The Emotional Scars from a C-Section

http://www.chicagotribune.com/lifestyles/sc-psychological-effects-c-section-family-0606-20170518-story.html

For many women childbirth is a happy, fulfilling and empowering experience. For others it can be one of the most traumatic events of their lives. It can bring them a sense of accomplishment or failure, joy or trauma.

Emotional reactions and adjustments to a cesarean birth vary widely. Some women recover quickly from a cesarean and see it as just one more step in their journey as a mother. Other women can experience sadness, disappointment, loss of self-esteem, guilt, and anger, especially in the cases of emergency C-sections or after a long and painful labor, had general anesthesia, or were separated from their newborns after the birth. Some common perceptions are that they were not involved in the decision-making process regarding their care, were submitted to unwanted, invasive and painful interventions, perceived care as inadequate or unnecessary. A lot of women even see it as physical assault and a form of institutional violence (or “obstetric violence”): a form of violation against women’s rights, appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it.

A negative experience of a primary cesarean birth may last years and affect a woman’s future pregnancies. It can be so terrifying that some women choose to  have a cesarean in a future pregnancy rather than experience labor again or even to avoid future children altogether.

A U.S. survey of women’s first births in 2005 revealed that women who had a cesarean birth were more likely to feel frightened, helpless, and overwhelmed and less likely to feel capable, confident, powerful, and unafraid while giving birth. “Assaulted, violated, voiceless, out of control” are some of the things they report.

Several women experience a feeling of loss, grief, personal failure, distress, anger, powerlessness, negative impact on self-esteem and self-confidence as a mother. There is at times a delay in bonding and attachment, the mother is still recovering from anesthesia or is in physical pain, or is taking a lot of pain medications; sometimes breastfeeding can be more challenging for the first few hours or days. And today we see an overwhelming pressure to breastfeed (which is cyclical, a few decades ago there was not that social expectation or pressure to breastfeed). There can be long term effects on spousal relationship and the new mother’s ability to take care of the baby.

C-section is considered a risk factor for PTSD and it is said to be a consequence from a high level of anxiety about a situation which she has no control of. Increased anxiety during the third trimester greatly contributes to increase the risk.

They experience childbirth as a traumatic event, 6% meeting criteria for PTSD in the PP period (their psychological distress is similar to those experienced by war victims and natural disasters, for example). The stress response symptoms include:

• Intrusive thoughts and re-experiencing of the event in flashbacks or nightmares.
• Avoidance of places or people that might trigger a reminder of the event. Symbolic or real reminders of the event bring out intense feelings of distress.
• Numbing of emotions and general responsiveness.
• A sense of hyper vigilance or increased arousal.
• Disturbed sleep, anxiety, lack of concentration, feeling irritable or angry.
• Nightmares and flashbacks
• Difficulties with bonding and attachment
• Sexual issues with partner
• Depression

 PTSD as a consequence of childbirth is vastly understudied and all the data we have are from case reports.

We’re seeing an increasing trend North America, where the c-section rates increased from 10% to 30% in the past 25 years. (As a reference, the WHO recommends between 10-15 C-sections per 100 live births).

It is important to notice that traumatic experiences related to childbirth can happen both ways, with vaginal and cesarean deliveries, but we have evidence that vaginal deliveries typically imply superior physical health, which leads to better quality of life in general. 

Elective C-sections are culturally accepted and are actually the norm in a lot of places and there is a reverse phenomenon in Latin America, for example, where we see rates of up to 50% of C-sections, and numbers close to 70% among higher socioeconomic women with higher educational level and private insurance who opt for an elective CS.

A lot of those women fear complications from a vaginal delivery, like limb fractures, hypoxia leading to speech delays and paralysis etc. Elective cesarean section exemplifies the avoidance behavior typical of PTSD. A lot of them have a higher need to be in control and chose an elective procedure, sometimes influenced by bad experiences reported by their mothers or sisters or friends.

There are several factors to consider that will shape a woman’s feelings about childbirth: the reason for which the cesarean was performed; her cultural values; her beliefs and expectations of her birth experience; prior traumatic events in her life (like sexual trauma or domestic violence); the social support available to her during pregnancy and childbirth; her own perception of how she was treated by her caregivers; her involvement in making decisions regarding her care; and her personal sense of control of her birth. 

So it is really no one’s job to judge the woman’s choice and her rights over her body, or the way she experiences childbirth one way or another. This is one of the most important moments in a woman’s life and each decision and outcome should be individualized and should take into account the woman's prior experiences and perceptions, expectations, control issues, cognitive biases, medical comorbidities, psychological factors and support systems.

What to do?

First of all, it is important to help the woman understand that a normal delivery is not a synonym of vaginal delivery.

A good childbirth outcome is a healthy mom and a healthy baby and everything else is secondary. Some things will be out of our control and that is fine. A delivery may last a few hours, sometimes a little over a day. Motherhood is a lot more than giving birth. It starts with a nine-month experience and it lasts for the rest of your life.

Support groups or new mothers groups can help healing and change perceptions and cognitions.

Promote bonding time and skin to skin contact immediately following the procedure. There’s a movement for humanized C-sections, which limits drug exposure and procedures to the minimum necessary and promotes bonding/ attachment and encourages breastfeeding almost immediately after a C-section.

Lastly, recognize the tremendous power that exists on a C-section scar. If anything, it should be empowering and a source of pride.