one who will listen nonjudgmentally over and over again, as long as is needed. He needs to know that his healing is important (and many spouses have a lot of buried emotions after a c-section) but that your healing is very important too, and that you need his support to heal in your way, not his.
One suggestion that works for many women is to schedule specific times to focus on birth issues and discussion of birth-related feelings with their husbands. The husband has to promise that during this time he will really listen to the woman's feelings and try to understand them, and that he will not judge them or dismiss them. The wife has to promise that she will try to limit her birth discussions with him to these times, so that he can have the relief of 'birth-free' times when the subject is tucked away and the two of you can focus on your relationship, your family, or other issues in your lives. Scheduling specific times can provide the outlet the woman needs, an opportunity for discussion of important birth issues between partners, yet contain the grieving into more manageable chunks so that the couple doesn't spend all its time being dominated by this issue.
Another difficult issue impeding communication with husbands after a cesarean is that deep-down, many women are angry with their husbands for not protecting them from the cesarean or the interventions that led to the cesarean. This anger may not be on a conscious level. Many women do not think they are angry with their partner, only to find later that when they really explored their feelings deeply, they were angry. Sometimes men perceive this intuitively, and so they avoid the whole subject.
The anger women feel towards their partners may have a real basis, or it may not be rational. Many women know that it was unfair to expect their husbands to protect them from interventions or to stop the cesarean from happening, yet they are still angry anyhow. This is a very common feeling! It may not be fair, but those feelings are there. If they are not acknowledged, they fester and poison your relationship. Getting them out is important.
Many women find that they can deal with it by journaling about it, working through their feelings on paper before discussing them with their spouses. Or they can talk them over with a neutral person, in a cesarean support group or online. They can acknowledge that the feelings may not be fair, but that really feeling and acknowledging them anyhow can lessen their toxicity and help the woman move beyond them.
Each woman must decide for herself whether or not to share those feelings of anger or disappointment with her spouse; whether it is important to share depends on the relationship you have, what occurred, and what tensions you share for the future. If you are afraid that the same problem will recur, if you want to hire additional labor support and he finds that threatening, or if you need more support or a different kind of support from him next time, sharing the feelings may be important to help you clear the air and change things for next time. On the other hand, some women find that if they really deal with it on paper or in therapy, they do not have to share those feelings fully, or can concentrate instead on expressing clearly how they need their husband to support them in their next birth.
Conflicts Over a New Pregnancy
When the subject of a new baby comes up, new tensions in the relationship may well arise. Although both spouses may strongly desire to have another baby, going through pregnancy and birth again brings up all those difficult memories and issues from the prior birth to deal with again. The wife may re-experience all the emotional upheaval and disappointment of that birth over again, and she may need to start to re-tell and re-hash her birth experience, which can be very frustrating for the husband to have to deal with all over again. And the husband may have his own issues to deal with again.
The husband may be reluctant to commit to having another baby because of how difficult it was to deal with before, because he saw what happened to the mother emotionally afterwards and is afraid it may happen again, and because he may be afraid for the mother's physical health as well. The wife may be reluctant to commit to another baby because she is filled with fear of complications recurring, ambivalent about the discomforts of pregnancy and birth, or may not feel like she has enough birth choices to avoid another birth like that again.
Frequently, spouses disagree about pregnancy and birth decisions for next time. The husband may have a strong desire to push for an elective cesarean to just get it all over with; facing the uncertainty of birth and the pressure to support the woman through labor again may be too much for him to deal with emotionally. On the other hand, the wife may have a strong desire for a Vaginal Birth After Cesarean, which may put her in conflict with her family members, her husband or even her provider. Having to fight for this chance can be exhausting at a time when a woman most needs support, yet frequently encouragement and assistance is at its lowest during this time.
Sometimes, the woman has done a lot of research and may choose birth options that a husband is not prepared to deal with. For example, many husbands are threatened by the idea of hiring additional labor support, avoiding pain medications, seeing a midwife, having the baby in the water, or birthing outside of the hospital, yet these options are often very helpful in achieving a VBAC. The husband may find his wife's newfound independence very threatening, the idea of questioning medical authority unthinkable, or he may simply be overcome with fear for her physical safety. These are often issues that take time to work through, and usually reflect deeper issues between the couple, or his own underlying individual issues crying out for healing.
There is no one easy way to work through these issues. Oftentimes, it is useful to have each partner reflect on their own time what they want out of the next birth and why, and then consider what deeper issues might be behind these desires. Then they can schedule time to come together and listen to each other's points of views neutrally and without having to decide anything yet. Nicette Jukelevics suggests that the following format can help partners communicate more effectively:
Sometimes it is helpful to restate the other person's opinions and issues to show your understanding, to clarify any questions or confusion, and to share and emphasize your common priorities. Then take time to go away and reflect on each person's point of view, and to do research on any issues that arise. Return later on to discuss what you have found out, to work through your issues, and to see if there is room for compromise.
Counseling with a childbirth educator or birth issues therapist can also be helpful in finding out more about birth care controversies, uncovering the real emotional issues behind any conflicts, finding ways to work through fears, and to come to some understandings about these issues. Journaling exercises and birth art are often particularly powerful ways to work through such concerns.
Sometimes, the woman is more ready to deal with these issues than her husband is. Many husbands carry such fears and emotional baggage from the previous birth that they refuse to discuss the issue at all, refuse to do any reading about birth issues, refuse to consider alternative arrangements for birth, and emotionally wall themselves off. Many couples who have experienced traumatic birth find themselves at an emotional impasse at some point in the next pregnancy.
This is a very difficult situation. The mother has to respect that the father is dealing with his own issues, beliefs, and fears, and that they may be so strong that they do not allow him to be empathetic or consider alternatives. Usually, in time, most fathers are able to eventually start working through their feelings and deal with the upcoming birth, and the couple is able to reach some type of compromise. However, on rare occasions, sometimes the mother has to understand and respect that the father simply cannot deal with this issue for whatever reason, and make arrangements for other support. She may need to realize that this problem is not really about her but about his own issues that simply are too difficult to deal with right now.
Although the mother should make every effort to connect with her partner and try to work through problems, she cannot let his issues keep her from doing her own birth work and processing. This is her body, her baby, and her life, and her pregnancy will proceed whether or not her partner decides to work on his own issues. Even if the father is absolutely obstinate, she should not put dealing with her own feelings and issues on hold. Go to counseling alone, do your own journaling, read lots of books on your own, experiment with birth art anyhow. Do what YOU have to do in order to grieve your last birth and help make space for the next birth to be more empowering and healing.
Oftentimes, the mother proceeding with her own work and issues helps the father past his reluctance and he becomes involved anyhow. Many mothers also find subtle ways to involve the father more, such as leaving a birth book open to a certain chapter in the bathroom for the dad to look at if he chooses, or leaving a pamphlet in the father's briefcase for him to read on a trip. Scheduling time away from the other children to relax and reconnect as a couple can be helpful in re-opening the lines of communication. Writing a formal letter about your feelings and mailing it to him often 'reaches' him when normal spoken communication has been closed off emotionally. Other moms find getting the father to another childbirth education class (preferably a non-hospital, non-traditional class series) is key in getting him to open up and consider difficult issues. Although many men have to be nearly dragged to class initially, most eventually feel that it was very useful in working through birth issues. The process of getting a reluctant partner to deal with birth issues and grief is often a long and difficult one, but most women do find that eventually some progress does come.
Ideally, a woman and her husband should find a way to come to agreement about birthing issues for next time. The husband has to remember that although the baby is from both of them, the birth is from the WOMAN'S body and ultimately the choices about how to birth are hers. He may have to learn to question all of his assumptions about the 'proper management' of birth, the infallibility of doctors, and the ability to control the process of birth. A woman may have to find the strength to stand up for herself and her baby, to assert herself in her care, and to research and advocate for birth issues. She will have to reach down and find out what is truly important for her in birth, and what it is possible to compromise on. Together, they must make priorities and important choices, and find a way to come together as a family for a better birth.
Summary
Some women get over a cesarean very quickly, and some women take years to get over it. It is the husband's responsibility to be responsive to his wife as she goes through her healing process, but it is the woman's responsibility to help her husband understand what he needs to do to support her while she heals. She should not feel guilty for asking for his help, but neither should she expect him to read her mind or do her healing for her.
It's important to recognize how hard it is for the partner of a c-section mother to watch his partner go through the labor, surgery and recovery; re-examining that can be very scary for the spouse. And dads have their own emotional issues to deal with; moms need to understand and give them space to deal with their issues too. However, recovery is about personal AND mutual healing, and it can actually greatly aid the communication in your marriage to pursue discussing these issues carefully.
Remember that healing proceeds in stages, and that every couple's journey is different. Expect that there will be bumps along the road, the most difficult of which is often dealing with subsequent pregnancies and choices about these. Given time, these can be a path to tremendous growth and healing, however difficult they are to deal with at first.
Don't expect your spouse to be your only support; the care and understanding of other women in a personal support group or an email mailing list is also a crucial part of recovery. Also consider a personal journal to vent in, or a birth issues counselor who can help uncover and work through difficult issues in a safe space. Childbirth education classes that specialize in emotional preparation for pregnancy can also be a vital part of personal recovery and preparation for future births.
Be sure to have room for other meaningful conversations and contact with your spouse; don't let your whole relationship be about the birth! Spend time with and rediscover your partner; he needs nurturing and healing after a difficult birth, too. Together, with time and care, you can both find your way to healing.
Different women have different timelines for grieving after a cesarean. There is no right or wrong course for grieving; women need to grieve in their own way and their own time.
Some women need to grieve their cesarean right away. The experience of the labor and delivery may be so immediate in their minds that it is an emotional necessity to deal with it right away. Some women also need to deal with their grief quickly in order to bond more closely with their babies.
For other women, however, the experience may have been so traumatic that it is impossible to integrate psychologically right away, and they may need to create more emotional distance from the birth in order to function. For these women it may be healthier to put the experience 'away' for some time so that they can concentrate on the new baby and the intensive demands of new parenthood. This is often especially true for women whose labor or cesarean was particularly traumatic.
The woman who is 'fine' with her c-section at first often experiences delayed grief later on. Frequently this occurs as the baby gets a little older and less demanding, around the anniversary of the baby's birth, when the woman is ready to start conceiving another child, or when a friend/relative that is close to them has a baby. This is very common and is a natural time to work on integrating the previous birth into herself.
Sometimes a mother may feels like she is 'fine' with her cesarean and has moved on. It may only be later that she becomes aware of a deep and searching need to relive, discuss, and second-guess the birth, especially if she later suspects that the cesarean may not have been strictly necessary. She may feel betrayed by her providers, overwhelmed with a sudden need to learn all about birth issues, and obsessed with discovering what really happened to her.
On the other hand, some women never do experience a need to re-live or second-guess their c-section, which is also fine. Not every woman is stressed by her c-section! Although many who feel 'fine' about it at first do go on to question or mourn it later, some do not. Women who are 'okay' with their c-sections should not feel guilty or pressured into angst. Each woman is unique in her process of accepting her birth experience, and no response is 'right' or 'wrong'.
However, if grief is a part of your response, it is important not to rush it. Oftentimes, women face a lot of pressure from friends and family to "just get over it," to deal with it quickly and then move on. Sometimes, the pressure is from the woman herself. In response, Madsen suggests:
Recovering from birth trauma or a related event is consuming; it can take up every waking and sleeping moment. Consider taking breaks. Commit to a conversation with a friend where birth is not mentioned. Go to a silly movie...Take a bath and keep the mind empty. It's natural to want to move through the healing journey as fast as possible; after all, who wants to be in pain or identify big feelings? 'Let's get this over with,' a woman says, and then is challenged by a much slower timetable which her healing requires...An affirmation to use is: a woman remembers and finds her feelings and memories as she is ready to remember and find them.
Don't rush your grieving; accept that your healing process will come and go in layers. You will work on mourning certain aspects of the birth intensely for a while, then things will ease off for a while, only to return in force again later. Again and again this cycle will probably happen, but each time the grieving is slightly different, the healing stronger, the burden lighter. Some authors compare grieving to a spiral, but one which moves UP and into the light. Work at your grief, but give yourself time and space to do it in your own way, and remember that while you may revisit the process periodically, your circle is a spiral that goes UP and moves into the light. It does get better.
"The urge to hold, cuddle, and touch a newborn is very strong in many parents. To be denied that urge by some life-threatening emergency, or, worse, by some routine hospital policy, can be deeply painful. The sorrow over not being able to have one's baby when the heart aches to parent and love is painful indeed. The long-range effects may be great unless the sorrow is released and the heart healed." Claudia Panuthos, Transformation Through Birth
For many women, one of the most difficult parts of cesarean birth is the lack of bonding time with their newborn. Many women worry deeply about the newborn while separated because they usually cannot physically see and touch the baby for some time. Many also deeply grieve that while they should have been the first to hold their babies, they were actually among the last to snuggle their baby; that virtually every staff member and family member got to hold and know their baby intimately before they did. This is a deep and very primal loss, and should not be underestimated by others. Biologically and emotionally, women are strongly programmed to interact with their children right after birth, to make sure baby is all right, and to cement their prenatal bond in a new and special way. Losing this period after birth is a deep emotional wound, one which is difficult to heal. Bonding can of course take place later, but that doesn't replace the precious time right after birth that can never be restored.
Even after the surgery is over, cesarean mothers often miss out on bonding time. Anesthesiologists regularly add drugs after the baby is born to make the mother drowsy and relaxed for the rest of surgery, but this makes many women feel completely drugged and 'out of it' for hours afterward, not just during the surgery. Many cesarean mothers mention how frustrating and deeply disappointing it was to be too groggy to really remember this time or to be in too much pain to enjoy their baby fully.
Women often also grieve lost breastfeeding opportunities. Hospital staff often give a cesarean baby a bottle of formula 'just as a precaution' or 'so the baby won't get hungry while you are waking up.' Therefore, many women are not only deprived of the first moments of baby's out-of-utero existence, she is also often denied the joy of giving baby his/her first meal, first bath, first diaper change----all those sentimental but oh-so-important firsts. And research does show that those 'innocent' bottles of formula and delays of first nursing does tend to make a cesarean mother's milk come in later, may impact milk supply negatively, and may create nipple confusion. Research shows that cesareans do negatively impact breastfeeding rates, and the loss of this connection can be yet another loss a woman has to assimilate.
Some women also feel disconnected from their cesarean babies, which often causes great guilt. Since most c-section moms do not get to see the baby emerging from their bodies, to some the baby may seem unreal or as if it's the wrong baby. The lack of that primal knowledge of feeling and seeing that baby emerge from your body, of holding it right away afterwards, of knowing that this is your baby, can be devastating to the bonding process.
Lois Halzel Freedman in Birth As A Healing Experience notes that one study that compared vaginal and cesarean deliveries found that 88% of women having a vaginal birth held their babies within the first hour after birth, whereas only 9% of cesarean mothers held their babies within the first two hours of birth. She writes:
When women tell me that they did not hold their babies for a few hours after birth, or even for as much as twenty-four hours after their cesarean section, they express grief and feelings of loss about this. Sometimes women feel unsure whether the baby is definitely theirs and may experience guilt over their doubts. Some say they had not cared about holding the baby because they had felt so physically uncomfortable. Many women stated that they grieved over the memory of not seeing their babies and not caring about seeing them. This indicates the importance of the emotional need for mothers and their newborns to have physical contact soon after a cesarean section.
Sometimes, those who experienced particularly traumatic births may subconsciously blame the baby for the experience. Although this sounds terrible to outsiders, what is usually going on is that these mothers are just too pre-occupied with what has happened to them to be able to open their hearts fully to the baby. They are overwhelmed by their experience, and because of the nature of birth, in their minds the baby is part of the source of the pain. Subconsciously, even the most loving and attentive mother sometimes is a little angry with her baby for being malpositioned, for getting 'stuck,' for developing distress, etc. It doesn't mean that these mothers don't love their babies or are poor mothers, just that what has happened to them is overwhelming and difficult to deal with, and they are human in their responses.
Because of delayed access to the baby, less than ideal bonding time, interference from pain medications, delayed access to nursing, or inability to see the baby emerging from their bodies, some cesarean mothers can have difficulty bonding with their babies at first. This state does not persist forever. Most moms who have trouble bonding eventually experience a breakthrough and bond just fine-----but they may mourn forever the time lost to them. Sometimes the process takes days, sometimes weeks or months or longer, but usually at some point, most mothers find the opportunity to 'fall in love' with their babies after all.
On the other hand, some women who experience traumatic births bond fiercely and immediately with their children. Trauma and difficulty do not always impede bonding; sometimes it has just the opposite effect. These women may be intensely connected with their children, and the level of bonding can be quite fierce. The trauma in these cases only helps to focus the mother's attention on her child, and the effect may be so strong that other concerns may drop away. Recovery in the more extreme cases may involve relaxing enough to loosen vigilance or to include others within their tight world of focus and concern. However, fierce bonding can also be just another legitimate response to a tremendously challenging situation----another way of coping.
Women who experience cesareans may have bonding issues with their children. Although bonding eventually occurs, some women find it delayed by the experience of surgical birth, or mourn deeply the time lost to them immediately after birth. Each woman needs to deal with the trauma in her own way, accepting her response as normal and human, and move beyond it into healing and closure as time goes on.
Breastfeeding Issues and Impact
Breastfeeding can be the source for additional trauma after a cesarean, or it can be a source of great emotional healing. Studies show that breastfeeding initiation rates are lower after a cesarean, and not nursing can make a mother feel even more disconnected from her baby. If mothers experience difficulty breastfeeding after a cesarean, many report that it made them feel even more like a 'failure' than before. Of course they are not 'failures' at all, but the feeling is not unusual.
On the other hand, if women are able to breastfeed successfully after a cesarean, they often find that they are able to 'reconnect' with their baby through this experience, to firmly cement their missed bonding, and to feel like finally, their bodies "were able to do something right." Many cesarean moms report that breastfeeding was a source of significant emotional healing after their cesarean.
Cesareans can make the physical act of breastfeeding more difficult or more painful, but there are techniques that can help make the transition easier. Unfortunately, not all hospitals are very good about helping post-cesarean moms very well. You may need to actively seek out help, preferably from a professionally certified lactation consultant (identified as "IBCLC").
How a Cesarean Can Interfere with Breastfeeding
Breastfeeding is more difficult after a cesarean for many reasons. Nursing your baby as soon as possible after birth ensures the jumpstarting of hormonal processes designed to ensure milk supply, and aids in the woman's physical recovery afterwards. Although a few women are able to nurse their babies right on the table during surgery, most have to wait until they are in the recovery room. A few misguided hospitals still have the outdated practice that forbids breastfeeding during the mother's time in the recovery room, so their babies must wait even longer to nurse for the first time. In addition, many women are so groggy from drugs after the surgery that they are not able to nurse for many hours afterwards. This delay in first nursing definitely impacts milk supply, often delays the appearance of mature milk, and undermines a woman's confidence and desire to breastfeed.
Many cesarean babies are given bottles of formula routinely, which research clearly shows also lowers the rate of successful breastfeeding (Blomquist 1994). Because cesarean mothers' milk may be delayed in coming in, the baby may be at more risk for excessive weight loss after birth, which usually means more bottles of formula. If the mother had pitocin during the labor, jaundice rates are higher, which may erroneously mean even more bottles of formula. The more bottles are given, the less the baby is nursing, and the less the mother's supply is stimulated. Between the delayed access for first nursing and the bottles of formula routinely given, many cesarean mothers experience a delay in their milk coming in, low milk supply at first, and difficulty nursing due to nipple confusion from bottles. Indeed, Perez-Escamilla et al. (1996) found that cesarean mothers were much less likely to initiate breastfeeding or to breastfeed for less than one month.
Physical factors that accompany cesareans can also interfere with breastfeeding. If a woman experiences excessive blood loss during surgery, she may experience anemia afterwards, which can interfere with milk supply significantly (Willis and Livingstone 1995). If you experience dizziness, weakness, and extreme fatigue after your cesarean, strongly request that your iron levels be checked; early treatment can prevent or minimize problems with milk supply, and speed your recovery significantly.
Positioning can also be more difficult after a cesarean. The usual 'cradle' nursing position can be painful after a cesarean, since this places baby against an abdomen that has just been traumatized. Many women can still use the 'cradle' position after a cesarean by putting a pillow over their incision and putting baby on top of that pillow. Other women prefer to nurse lying down after a cesarean; women who are well-endowed or who find it difficult to nurse lying down usually find the 'football hold' the best position. For more information on breastfeeding after a cesarean and illustrations of all these various nursing positions, read The Nursing Mother's Companion, The Womanly Art of Breastfeeding, or So That's What They're For! Breastfeeding Basics. You can also find more information and illustrations online at www.promom.org, www.breastfeeding.com, or www.lalecheleague.org.
When Breastfeeding 'Fails'
Mothers who experienced great difficulty in breastfeeding and gave up (or who had to supplement because their supply was impaired) often feel great guilt, frustration, or anger. The reasons for their difficulties may vary widely. Some may not have been adequately prepared emotionally or physically for breastfeeding, or may have lacked adequate instruction and support about starting or preserving breastfeeding. Some were very likely sabotaged by medical mismanagement (i.e. supplementary bottles), and some may have experienced a lack of support at home or from family members. Others may have undiagnosed physical causes, such as maternal hemorrhage, anemia, retained placental fragments, hypothyroid levels, or birth control pill prescriptions that cause their milk supply problems. These women are quite likely to be able to succeed at breastfeeding again with another child, given adequate information, care, and support, but still need to grieve and vent about their difficult experience this time.
Although most breastfeeding 'failure' after cesareans is due to medical mismanagement, it is important to note that there are a few women who are not able to breastfeed fully even when extremely well-prepared and supported. These dedicated women do everything possible to ensure success, get timely professional help, pump religiously to increase supply, etc., yet are never able to produce enough milk to fully sustain their child. No one knows exactly how many are truly unable to breastfeed since medical mismanagement is so common, but. there is a very small percentage of women whose breasts never change during pregnancy and never get any milk, and there is a slightly larger group who get some milk but not enough to fully support their baby without supplementation. This is probably due to hormone imbalances, but no one quite understands what really happens in these cases.
Among these mothers are some women with Poly Cystic Ovarian Syndrome. Although no one has documented exact numbers, lactation consultants have observed that some women with PCOS have trouble breastfeeding and need to partially or fully supplement. Although most women with PCOS are able to breastfeed fully (and up to 20% even overproduce milk due to very high prolactin levels), there are some women with PCOS who must partially or fully supplement, despite doing their utmost to nurse. This is NOT a failure of these women to be proactive about breastfeeding; it is a physiological imbalance.
Unfortunately, nearly all research into PCOS in the past has covered reproductive issues; PCOS medical researchers are generally very uninterested in lactation issues, and there is little funding for it. In the lactation research community, there is beginning to be some acknowledgement of the problem, but the information is mostly anecdotal and speculative. Some women are beginning to experiment with herbs or insulin-sensitizing agents, but formal data on the safety of this approach for infants is not readily available yet. Therefore, help for this difficult problem at this time is significantly lacking.
PCOS mothers should be strongly encouraged to breastfeed, since most of them do so successfully and it has many potential benefits for mother and child. However, they should be extremely well-educated and proactive about breastfeeding, and receive careful help and monitoring from lactation experts.
Remember that any amount of breastmilk a baby gets is greatly beneficial for its antibodies and protective immunological properties. Even if a mother is not able to fully nurse her child, the baby benefits greatly from any amount of breastmilk it does get. How long to sustain this must be left up to the mother involved; it is not always an easy process and the benefit to baby must be balanced against the stress that is placed on the mother. Kmom would encourage these mothers to nurse their babies as much as they can for as long as they can, but if the process becomes too stressful, each mother must be encouraged to do what is best for the mother-child pair as a unit, and this decision must be respected.
Summary
In conclusion, it's true that the success rate of breastfeeding after c-sections and traumatic births is lower than after normal birth (Perez-Escamilla, 1996) since conditions that surround these deliveries often interfere with breastfeeding, there may be less support from the staff, or the mother may be separated from baby more. But it's worth pointing out that many women who experience traumatic births or c-sections are able to preserve breastfeeding anyhow, and report the experience of breastfeeding to be one of their best acts of self-healing.
It does seem that women who are able to breastfeed successfully experience less severe levels of Post-Partum Depression and quicker bonding after a traumatic birth, while those who find breastfeeding difficult or give up quickly may find it more severe (Laufer, AB, Journal of Nurse-Midwifery, 1990). This may be related to hormone levels (since women who do not breastfeed tend to 'crash' more quickly and do not get the moderating benefits of prolactin and other hormones), or it may simply be emotional.
Emotional support for women after birth is sorely lacking, even for those who end up with a relatively normal birth experience. For those who endure a traumatic labor, c-section, and also have trouble breastfeeding, the emotional devastation can be particularly difficult. The sense of betrayal by one's body can be acute, and there may be little support and even blame from medical personnel and family. These women's difficulties need to be acknowledged and supported, and a safe place to vent is important.
Unfortunately, resources for this are few and far-between at this time. One online resource, however, is available for those who have had great difficulty breastfeeding, MOBI (Mothers Overcoming Breastfeeding Issues). A web page with more information can be found at www.internetbabies.com/mobi/. By all reports this is an excellent resource, and Kmom highly recommends it.
To have the great frustration of having to deal with a cesarean and then not be able to fully breastfeed afterwards can magnify the grief and frustration intensely. It is important to fully grieve all the losses involved with birth, including those involved with breastfeeding. Find the emotional supports and groups that understand what you've been through, who will listen to your grief and disappointment, who can give you valuable information and help, and who can help you move on positively no matter what happens. But rest assured, whether or not you were able to breastfeed, you can go on to emotional healing.
Many women who have experienced a difficult birth report afterwards that hearing about other women's births is very hard for them. It's very common to feel envy, anger, sadness, or depression. All the old feelings about your own birth experience may resurface again too. Even when you have done a great deal of work processing your feelings, it's still not unusual to be broadsided by the intensity of your feelings about someone else's birth story.
Sometimes, when you hear someone else's difficult birth story, it can bring back bad memories in a very visceral way. Confronting these memories yet again can be daunting, and you may wonder if you will ever get to a place where you won't be surprised and devastated by these memories again. Or you may take on the other person's grief so strongly that you make it your own.
Many women experience the opposite problem-------becoming upset by other women's good birth experiences. If your own birth experience was long, painful, and traumatic, it can be very hard to listen to the experience of someone who gave birth in two hours and found labor to be 'no big deal.' It's often especially difficult for women who experienced problems from interventions like epidurals or inductions to listen to the stories of women who chose these interventions without thought and sailed through without problems. It's hard to hear someone else rave about how fabulous their epidural was when complications from your own epidural is what led to your cesarean.
Finding it difficult to listen to other women's easy birth experiences is only human. It's certainly not that we want our neighbor or our sister-in-law to have a difficult birth---of course we don't wish them any ill! But it's hard when the thing we want most, some women have so easily and treat so carelessly. And to add insult to injury, these are often the very women who find it so difficult to empathize with our feelings, as they cannot seem to understand how traumatic birth can be sometimes. Although we don't actively wish ill will on anyone else, it is only natural to want for other people to truly understand our pain and what we have gone through. When they can't or won't, it's only natural to feel isolated, sad, and burdened by our feelings.
Many women who have gone through difficult births also find that they want to 'save' other women from difficult births too. There is nothing wrong with this; our obstetrics system is greatly in need of change and it takes people with passion to do this. It's wonderful if you can take your grief and turn it into passion for a worthy cause! We need more women to speak out about childbirth issues and become activists for reform. Only when enough women agitate for change will it happen.
But there's a fine line between passion for a cause and trying to control others. If you find yourself accosting every pregnant woman you meet and 'witnessing' to them in a way that makes them uncomfortable, then you may be projecting your own issues onto someone else and falling into the co-dependent's trap of trying to make other people's choices for them. There is nothing wrong with offering information about choices to those who are interested in hearing, but beware of trying to control them. You cannot re-do your own choices through them, and you cannot reform a whole system of birth by making someone choose the way you would. The decisions have to be theirs, whatever the consequences.
Ultimately, childbirth decisions are up to each individual, and while we can (and should!) advocate and educate, we cannot control others. If we do, we become guilty of the same kind of paternalism that we object to in mainstream obstetrics. Remember, another person's childbirth decisions don't really reflect on you, only on their own beliefs and priorities. Choosing differently than you does not invalidate your opinions or your choices. Put the information and your passion out there to the universe, and then let go of trying to control the outcome.
Finding other people's birth stories hard to hear and trying to influence other people's birth choices are natural responses to grieving a difficult birth experience, and seems to be a normal stage of the grief process. Don't feel guilty for a perfectly normal response! However, an extremely strong reaction to a birth story or the need to control other people's choices may indicate that you have issues of your own that you still need to deal with.
Eventually, you will progress to a point where every birth story you hear is not devastating to you, and every person's birth choice is not a reflection of you as a birth activist. Try to get to a place where other people's birth stories are simply their stories, and other people's birth choices are simply their choices, not threatening to the validity of your choices or experiences. Don't be hard on yourself if the process is not always easy; progress will come with time and healing. Eventually, you will find the balance between activism and loving detachment that is right for your life.
Grieving Stages and Post-Partum Depression
Grieving Stages
Emotionally, many women who have a cesarean experience a grieving process. Grieving stages are not usually experienced in a clear linear progression and many people experience them in periodic cycles. Most c/s mothers experience these in one degree or another. Though it is distressing and stressful, most are able to deal with it in a mentally healthy way in spite of the circumstances.
Grieving stages are NORMAL responses to the stress of loss, and reactions like these are not unusual at all. These responses are healthy responses, allowing women to gradually integrate a distressing experience rather than having to assimilate it all at once and become overwhelmed. Examining typical responses does not imply that they are unhealthy, just that they are not unusual. Given time, responses do change as a woman integrates her experience more fully.
Denial is the response that some women have initially. Some women need to justify that their cesarean was necessary, no matter what. Many believe their OB's dictate that, "A 6-pounder couldn't get through that pelvis" or that "Your babies are just too big," or are unwilling to see that interventions may actually have caused the fetal distress that necessitated her cesarean. This is not to say that all cesareans are unnecessary; some actually are life-saving and necessary. But the fact that many are preventable is a difficult conclusion to come to soon after your own cesarean. For their own sanity and immediate recovery, most women need to believe at first that their cesarean was absolutely necessary, and only later are able to consider the circumstances more objectively.
In addition, culturally our society has a hard time dealing with strong negative emotions in general, and generally teaches us to suppress or medicate them. In Rebounding From Childbirth, Lynn Madsen writes:
Our society encourages...denial of any pain...Emotional pain is either medicated or disregarded completely. When a woman wants to acknowledge pain or view it positively, she stems a strong tide of denial. Also acknowledging current pain may unleash past personal wounds formerly suppressed and now accessible. She fights uncountable messages to avoid, medicate, and eradicate pain instead...She avoids the depth and impact of her birth experience, avoids what her body is trying to tell her. Fear of strong emotions is a primary cause of denial.
Many women initially deny that their cesarean was distressing, or minimize the pain it brought them. This is very functional. They may need to concentrate instead on the fact that their beloved baby is here, they may need to get on with concentrating on baby's needs and their own physical recovery, or they may simply not be ready to deal with the full psychological impact of everything that has happened to them. For some, a cesarean really is no big deal and never will be. But for others, the psychological and physical pain of their cesarean has to be minimized at first in order to move on with their life and deal with the immediately important tasks of bonding with their baby and dealing with all the other emotional upheavals of becoming a new parent.
Denial is a very normal stage, and can be a very healthy response to an overwhelming situation or reactivation of old wounds. In time, the woman will come to grieve her experience in the way that she needs to. Acknowledging the pain will help her move through it.
Anger is also a perfectly reasonable response to unexpected or undesired cesareans. A c/s mother may blame a provider or common medical policies for the problem that caused the c/s, or she may even feel angry at her child for 'causing' the problem. More commonly, she directs her anger inwards towards herself. This is especially prevalent in large women or those with fertility problems, who often feel like their bodies have failed them yet again and weren't capable of birthing normally. The prevalence of size bias and harassment by many medical providers can add to the post-surgery burden a larger woman may feel, too.
Again, these feelings are normal and healthy; they should not be suppressed but freely expressed and gotten out of the body. Suppressed anger can be very harmful and often reveals itself as disease later on; but channeled anger can transform your own life and the lives of others. When the mother is ready, it helps to express the anger and channel it into a positive direction, whatever seems most appropriate to you. Many women who have had the most traumatic births take their anger and transform it into helping other women, into becoming birth activists and professionals, into reforming birth protocols to be more humane. Use the gift of anger.
Bargaining or negotiation is often interwoven with denial issues. For some women, acknowledging the possibility that her cesarean might have been unnecessary or that her doctor's actions might have put her child or herself at risk is too difficult to face. They may only be willing to see being 'saved' by the cesarean or 'rescued' from a difficult situation; rationalizing the difficulties of cesarean birth by seeing it as an exchange for the life of their child or a 'rescue' from pain. Their ability to accept their cesarean and move on emotionally is based on this bargaining, and if something happens that makes them question this bargain, then their world is often shaken in a major and very disturbing way.
Bargaining often also takes place in the next pregnancy, as the mother faces her fears of the complications or birth trauma repeating. The mother may unconsciously negotiate past the problem----'please God, just let me get past 6 cm'----or negotiate for the safety or health of her child. Again, this is not an unusual process and may be very helpful to the mother.
Depression often happens as a woman begins to truly integrate her birth for the first time. The full scope of what happened to her finally registers, she mourns the loss of time with her newborn, and she starts to reconcile her ideal birth with what actually happened. In most cases, this process is not usually severe, and is the beginning of acceptance.
A more difficult depression can result if a woman realizes that her cesarean (and all her suffering) was unnecessary. Even when a cesarean is necessary depression happens, but it can be especially strong when a woman realizes it all might have been prevented. How she responds to that knowledge and uses it can help her out of the depression stage, but sometimes reconciling the full scope of her birth with the knowledge that it might have been prevented tips women into full Post-Partum Depression.
For many women, depression also ties into underlying issues in their life, such as feeling that their bodies 'don't work right' or 'betray them,' of feelings of invasion and intrusiveness from the surgery that may be related to past issues of abuse, etc. Depression can also have a biochemical basis; women who have had a past episode of depression tend to be more prone to developing it after childbirth too, when hormonal fluxes may contribute to the problem.
Acceptance is the so-called final stage of grieving, where a woman can come to accept her cesarean as a part of her life. As Madsen writes:
The universe is great enough to include both the loss and the gain...Healing does not mean that the past and related feelings are buried and gone. They are not forever out of a woman's mind, never to bother her again. Healing is feeling the presence of the traumatic experience at its own place at the banquet table, amongst all the other guests. It is amongst the good times, the other children, friends, accomplishments, and even the wonderful births. Another leaf is placed in the table to accommodate all the guests, for no one is banished...Imagine setting a place at the table for the birth a woman wishes had happened differently. Let that image in.
After a difficult birth experience, a mother may never love the experience or be glad it happened to her, but she can accept that it did happen, and although painful, that it may have brought many important lessons into her life. Acceptance does not mean being glad to have gone through the experience; it simply means accepting that it has happened, permitting it to be a part of your life, and recognizing that good things, too, can come as a result of transformative pain.
Stages of grieving rarely come and go in nice, neat little parcels of sorrow. They do not follow a linear progression; women can jump from one stage to another and back again for some time. Often they are cyclical in nature, a spiral progression of healing that proceeds upwards, towards the light. Over time, healing does occur, grieving progresses, and little by little things DO get better.
The key is to let yourself experience your feelings fully, to express those feelings completely, to consider what underlying issues may be reflected in your grief, and to find ways to work through your grief issues and release them. It is when we resist feeling things and working on them that we tend to get 'stuck' and unable to move on. As the old saying goes, "What we resist, persists."
Post-Partum Depression
Lois Halzel Freedman in Birth as a Healing Experience notes that several studies have found that women who had cesarean births were more likely to experience depression afterwards, and sometimes this depression or 'baby blues' can progress to the more serious Post-Partum Depression. Many new mothers experience some degree of 'baby blues' (often as a function of changing hormone levels), while others go on to experience the more severe PPD. Usually women who experience PPD are the women who are most at-risk for depression because of biochemical problems, hormonal imbalances or unresolved childhood issues, but women who have had traumatic, unsatisfying, or unexpected birth experiences can also experience PPD. In fact, some cases of what is called "PPD" may actually be birth trauma instead, or the two may go hand in hand.
It is unknown how many women who have had cesareans go on to experience PPD, but anecdotal observation indicates that the rates are probably higher than in women who had easy vaginal births. A lot has to do with whether the cesarean was expected or unexpected, welcome or unwelcome, traumatic or easy, how your physical recovery goes, how much sleep you are able to get, and how much support you have post-partum.
Some women are more at-risk for post-partum depression than others. Women who have a history of depression or other problems are probably the most at-risk for PPD. Women with Poly Cystic Ovarian Syndrome (PCOS) are often also prone to depression as a result of hormonal imbalances from PCOS. Women who have experienced a major recent loss in their life (such as divorce, family death, or other emotional crisis) may also be more vulnerable. Women who have a history of addiction, women who have been abused in their past, or women who have co-dependency issues should also be more alert to the possibility of PPD. However, it is also VERY important to note that many women who have 'risk factors' for PPD never experience any at all. Just because you have a risk factor for PPD doesn't mean that you will experience it!
Even among Post-Partum Depression literature, very little attention is paid to the role that cesareans and traumatic birth experiences may play. Doctors often tend to ignore these issues as irrelevant; they have been trained to think that the only thing that really matters is a live, healthy baby at the end, and that the process of achieving that is basically irrelevant. The importance of the mother's experience or the child's experience is very foreign to their training, and the idea that a difficult experience might result in long-lasting psychic trauma seems ridiculous to most.
Doctors are trained to think of the person in the mechanical model, and so usually treat any manifestation of PPD as simply a hormonal or biochemical imbalance. Therefore, they most often respond by prescribing drugs for it. This can be helpful in some cases, as hormonal and chemical imbalances can cause or add to depression. However, their training and world view usually prevent them from recognizing the impact a traumatic birth experience can have, the importance of grieving a traumatic birth, and the importance of counseling and support in recovery. All of these can be important in helping women recover.
Most women with PPD recover with the help of a support group, a therapist, understanding friends, and time. If a traumatic birth has occurred, it is very important to work through that with a support group or therapist that understands this issue well and can facilitate healing techniques specific to the woman's needs. For a few women, though, drugs can be extremely helpful and should be considered if other measures do not help sufficiently. Some herbs are also helpful and can be tried in lieu of traditional drugs (with careful consultation of an herbal expert and your provider).
Women who have a past history of depression (especially depression needing medication) are the most likely to need chemical help to recover from PPD. However, it is important that drugs or herbs not be the only approach to helping women with PPD; grieving a traumatic birth IS also an important part of helping many women with PPD. Often the PPD issues are tied up with other life issues that need healing as well; an integrated approach is very important in these women.
It is controversial whether PPD drugs should be used during breastfeeding, and there is not a great deal of research on the subject. The choice depends on the type of drug used, how old the baby is, how much the mom needs it, the dosage, and many other factors. The possible risk to baby must be weighed against the possible benefit to the mother (and therefore to the baby and its care), and this is a complex question, not easily quantified.
Information about use of PPD drugs during breastfeeding can be found on some of the various breastfeeding websites such as www.promom.org, www.breastfeeding.com, or www.lalecheleague.org. Dr. Thomas Hale also puts out a book (revised every year) with information on various medications and their suitability during breastfeeding. This book is called Hale's Medications and Mother's Milk and is often available from various medical libraries or lactation consultants. Information about this book and where to purchase it can be found at http://neonatal.ttuhsc.edu/lact/index.html.
Post-Partum Depression is a serious and real problem for many women. Although chemical and hormonal imbalances can be a significant part of the problem, an under-recognized cause of PPD can also be unresolved life issues or grief over traumatic birth experiences. Often, the most severe cases are a combination of the three of these, and treatment must start to incorporate all three components instead of just giving medications. How a woman gives birth CAN matter, and discussing this issue should be a part of all PPD counseling.
Post-Traumatic Stress Disorder
Some women have such difficult births that they even experience Post-Traumatic Stress Disorder (PTSD). A sudden emergency/'crash' c-section, one where the surgery was especially difficult or painful, one that required a great deal of drugs or general anesthesia, or one where the baby was in danger or died often involves higher rates of PTSD. This Post-Traumatic Stress Disorder often manifests itself in flashbacks and dreams, physical sensations or stimuli causing intense anxiety or recollection, jumpiness, and increased incidences of Post-Partum Depression. Some cases of PPD may actually be unrecognized cases of PTSD.
Traditionally, Post-Traumatic Stress Disorder (PTSD) is usually associated with soldiers who experience flashbacks of a war, victims of terrible abuse, or victims of accidents and crimes who experience flashbacks too. However, women who have had an extremely difficult birth may also experience PTSD, something that mental health providers are only now beginning to realize. As Madsen says, "Trauma is trauma, and its identification is one more way of acknowledging the power and importance of the birth experience."
In the past, in an unconscious sexism, few had thought that the common experience of childbirth might be equated with the terrible occurrences that can happen in war, abuse, accidents, or crime. However, now some are beginning to realize that childbirth by its nature is an extremely intimate and vulnerable time, and that birthing women may experience just as valid a sense of threat. Most women who have had a difficult birth will not experience PTSD, but a few will. It is important for them to realize that they are not crazy, that their feelings are real and valid, and that healing is possible.
What Is PTSD?
PTSD can occur when a person has experienced "an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one's life or physical integrity; serious threat or harm to one's children...." etc. (from the Diagnostic and Statistical Manual, DSM-III-R, as recounted by Lynn Madsen in Rebounding From Childbirth). The traumatic event may be reexperienced in at least one of the following ways:
People with PTSD often persistently try to avoid stimuli associated with the trauma, or experience numbing of general responsiveness, possibly including:
Many women also experience persistent symptoms of increased 'arousal' around things associated with the event. (The arousal they refer to here is not sexual, simply emotional or physical expressions of distress at being reminded of the event.) In other words, simply thinking or talking about the event (or even driving by the hospital where it happened) is enough to make a woman's pulse race, her heart jump to her throat, her stomach to flutter, or to have an anxiety attack. Other symptoms can include:
Another common feature of PTSD is a very strong fear of the traumatic event recurring. All of these symptoms and disturbances are usually ongoing, lasting for weeks, months, and sometimes longer. Women who suppress their response at first can also have a delayed onset of PTSD.
An Example of PTSD: Kmom's Story
To give an example of PTSD after childbirth, Kmom experienced surgery without complete anesthesia in her first cesarean. This was not just feeling 'a little bit of tugging and pressure,' this was feeling the surgery intensely. Surgery with inadequate anesthesia certainly qualifies as being 'outside the range of usual experience,' and it was certainly a 'threat to physical integrity!' Although not the classic experience of trauma that causes PTSD, being cut open with full feeling meets the definition of "an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one's life