International Cesarean Awareness Network

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CBAC Guest Post: My Body Is Not Broken and I Can Heal

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When I found out I was pregnant the first time, I didn’t know much about the process or the world of birth. I did know that I would like to birth with as few interventions as possible. After all, women have been birthing for thousands of years, it should be no big deal, right? A woman’s body was made for this task. Childbirth is so beautiful to me and I love the pictures and videos of women and the pure bliss on their faces when they are handed, or catch their own, baby for the first time. I was young, healthy, and active so I assumed that would work to my advantage. I read a few books during pregnancy, but none specifically dealing with birth.

My first labor started on a Monday evening just after midnight. By early the next morning, we decided to head to our birth center an hour and a half away. Contractions had slowed down at that point and I started to feel nervous about having made a false alarm. Both of our families were already headed there too. As the day went on, I made a little progress and went from being dilated to a 4 at arrival to a 6 a few hours later. I ended up staying there for several hours. I started feeling pressure to “hurry up” although I had no idea how to make that happen, I also didn’t know how those feelings could play into labor in a bad way. Eventually, my midwife wanted to break my water and I consented. When she did, she also helped me dilate to a 7.  This totally changed the way I was able to manage labor. It felt like there were no breaks anymore and it was just one long, continuous wave of a contraction. A few more hours passed and I was still at a 7. My midwife suggested we transfer to a hospital and I get an epidural, to which I ultimately consented. In my mind, I went right past the epidural and thought I was basically headed straight for a c-section. At the hospital, they gave me nitrous oxide for pain management and hooked me up to monitors. At this point, I slipped into another world and was only vaguely aware of what was going on around me. Everyone was focused on my son’s heart rate on the monitor; this was the first time in my entire labor that his heart rate showed any sign of concern, so I assume it was an issue with the nitrous oxide. The doctor came in to check me again, still a 7. To my knowledge, an epidural was never even suggested, although there was still no emergency. She mentioned a c-section. I would dare to say that at the height of labor, a woman is in the most vulnerable position possible and unable to even think coherently. I was so exhausted, at this point we were in the early hours of Wednesday morning and I hadn’t slept since Monday afternoon. I consented almost immediately. I was done. My record shows my first c-section was performed as a result of “failure to progress.” Of course, there isn’t much that can ruin the first time you hear your baby cry, and I definitely still treasure that moment. My healthy, full-term baby was taken to the NICU and multiple family members got to hold him before me. He was finally brought to me two hours after the surgery.

I had a really hard time processing that birth. I questioned everything from start to finish. I didn’t know that birth trauma was a thing. I told myself the surgery was necessary. The doctor had held up my placenta and said there was a little meconium in it and also said the cord was around Ryan’s neck. So I chalked it up to an emergency. I didn’t know until later that there are a lot of misconceptions between both of those “problems” during the birth process. I walked away from the birth that I anticipated being so much different feeling battered, scarred, and defeated. And I didn’t know that it was okay to feel that way.

I was told about ICAN while I was still in the hospital. I joined a Facebook group for a local chapter and started to learn that I wasn’t the only one who felt the way I did after my birth experience. Once more time passed and my memories weren’t as hormonally charged, I started to recognize times when I should have been more supported during labor. I also started working on making peace with the way things had gone.

When I got pregnant the second time, my due date was just three years shy of my c-section. I started searching Facebook groups for VBAC stories in my area trying to find an OB who would be supportive of that option. I had read facts and statistics and I knew that was the route I wanted to go. I ended up finding a fantastic doctor who was very supportive of my choice. I had seen some books suggested and around 20 weeks I started to read about birth. Again, I went to Facebook to search for a doula. I found a name and started messaging her. It turned out she was also planning a birth class series to start not long after that. I met her in person, for something totally unrelated, a few days after I had messaged her, and I knew I wanted to hire her pretty much immediately. That decision was further solidified once we started our class. I could tell how knowledgeable and experienced she was.

Moving forward, I had a typical, healthy pregnancy with a few more aches and pains than the first, but nothing major. I started drinking red raspberry leaf tea at least once a day in my second trimester. I also started going to the chiropractor regularly. I did as many things as I could think of to increase my chances of a successful VBAC. Then I got to my 36-week appointment. The doctor went to check the baby’s position and he was transverse. His head was up under my rib cage and his feet were dangling down my side. At that point, there was still plenty of time for the baby to turn, but it spiked alarms in me just due to the fact that I was a VBAC patient. I wanted him to turn ASAP. I went to Spinning Babies website and read about what to try. I folded up a baby blanket to put behind my back in the car so I would be able to sit with good posture and have my spine in the correct position. I also went to the chiropractor. At my 37-week appointment, baby was head down. I sighed in relief. After that point, I avoided lounging in a chair or reclining. I sat on my birth ball frequently and got in several different positions that were supposed to help with positioning.

I started to get antsy as I approached 39 weeks. I think I knew intuitively that he wouldn’t be coming that week, but I was hopeful because my sister-in-law had gone into spontaneous labor at that gestation just two months earlier. I went in for my 40-week appointment and wasn’t dilated. At this point, labor was all I could think about. Although my doctor was in no hurry to talk about induction, I was still anxious because I didn’t want it to come down to that. He even told me I could go as close to 42 weeks as possible before we did anything to induce. The night of 40 weeks and 1 day, I lost a large portion of my mucous plug. I’ve never been so excited to see bodily fluids in my life. I still didn’t have any other signs, but the next day I could tell that part of the barrier between the baby and the world was gone. That day was mostly uneventful. I woke up on Thursday, 40 weeks 3 days, and had even more mucous. This time it was pink-tinged. I was elated again. I knew this meant something. The morning went by fairly normally. Just before noon, my son and I went for a walk down our street, which we had done several times in the weeks leading up to my due date/labor. About 30 minutes after we got back, I started to have some mild contractions. After I got him put down for a nap, I got into my bed to do the Miles Circuit that my doula had shared with me, as well as take a nap. I had a massage scheduled for that afternoon with a therapist trained in pressure points to induce labor, talk about good timing. By the time I got up from the second position of the circuit, I was having some regular but mild contractions. I asked my mom if she would come and drive me to the massage because they were just strong enough that I didn’t think I should drive myself. After the massage, we picked up dinner. While we waited for our food, the contractions got stronger but I was still able to act normal. Once we made it home, I got on my birth ball and sent a text to my doula to let her know what was going on. I ate quite a bit of pizza, drank a ton of water, and took a shower. All of those things will help pre-labor contractions stop. They didn’t stop. I went on about the evening as normally as I could. Once we got in bed, I was planning to try to get some sleep. I determined after a while that sleep wasn’t happening so I started on the circuit again. Once I got into the second position, the contractions started to get much more intense. I decided to go take a bath to try and take the edge off because I was wanting to labor at home as long as possible. I let my husband know that I was unable to sleep and I was fairly certain we would need to leave somewhat soon. I got in the bathtub and I was having more intense contractions every 4 minutes with more subtle contractions 2 minutes between them. I wasn’t entirely sure how to gauge that pattern. I lost the ability to carry on casual conversation and I was focusing on contractions, so we knew that was about the time to head to the hospital. My husband called our doula and she agreed to meet us outside of labor and delivery. My contractions didn’t change with the change of environment, luckily. I was so afraid to have a “low number” when they checked me. I was a 4, which wasn’t what I hoped for, but I also didn’t have the mental capacity at that time to really think about it. They got me into a room and got my IV line in. I requested no Pitocin or saline at that time, so aside from the fetal monitor, I wasn’t hooked up to anything. It was probably about 4 am by then. A little after 5, they said my doctor had wanted me checked again and I had gone to a 5.5, which I was happy about! After that point, the time frame is a complete haze. My doctor came in fairly early as he had two surgeries scheduled for the day. He checked in with me before the first one and the nurse said I was dilated between a 5 & 6. He said he would just let me labor and would be back to check after the first surgery. I surprised myself and actually did spend most of my labor in bed. One of the more comfortable coping positions I found was sitting on the edge of the bed and melting into my husband’s arm. The toilet and the birthing ball were torture. When the doctor made it back in, I was an 8. I don’t honestly remember even hearing this part. I do remember he said he would “try to make it back from surgery to deliver.” I also recall crying and saying “Why does it hurt so bad?! Make it stop!” Which, if you know anything about labor, you might recognize this lovely stage as transition. Subconsciously, I knew I was in transition, so I just let it all out, plus, one of the birth books I had read said that crying can actually help the body relax because of the release it provides. My doctor’s second surgery was scheduled for 9am. Before he came back, he had called the nurse and wanted to break my water. I really did not want to because I had done that in my first labor and it drastically changed my coping ability, I was already feeling so much intensity, I didn’t want to make more. When he actually came back to my room, he checked me again and I was a 10 and my water broke while he was checking me. At that point, I didn’t have the urge to push. No one tried to make me push either. I actually started dozing off between contractions.  Every now and then I would catch a glimpse at the clock on the computer and was always surprised that it was still so early in the day. Somewhere in my distant mind I thought, “We’re going to have a baby by noon!” Well, time went on and I still had no urge to push. I was still feeling every bit of the intensity with the contractions though and I wanted to try to help get it over with in any way I could so I asked if I could start pushing. My doula let the nurse know and she came in and they set up the squat bar at the end of the bed. During the contractions, I would sit straight up on the edge of the bed and hold the squat bar with my hands and bare down. Between some contractions, I would lay back against the bed. When I felt one coming on again, I would reach out my hands and my husband and my doula would help me sit back up. Eventually, my doctor had come to tell me he was going to have to leave for a surgery at a different hospital that he had that day. Luckily, I was totally unaware of the time, because the pushing routine went on for 4+ hours. The baby was still just not quite as engaged as he needed to be. The nurse who was with us all day and the doctor who came in were great. Ultimately, they starting asking if I would agree to some Pitocin to help make the contractions more effective or else we might need to consider another c-section. I really didn’t want to use Pitocin for a lot of reasons. Once surgery was suggested, I kind of just shut down, I laid back on the bed. I asked my doula what she thought and I ultimately just started saying I wanted surgery. It was so hard to think I was fully dilated and having a baby early in the day and to still be in labor 6 hours later. I was exhausted. I just wanted some relief. The nurse asked if I wanted anything for pain, which I had said no to until this point, and I told her I did. She started morphine in my IV line. After that I was basically on a countdown in my mind to when I would get the spinal tap. I’m sure no sane person would ever think such a thing about major surgery, but there isn’t much that I could compare an unmedicated labor to. You close off everything and enter your own world and remain so vulnerable on the outside. Hearing a c-section being mentioned was like waving a carrot in front of me. Did I want to have one again? No way. But I knew what to expect and I knew that there was a time limit on that. Otherwise, I didn’t know how long we would go on. I don’t think I would have come to that conclusion as easily or quickly had I not already had a previous surgery. Finally, they came to get me for surgery. Once I got in the room, a friend I had grown up with greeted me, she was a surgery tech, which may have been more awkward if I wasn’t sky high on morphine, considering I was stark naked on a table. She may have even been the one who put my catheter in, I have no idea, but it was nice to see a familiar face. We talked throughout the surgery. She actually informed us when they pulled my son out that he had a ton of hair! They let me do a few minutes of skin to skin on the table, a new experience for me, and then took him to the NICU to be checked over. Levi left with him and I kind of dozed off while they were putting me back together. They wheeled me to my recovery room where my doula shortly found me and we talked while the nurse finished up some of my chart. Levi came wheeling Nate in probably 45 minutes later and they brought him to me and we did more skin to skin and I started trying to help him latch. A few family members stuck around for a little while and then headed home. While we were in the hospital, I rested as much as possible. If the baby was asleep in his bassinet, I went to sleep. I had been down this road before and I knew the more I let myself heal, the faster I would heal and the faster I would feel better. Once I got the baby to latch, he was great at nursing. I had some struggles the first time, so this was a welcome relief. I had forgotten how physically difficult the surgery was the first few days afterward. When they took out my catheter and I got to stand up for the first time, my legs barely worked, but I was just happy to be unhooked from almost everything. We got discharged pretty early on the day we got to leave, which was fantastic. I made sure to rest as much as I could within the first days I went home. I had the good fortune to recover from both labor and a c-section, but it wasn’t too bad. Mentally, I was in a completely different place postpartum. I’m sure that is due in large part to resting, but also in being able to more easily accept the end result of my labor.

Although a repeat c-section was the last thing I wanted, I learned that it isn’t only surgical births that can cause trauma. I also learned that it isn’t exclusive to surgery to require extra healing time after birth. Postpartum hormones are not any more difficult as a result of a cesarean, they vary for each person and each situation. Having or choosing a c-section is not taking “the easy way out” and I am not any less of a woman or a mother. I walked away from my first c-section questioning everything and feeling defeated. I walked away from my second labor and c-section feeling victorious for what my body was able to accomplish. I felt loved and supported during the entire process. It was a very healing experience for me, which is something I never dreamed I would feel. Sometimes we make plans, but God has different plans that He uses to teach us with.

 

Post contributed by Brooke McInerney

CBAC Guest Post: Physical Recovery After CBAC

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During February 2018, birth stories and articles featured on ICAN’s blog will be focused on CBACs – Cesarean Birth After a Cesarean. It is a term used to describe a birth that was planned as a VBAC, Vaginal Birth After a Cesarean, but instead resulted in another cesarean.

Physical Recovery After CBAC

By Pamela Vireday

Artwork by Molly Remer, from Brigid’s Grove Etsy Shop

Physical Recovery

Having a CBAC is hard. Usually, it involves recovering from both the rigors of labor and major surgery and of course recovery can be harder after multiple cesareans. In addition, CBAC mothers have a higher incidence of complications like infections and bleeding, and about 2% experience significant morbidity.

It is hard to process emotions when your body is struggling to heal. Many women find it is helpful to focus first on physical recovery after a CBAC. Here are some ideas to help promote physical recovery.

  • Rest as much as you can – The most potent tool for physical healing is rest. If you are doing too much, your body must divert energy from its recovery. It can be hard to get enough rest with a new baby, but with the support of others, you can prioritize as much rest as circumstances allow
  • Ask for help – Don’t be afraid to enlist help from friends, family, your partner, or a post-partum doula. Others should be doing the cooking, cleaning, shopping, and caring for other children; your priority is to feed the baby and sleep as much as possible at first
  • Take pain meds when needed – Don’t neglect pain medication post-partum; you’ve had surgery. Take them a little bit early, before the pain gets ahead of you. Taper them off over time, but don’t be afraid to take them for as long as you need them
  • Set up your home to make recovery easier – Have all the supplies you need right at hand, including a water bottle, the phone, extra diapers and burp cloths, healthy snacks, a footstool, and extra pillows to make positioning more comfortable. Include some entertainment for yourself (a book, the TV remote, music) for those moments when baby just won’t let you get up
  • Eat healthily – Your body needs help to repair tissue and replace lost fluids. Get plenty of iron-rich and vitamin C foods and stay well-hydrated to replenish your blood supply. Adequate protein plus vitamins A and E are important in helping to rebuild tissue. Let others feed you, but keep around plenty of easy snack foods like string cheese, nuts, fresh and dried fruit, and pre-sliced vegetables to make grabbing a bite easier while caring for the baby
  • Don’t go back to your regular schedule too quickly – Many women go back to a normal schedule too soon after a baby is born, and their body lets them know it’s too soon with increased bleeding and pain. Respect what your body is telling you. Take it easy for as long as you can once you get home from the hospital
None of these hints is a magic pill that will wipe away all pain and difficulty. You still will have a surgical recovery, with all the pain and fatigue that entails. Although CBACs are usually harder than primary cesareans, not all are hard. Some have an easy recovery. Others have more difficult recoveries, and a few have very complicated recoveries. Let’s talk more about these.

Dealing with Complications

Although major injuries are quite unusual after CBAC, they do sometimes occur. Women who have experienced major physical trauma (like severe bleeding, significant infection, severe scar tissue, surgical injury to nearby organs, uterine rupture, or hysterectomy) will need significant support as they recover.

If you have experienced complications, it is important to take recovery slowly, since setbacks can easily occur. Get as much rest as possible and seek out complementary therapies like acupuncture, chiropractic, Maya Abdominal Massage, physical therapy, or nutritional counseling to help support your recovery.

Bleeding 

One study found that about 35% of CBAC women experienced significant bleeding, while other studies have found much lower rates. Differing thresholds for defining hemorrhage explains many of these differences, but blood loss is a real risk to be aware of.

If you experienced significant bleeding during your labor or cesarean, have your provider check you for anemia. Being anemic can make healing more difficult, impair milk supply, and prolong fatigue, yet many providers are not proactive about monitoring for this. Taking extra iron, eating iron-rich foods, and taking supplements like Floradix can help your iron levels recover. Women with hypothyroidism may have more trouble with anemia and should probably be extra proactive about this and have additional tests.

If you experienced a major hemorrhage, you should be watched for Sheehan’s Syndrome. This is when part of the pituitary gland dies due to a relative lack of blood supply to the area if a hemorrhage happens during childbirth. This can impact milk supply negatively and eventually lead to secondary thyroid dysfunction and many other distressing symptoms. Sheehan’s Syndrome often doesn’t present fully until years later, sometimes not fully triggered until a successive health crisis (surgery, infection) causes an adrenal crisis. If you experienced a major hemorrhage during your birth, be aware of the symptoms of Sheehan’s Syndrome and be ready to advocate for testing if needed.

Infection

Women who have a cesarean after a VBAC trial of labor have increased rates of infectious morbidity. One study found that 25% of CBAC women experienced chorioamnionitis afterward, although other studies have found lower rates.

If you experienced a major infection after your CBAC, this can involve a long hard healing process. If you are still in the hospital (or are readmitted later), ask about IV antibiotics instead of oral ones, and ask for a consult with a wound or infection specialist.

Some women have had better healing on an infected cesarean wound using a wound vacuum (Negative Pressure Wound Therapy, NPWT), while others have found it painful and not very useful. Basically, it sucks out fluids and infection and draws more blood to the area to improve healing. Bandages are changed about 3x/week, which some women find quite painful; be sure to take your pain meds at least an hour ahead of time. Some people report that using alcohol between the skin and the bandage ahead of time can help remove adhesive tape more easily, and infusing saline first into the sponge inside the wound can ease its removal considerably.

Medical-grade honey is another option (FDA-approved) that has shown some promise in limited studies. It is rarely utilized for cesarean wound issues in first-world countries but can be another option to consider if you do not want the wound vacuum or find it too painful. You might have to strongly advocate for it since it is used more often in non-obstetric wounds and most OBs won’t be familiar with it.

If you are heavy, ask about using weight-based dosing for your antibiotics. Not all antibiotics need weight-based dosing but many do, yet the research shows that the majority of doctors tend to under-dose patients of size, especially those with a very high BMI. Research also shows that “obese” people benefit significantly from longer courses of antibiotics, IV antibiotics instead of just oral ones, and more frequent dosing regimens, so ask your care provider to consider these options too.

Scar Tissue and Nerve Damage

Some women develop significant internal scar tissue (adhesions); the more cesareans you have, the more at risk for adhesions you are. One study found that 46% of women with three or more cesareans had developed “dense” adhesions. These types of adhesions can lead to significant pelvic pain, difficult menstruation, and even bowel obstructions.

Severe cases of adhesions may require additional surgery to break them up. Although this has the risk of creating more adhesions, some women find significant relief with it. Other women are able to address pelvic pain from adhesions through physical therapy, massage, yoga, acupuncture, and Maya Abdominal Massage techniques, which can help loosen and break up the scar tissue.

Some women experience long-term numbness after their cesarean from nerve damage. Although this has little medical significance, it can have significant emotional significance to the woman involved, who may mourn the loss of sensation in the area. Sometimes an “itching” feeling can be felt from the inside, even though scratching on the outside does not help. The loss of sensation in the area around the scar is often cited by cesarean mothers as one of the more distressing results of their cesareans. Again, the techniques above may help loosen scar tissue and restore some degree of nerve function.

Injuries to Nearby Organs

Because the uterus is located in the abdomen, one of the risks of surgical birth is injury to nearby organs like the bladder and bowels. This is not a big risk, but if it happens to you it is a big deal.

One study found an incidence of 0.86% of bladder injuries in women who had a CBAC after a trial of labor. Although this risk is low, it does increase in the face of prior cesareans, especially if dense adhesions are present. It is also increased in the face of induction and augmentation.

Sometimes these injuries occur for other reasons. One CSAC mother I know shares her story of recovery after a severe surgical injury by a doctor who was angry with her for laboring “so long”:

My bladder was severely damaged through a surgical error during my CSAC. The surgical error was made in an O.R. environment of carelessness and anger that I had fought against CSAC and labored for so long (~60 hours).

Things that helped me recover were: Time, innate stubbornness, acupuncture to help my bladder relearn how to contract after surgical reconstruction, EMDR therapy for PTSD, and antidepressants. My recovery was long and so hard and 7 years later I can finally see the progress I’ve made.

Uterine Rupture

Uterine rupture is rare but it does happen occasionally. When it happens, it can be absolutely devastating, emotionally and physically. Although usually, the rupture is able to be dealt with in a way that preserves both the uterus and the baby, in worst case scenarios the uterus, the baby, or both may be lost. The mother can be left with tremendous physical and emotional trauma.

Obviously, the mother will need to watch for many of the complications listed above. Sheehan’s syndrome, in particular, should be monitored for. Once the initial healing is over, the mother may feel better physically with some of the complementary therapies listed above.

There are groups that specialize in support for women who have had a uterine rupture. You can find more information about these groups here and here. Please also look into the resource groups listed below that help women deal with birth trauma.

Hysterectomy

Women who have a CBAC are at increased risk for hysterectomy, although the absolute risk for this is also low. In one study, about 1% of CBAC women had a hysterectomy during labor.

Of course, if you are among that 1%, it feels like a very personal risk. To lose your uterus and all future childbearing potential is a tremendous grief. Even though the hysterectomy may have been necessary, it still can be traumatic to recover from physically. Hormonal changes due to the hysterectomy may intensify both the physical and emotional recovery. Find a sympathetic care provider to help ease you through these changes. A naturopath or a doctor with a more “alternative” mindset may be your best bet. Acupuncture may also help ease these changes.

Unfortunately, there are not a lot of resources available specifically for women who experience hysterectomy after a trial of labor. There are groups that offer support after hysterectomies in general; these groups can be found here and here. If you search on these sites for “hysterectomy during childbirth” you will find other women who have had similar experiences. Here is a link to an article on coping with unexpected hysterectomies.

Women who lose their uterus during childbirth may develop symptoms of Post-Traumatic Stress Disorder (PTSD). There are a number of organizations out there who can help women dealing with PTSD after childbirth, including Solace for Mothers and others listed below.

Conclusion

The good news is that research shows that the rate of significant complications after a CBAC is quite low. Medically speaking, most CBAC mothers will experience a pretty unremarkable recovery.

However, recovering from a cesarean is always a challenge, especially when you already have older children to take care of. Many mothers try to do too much too soon and end up delaying their recovery and exhausting themselves. It’s important to remember that you’ve had major surgery and to let others take care of you as much as possible.

If you experienced a complication after a CBAC, that can make your recovery, both physical and emotional, harder. Even more difficult are the rare but very serious complications like injuries to adjacent organs, uterine rupture, or hysterectomy. If this has happened to you, please be sure to get extra support for your physical healing and personal support for your emotional healing.

Although most women benefit from focusing first on their immediate physical recovery, sometimes the emotions of a CBAC are so overwhelming that they need to be addressed right away in conjunction with the physical healing.

If you feel overwhelmed emotionally, find a way to debrief the birth as soon as you can. This can be with your providers (if they are supportive), with a doula, with a birth-friendly therapist, or with your partner. The important thing is to find someone who is truly supportive and emotionally safe to speak to, not someone who will downplay your emotions or tell you to “just get over it.”

Finding a support group of like-minded women who have been through a similar experience is also vital in dealing with birth trauma. See the resources below for links to birth trauma resources and support groups.

Resources

Emotional Support for CBAC Mothers: 

Emotional Support After a Difficult Birth: 

References 


*Note: The medical community uses the term “failed” in the following abstracts. Do not let their terminology bring you down. We are NOT failures and we did not fail. 

Scifres CM, Rohn A, Odibo A, Stamilio D, Macones GA. Predicting significant maternal morbidity in women attempting vaginal birth after cesarean section.Am J Perinatol 2011 Mar;28(3):181-6. PMID: 20842616

…We set out to identify factors that are predictive of major morbidity in women who attempt VBAC. A nested case-control study was performed within a large retrospective cohort study of women with a history of at least one cesarean. Women who attempted VBAC were identified and those who experienced at least one complication of a composite adverse outcome consisting of uterine rupture, bladder injury, and bowel injury (cases) were compared with those who did not experience one of these adverse outcomes (controls)…Of 25,005 women with a history of previous cesarean, 13,706 (54.9%) attempted VBAC. The composite outcome occurred in 300 (2.1%) women attempting VBAC. Using logistic regression analysis, prior abdominal surgery (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.2 to 2.1), augmented labor (OR 1.78, 95% CI 1.29 to 2.46), and induction of labor (OR 2.03, 95% CI 1.48 to 2.76) were associated with an increased risk of the composite outcome. Prior vaginal delivery (OR 0.39, 95% CI 0.29 to 0.54) was associated with decreased risk for the composite outcome…Women attempting VBAC with a history of abdominal surgery or those who undergo augmentation or induction of labor are at an increased risk for major maternal morbidity, and women with a prior vaginal delivery have a decreased risk of major morbidity. The multivariable model developed cannot accurately predict major maternal morbidity.

Obstet Gynecol. 2006 Jul;108(1):21-6. Maternal complications associated with multiple cesarean deliveries. Nisenblat V1, Barak S, Griness OB, Degani S, Ohel G, Gonen R. PMID: 16816051

…The records of women who underwent two or more planned cesarean deliveries between 2000 and 2005 were reviewed. We compared maternal complications occurring in 277 women after three or more cesarean deliveries (multiple-cesarean group) with those occurring in 491 women after second cesarean delivery (second-cesarean group). RESULTS: Excessive blood loss (7.9% versus 3.3%; P < .005), difficult delivery of the neonate (5.1% versus 0.2%; P < .001), and dense adhesions (46.1% versus 25.6%; P < .001) were significantly more common in the multiple-cesarean group. Placenta accreta (1.4%) and hysterectomy (1.1%) were more common, but not significantly so, in the multiple-cesarean group. The proportion of women having any major complication was higher in the multiple-cesarean group, 8.7% versus 4.3% (P = .013), and increased with the delivery index number: 4.3%, 7.5%, and 12.5% for second, third, and fourth or more cesarean delivery, respectively (P for trend = .004). CONCLUSION: Multiple cesarean deliveries are associated with more difficult surgery and increased blood loss compared with a second planned cesarean delivery. The risk of major complications increases with cesarean delivery number.

Am J Obstet Gynecol. 2007 Jun;196(6):583.e1-5; discussion 583.e5. Perinatal outcomes after successful and failed trials of labor after cesarean delivery. El-Sayed YY1, Watkins MM, Fix M, Druzin ML, Pullen KM, Caughey AB. PMID: 17547905

…Matched maternal and neonatal data from 1993-1999 in women with singleton term pregnancies with prior cesarean undergoing trial of labor were reviewed. Women with uterine rupture were excluded. Maternal and neonatal outcomes were analyzed for successful and failed trials. Predictors of success and failure were examined. RESULTS: 1284 women and their neonates were available for analysis. 1094 (85.2%) had a vaginal birth and 190 (14.8%) underwent repeat cesarean. Failed trials of labor were associated with higher incidence of choriamnionitis (25.8% vs. 5.5%, P<.001), postpartum hemorrhage (35.8% vs. 15.8%, P<.001), hysterectomy (1% vs. 0%, P=.022), neonatal jaundice (17.4% vs.10.2%, P=.004) and composite major neonatal morbidities (6.3% vs. 2.8%, P=.014). CONCLUSION: Failed trial of labor in women at term with prior cesarean is associated with increased maternal and neonatal morbidities.

Permission to repost given by Pamela Vireday. Read more on her blog.

CBAC Guest Post: Charlie’s Birth Story

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During February 2018, birth stories and articles featured on ICAN’s blog will be focused on CBACs – Cesarean Birth After a Cesarean. It is a term used to describe a birth that was planned as a VBAC, Vaginal Birth After a Cesarean, but instead resulted in another cesarean.

Charlie’s Birth Story

February 8, 2016

It’s taken me six months to blog the story of Charlie’s birth. I don’t know why, exactly. Partially, I wondered if it would be interesting to a reader since she was delivered by cesarean. As someone who loves a good birth story and has worked with birth professionally for so long, I enjoy a good birth story about hours of primal labor that end in a magical, natural delivery. There are usually beautiful, raw, black and white photos attached and I almost always cry. I really wanted to achieve a VBAC (vaginal birth after cesarean) this time as I had romanticized that experience in my mind so much. Grayson was born six years ago via surgical birth and my memories of it seem very….surgical. I didn’t know the OB that delivered him, I was terrified of surgery, and the birth itself was quiet, sterile and cold. I had less happiness and support in my life at the time and I was a lot less secure in myself as a person and most certainly terrified to become a mother. I wanted Charlie’s birth to be 100% different. I mistakenly thought that it meant I needed to have an entirely different birth to achieve the experience I wanted. I was wrong.

In early August I found myself at the end of a long, hot, complicated pregnancy. From awful morning sickness and migraines to debilitating joint problems, the pregnancy won the award of “most miserable”. (That’s saying a lot since Grayson’s pregnancy was no walk in the park.) I had already been in the hospital a few times for preterm contractions, a car accident, and a “rule out pneumonia” visit that was determined to be a terrible virus. I was sick of being pregnant. On top of that, I worked in Labor and Delivery at the hospital where I would be delivering, and I was beginning to resent all the strangers that were coming in and leaving with their babies.

On the morning of August 6th, I woke up with my regular prodromal contractions. I had been contracting on and off for ten weeks at least. At 38 weeks they wouldn’t be stopped with medication, so I would just need to endure them and hope they would turn into labor. I had an OB appointment that morning at 11:00. At the appointment it was noted that my blood pressure was higher than normal, I was having strong contractions every two minutes, but my cervix hadn’t changed anymore. My wonderful OB monitored my contractions for about an hour. Based on the blood pressure readings and the regularity of my contractions, she recommended we schedule a repeat c-section for that evenings and felt it was the safest option. I agreed with her advice and she set it up with Labor and Delivery. By the time I left the office it was about 2:00.

Wait. What? No VBAC? I’m having the baby today? I’m 38 weeks. Is that too early? I came to my appointment alone. Grayson is at school. Tyler. Tyler is at work. I need to get gas. I should probably put on some makeup. I look awful today. Good thing I shaved my legs and cleaned the house this morning. I’m scared. I’m excited.

I called my sister-in-law to start the phone call chain. She lives three hours away and got in her car immediately according to the plan. It was important to me that she be there and it was prearranged that she drop everything and drive. I drove to the hospital, sat in my car for a few minutes and threw on some mascara and concealer, because, well, photos. I took a deep breath and went inside to have a baby.

It was so odd to walk in as a patient and not an employee. My sweet coworkers had decorated my room with balloons and streamers and greeted me with excitement and cheerful anticipation. I was already absorbing all the positive energy around me. Tyler soon arrived and we made eye contact and shared a “HOLY CRAP WE ARE HAVING A BABY TODAY” look.

I asked for my headphones. When planning a VBAC, I had so many ideas of ways to relax and personal things I wanted to help me labor. One thing I wanted during labor was to listen to Oceans by Hillsong United. It’s my favorite song. It’s calming, encouraging, and grounding for me. I put in my headphones and listened to the song. I centered in the moment, reconciled the fact that my plans had changed, and prayed for courage and protection for baby and myself.

Fast forward to epidural time. You should know that I hate surprises and I strongly dislike anything I can’t predict. The Anesthesia group came in to do the procedure and I was a total wimp about it. Apparently, I stayed still and calm on the outside, but the tears were falling and I was TERRIFIED the entire time. It’s normal for your blood pressure to drop some and to feel overwhelmingly faint for a minute, and I knew that, but I still had a total panic attack when that sensation hit me. Not only that, but I had all sorts of other weird sensations from having a needle in my spine. Tyler held my hands and maintained his role as my rock the entire time.

Epidural is in. I’m appropriately numb. It’s time to roll back to the OR. Full panic ensues.

I think I was still anxious from the epidural experience, add that to the overwhelming anxiety about the fact that I was about to have this baby earth side, finally, after months and months of a hellish pregnancy, and I am a total hypochondriac. It was a lot. It was almost too much.

They rolled me out and all I saw was my mother-in-law. She is my MIL by a technicality, but, she is my mother, emotionally (and has been for many years before she was a real part of my family). I whimpered out a little “I’m scared” through clenched teeth, and she gave me the reassuring maternal look, squeezed my hand as I rolled past, and then everyone was behind me. Even Tyler.

But I wasn’t alone. My coworkers (turned friends) surrounded me. The whole OR was full of familiar faces and voices laughing, cheering me on, talking, and even singing at times… (Don’t ask.) All of a sudden I was ok and I knew this was going to be the birth experience I wanted so much and never had. Everyone in that OR knew me, knew my wishes, knew my past, and prioritized my goals for MY birth and for the baby I hadn’t met yet.

Tyler came in once I was sufficiently prepped and ready. I remember asking everyone to keep talking and laughing so that I wouldn’t get nervous. (Let’s be honest, I work in Obstetrics and had some heightened fears based on some of the things I have seen occupationally.) They all worked to keep the room light and cheery while I made everyone promise I wasn’t dying or bleeding out. Tyler was ready with the phone to take photos and I was ready to meet this tiny person.

“Are you ready to see her?!” “She’s almost here!” “Get ready!”

6:24 pm. Cries. Sweet, strong cries. I heard the most glorious sound in the world.

My tears flowed. I looked up at my husband and his did too.

My doctor said “Here she is!” and held her over the drape. My arms were not strapped down per my request, and I was able to reach up and hold grab her arms. My sweet baby girl was finally here! In that moment I felt so complete and euphoric.

I had been granted “permission” to take her immediately after delivery for skin to skin and breastfeeding in the OR, which isn’t common yet, and I was super stoked about doing it. However, Charlie aspirated a little fluid and needed some help clearing her lungs, so she was taken to the nursery for some extra suctioning after they brought her back over for some more kisses. Tyler went with her of course and took a million photos.

About an hour after she was born, they brought Charlie to me for skin to skin. She was still on a monitor since her pulse and oxygen levels hadn’t fully regulated. Almost as soon as I took her, everything normalized.

I just remember looking back and forth at her and Tyler and feeling more love than I ever thought possible. Tyler would tell me over and over that he has never loved me more, or I have never been more beautiful and cry happy tears. We were so in love with our daughter, and each other, and our lives, and it was perfect.

Now, Charlie is six months old and we have had plenty of sleepless nights, drank gallons of coffee, walked miles around the house holding her, sang a million lullabies, changed countless diapers and made priceless memories as a family of four. We all get to know each other a little better every day and our love for each other continues to multiply.

My birth experience was everything I could have dreamed of and more. Her method of arrival was irrelevant. It was a beautiful birth day for a beautiful little person, and I hope I never forget a second of it.

Permission to repost given by Katie Crenshaw. Read more on her blog.

CBAC Guest Post: Cesarean Birth After Cesarean, 18 Years Later

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During February 2018, birth stories and articles featured on ICAN’s blog will be focused on CBACs – Cesarean Birth After a Cesarean. It is a term used to describe a birth that was planned as a VBAC, Vaginal Birth After a Cesarean, but instead resulted in another cesarean.

Cesarean Birth After Cesarean, 18 Years Later

By Pamela Vireday

Image from Wikimedia Commons, here

My CBAC Story

Eighteen years ago, my second child was born. He was born by repeat cesarean after a long, hard “trial of labor” which included 5 hours of pushing with no progress because he was big and posterior with an upright (“military”) head position.

I’ve second-guessed that birth for many years. It’s possible that if we’d pushed even longer, his head would have molded enough to fit through my pelvis and turn anterior on the perineum, as many posterior babies do. However, at that point, I was absolutely exhausted, in a lot of pain, and was worried about the wisdom of continuing when things had gone so long without progress. I knew a non-progressing labor was a risk factor for rupture, plus my baby had experienced some issues with his heart rate. They resolved, but I didn’t want to go into a repeat cesarean in true emergency mode because of a rupture or fetal distress, and emotionally I needed to make sure that I didn’t have an anesthesia failure like I did with my first cesarean.

At that point, I just had a strong sense of Inner Knowing that it was time to be prudent and stop before things became a real emergency. I believe I made the right decision, but it was hard to communicate that to my husband and support team. My doula treated me like I had wimped out and thrown in the towel too easily. I never heard from her again after the cesarean. It was clear she viewed me as a failure.

I dreaded having to go back to my VBAC groups and tell them I’d had a CBAC, but I gritted my teeth and did it anyway. I got some sympathetic responses, but mostly I got a lot of silence or tepid responses that felt judgmental. No one knew how to reply to someone who hadn’t gotten their VBAC.

Over the years, there was a lot of armchair quarterbacking about my decisions. People meant well, but I was left feeling pretty unsupported. And I didn’t feel I could really emotionally process the birth fully in birth spaces because I was afraid of discouraging new mothers or those planning their VBACs. No one wants to hear about when VBAC doesn’t work out.

Eventually, I was able to access some resources that helped me emotionally process my first two births. It took a lot of hard, emotionally grueling work, but in time I came to peace with those births, and I did have two VBACs afterward.

In some ways, the CBAC was healing from my highly traumatic first cesarean, but in other ways, it would always remain hard, even though I felt like it was a prudent and wise call under the circumstances. My consolation was my precious child, but his birth would always remain bittersweet to me in some ways, especially because of the initial lack of support. And that led me to try to improve support for other women who had difficult or traumatic births, especially CBAC mothers.

Expanding CBAC Support

If about 75% of labors after cesarean end up with a VBAC, that means that about 25% of these labors end with another cesarean. Where is the support for women who have an undesired second cesarean? Where is the acknowledgment of all the work they put in towards a VBAC, the hours of labor, the pain, the worry? Does all that preparation and work not count if you don’t end up with a VBAC?

In time, I began to realize there was a vacuum of support for the mothers who didn’t VBAC. It wasn’t just about my own experience anymore, but also about other moms. How could we make it so that all mothers felt supported, regardless of outcome? Shouldn’t we offer emotional support after any cesarean, whether it’s your first or another one?

I wasn’t the only one, of course. A number of us shared this experience of another unwanted cesarean, including people in the leadership of ICAN, and we began to talk about how to offer better support. One of the first things we did was ditch the terms used in the medical literature, terms like “Failed VBAC” or “Failed Trial of Labor After Cesarean.” We felt this was too judgmental and insensitive. We were not “failures,” we did not fail, and we should not have been on trial.

We created the term Cesarean Birth After Cesarean(CBAC) as a more mother-friendly alternative. It refers to a cesarean that occurs when the mother really wanted and worked for a VBAC but didn’t get one. These women had different emotional needs than those who wanted a repeat cesarean, and terminology needed to reflect that difference. So we used “CBAC” to differentiate another unwanted cesarean from Elective Repeat Cesarean Section (ERCS), where women truly wanted another cesarean and voluntarily chose it. Neither one is good or bad; they are simply different experiences.

There are many shades of CBAC. Most of the time, it refers to someone who labored and ended with another cesarean, but it can also refer to a cesarean performed before labor for medical reasons, because the mother had no choice, or because the mother was coerced or scared into a repeat cesarean. Some women prefer “CSAC” (Cesarean Surgery After Cesarean) because they consider the term “birth” too emotionally loaded. Women get to choose the term that seems right for their own experience. The important thing is to acknowledge and validate the range of feelings that women have over this experience.

Of course, all CBAC mothers are not alike. Having the shared experience of a CBAC doesn’t mean other details of our situations are similar. Each CBAC is unique, and each carries its own particular color and resonance of pain.

Some had disappointing or traumatic experiences, and some didn’t. Some felt very betrayed by their caregivers, while others had very supportive caregivers. Some felt they had a “prudent CBAC,” where although it was difficult, a repeat cesarean felt like the right choice under the circumstances. Some had an “empowered CBAC,” where even though there were disappointment and sadness, there was powerful learning and healing too.

Some CBAC mothers go on to have a VBAC eventually, while others never do. Some have multiple CBACs, each with their own emotional resonance. Some have a VBAC and then a CBAC, which has its own particular pain. A few have had the bitter experience of having lasting physical and emotional damage from their CBAC, including uterine rupture, hysterectomy, and damage to or loss of their baby. As always, each person’s experience is different and unique, and each CBAC mother needs safe space to process all the varying feelings about those experiences. But this can be difficult to do within regular birth forums.

Some people don’t think there needs to be any separate support for CBAC mothers (“a cesarean is a cesarean”), and to this day, many of us with CBACs still have our decisions questioned and second-guessed in birth forums. Although many doubters have come around to offer more support, CBAC still remains a topic of friction at times within the birth community. This needs to change.

New CBAC Resources

Over the years, we have tried to expand resources for CBAC mothers. We have offered several CBAC sessions at ICAN conferences and at local chapter meetings, and until recently we had a Yahoo group for online support.

In 2011, I offered a CBAC workshop at the St. Louis ICAN conference. The session was derived from discussions by mothers on the Yahoo CBAC Support Group, and many graciously consented to share their thoughts and quotes to help others. At that session, we brainstormed ways to offer further support for CBAC moms.

One of the main ideas was to have an online website devoted to CBAC support and information. So Melek Speros, Catherine Kowalik Harper, and I created a CBAC Support website, based on my material from the 2011 workshop and suggestions I got there. On this site, we share CBAC research, websites where CBAC moms can go for emotional healing, information on the unique emotional needs of CBAC mothers, suggestions for processing a CBAC, CBAC birth stories, inspirational quotes for healing, and suggestions for birth professionals to help them better support CBAC mothers.

ICAN has also created a new online support group via a Facebook page for CBAC mothers. This is a closed group; you have to be a CBAC mother to join. It offers intensive, personal support for those dealing with the aftermath of a CBAC.

ICAN is also about to publish a brand-new brochure on CBAC. It is intended for ICAN leaders and other birth professionals who may encounter a woman who has recently had a CBAC and is in need of extra support. We encourage birth professionals to include this brochure in a resource packet that they can send to women shortly after a CBAC so these mothers realize that they are not alone, that others have walked the CBAC trail and survived, and that there are resources for further support if they want it.

In future years, I hope we can create even more ways to help support CBAC mothers. If you have other suggestions for how we can do that, please add them in the comments section.

Final Thoughts

Eighteen years after my own CBAC, it remains a potent memory. My sweet little boy is a strong and independent man now, flying off on new adventures, but his birth is still a touchstone for many different emotions. Although I did eventually go on to have 2 VBACs after the CBAC, those experiences didn’t “fix” the CBAC or make it go away. They simply are different entities – not better or worse, just different. Although there are things I still mourn about my CBAC, I have learned to honor all my birth experiences, difficult or easy, because they are a big part of the person I am today.

The lessons I learned from my CBAC remain powerful and still resonate in my life. My CBAC helped me to be more compassionate about other people’s births, to recognize that sometimes there are just things that are beyond our control in the moment. It helped me to realize that sometimes birth is more about the willingness to heal and change; that birth is more about the journey and less about the destination.

In time I learned to honor both the disappointment and the joy in all my births, to remember that what counts most is the parenting we do throughout life rather than how we birth, but also that how we feel about our births counts, even years later. Our deep love for our children is a different and separate thing from our emotions about their births, and while these things intertwine, one does not take away from the other. We can honor the disappointment and mourn the difficulty of a birth while still celebrating and fiercely loving the child that came from that birth.

I found that out of my suffering came the ability to transform pain into advocacy. I found my voice in a new and potent way, and I have endeavored to channel the power of that voice to create change, as well as to create and hold safe space for other women and their unique experiences.

A CBAC is never an easy thing. The pain and disappointment of it stay with you forever, but like other grief, it does ease some and you find a way to live with it, just as you find a way to live with other disappointments in your life. You can celebrate certain aspects of it, you can mourn parts of it, you can still be upset that it occurred, but you honor what it has brought to your life, both difficult and wonderful.

You also learn that in time, out of the pain and conflicting emotions that accompany a difficult experience, there can also come great growth and power to create change for yourself and others. Just give yourself the gift of time and space for that healing. It will come.

 

Permission to repost given by Pamela Vireday. Read more on her blog.

 

CBAC Guest Post: Supporting Women When VBAC Doesn’t Happen – Part Three: Supporting the Mothers

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During February 2018, birth stories and articles featured on ICAN’s blog will be focused on CBACs – Cesarean Birth After a Cesarean. It is a term used to describe a birth that was planned as a VBAC, Vaginal Birth After a Cesarean, but instead resulted in another cesarean.

By Pamela Vireday

“Remember, no effort that we make to attain something beautiful is ever lost.” – Helen Keller

In the first post of our series – Supporting Women When a VBAC Doesn’t Happen – Part One: A Unique Grief, we discussed how women who want and work for a VBAC but end up with a cesarean have a unique grief that is different from a primary cesarean or an elective repeat cesarean. Many women who have experienced a CBAC say they felt unsupported and isolated. They had nowhere to tell their stories, nowhere to process their anger and got little sympathy from those around them.

In the second post – Supporting Women When a VBAC Doesn’t Happen – Part Two: The Forgotten Mothers, we examined what research there is on CBAC mothers and found limited wisdom to guide us. In the absence of research on how best to help CBAC mothers, we must rely on the words and experiences of CBAC mothers to tell us what they need.

In the final part of our series today, we suggest concrete ways that birth professionals can support CBAC mothers, based on suggestions made by CBAC mothers themselves. Keep in mind that each story and woman is unique, and the needs of one may be different than the needs of another. The best thing to do is to follow the lead of the CBAC mother; she will tell you in word and deed how best to support her.

Create a Safe Space for the Birth Story

One of the most important things that birth professionals can do to help CBAC mothers is to give them a safe space to tell their stories ― their full stories.

CBAC mothers often edit their stories for others, leaving out their disappointment or scary details because people only want to hear the happy parts. When they try to tell the full story, they may hear, “Just get over it already” or “Oh, we’re not going to talk about that again, are we?” CBAC mothers also often self-edit their stories in order not to discourage or scare other expectant mothers. But an untold story is one that weighs heavy on the heart.

Be the safe person to whom the full birth story can be told. Be truly present while listening. Don’t armchair-quarterback her story; suspend your judgment, put aside your own birth agendas, and focus only on supporting this woman, right now, in this situation. Eliminate distractions, use attentive body language, and really focus on the woman so that she truly feels like she is being heard.

Realize that she may need to tell the story multiple times; each time she tells it, she processes it on a new and different level. Ask her, “What do you need from me right now?” so she can tell you if she wants something more than just listening. If possible, check in with the woman’s partner, who may also need help processing or understanding why the mother is still coming to terms with her experience.

“Listen. Listen. And don’t contradict. Just listen. Don’t compare. Just listen. And don’t try to make me feel better. Just listen.” – Kristina R.

Use Creative Support Techniques

Once the mother is ready to start processing the birth story further, use reflective listening techniques. Listen to what she says, seek to understand what seems most important to her, and paraphrase back to see if you understood her point. Don’t make assumptions about how she is feeling or add judgments. Ask open-ended follow-up questions that invite her to explore her feelings if she is ready. Give her the time and space to come to her own conclusions about her experience.

Many women find that journaling, making art, singing, writing poetry, and participating in rituals is helpful in processing their emotions. This can be particularly helpful for those who get stuck in a negative feedback loop or who need to process significant trauma. Don’t be afraid to refer to a good birth-supportive therapist in your area if needed.

Validate the Mother

CBAC mothers need to have their experiences and feelings validated. Mothers need to be reminded that their hard work and accomplishments during birth are still valid, however, the baby was born. Acknowledge the amazing sacrifice she made in giving up her own dreams and bodily integrity for her baby.

“CBAC women need validation. They need encouragement that every birth can be different. Above all, they need to be appreciated for the work they did both before and during the experience, the sacrifices made for their babies, and the special place inside themselves that now carries yet another scar.” – Teresa Stire

“Effort does not always equal outcome. Give yourself credit for that effort, and don’t boil it all down to the moment of birth alone.” -Melek Speros

Encourage Bonding

Bonding can be especially difficult after a physically or emotionally traumatic birth. Others may have stepped in to care for their babies, which can leave some mothers feeling incompetent or disconnected.

Start by encouraging more time with the baby. Promote as much skin-to-skin contact as possible; this helps produce more oxytocin and may help breastfeeding too. Some women find bathing or napping with babies to be very healing.

It can be helpful to compartmentalize grief behind an emotional door so women can focus on their baby’s immediate needs, on their older children, and on their own physical needs. However, it’s important that women schedule time periodically to take out the grief, actively work through it, and then put it away. Otherwise, grief may intrude on the bonding process.

Give the Mother Support Resources

Create a CBAC Resource Packet that you can email or hand out as needed. Include a list of CBAC support sites, CBAC brochures, and names of local postpartum doulas or birth therapists. Edit it to each woman’s unique situation.

The International Cesarean Awareness Network (ICAN) has a new brochure about CBAC, which will be available soon in its store, as well as a website dedicated specifically to CBAC, including an archive of CBAC stories. In addition, there is a closed ICAN support group on Facebook just for CBAC mothers.

Although not all CBAC mothers experience post-traumatic stress symptoms, having birth trauma resources in the CBAC Resource Packet puts the ball in the mother’s court and lets her decide the emotional ramifications of her experience. It also gives her concrete options for reaching out for further support, possibly even long after your working relationship with her is over.

Help Her Connect with Other CBAC Mothers

CBAC moms are their own best mentors. This may be the only place CBAC women find others who truly “get” what they are going through.

The unique feelings around CBACs may mean that birth groups, especially those centering on VBACs, could be uncomfortable for a while. Many CBAC mothers feel intensely jealous when hearing other women’s easy birth stories. They may need to insulate themselves for a bit. Taking a break from birth-related groups for a while can be healthy and self-protective; she can return when she is ready.

Of course, not every support resource is perfect. Encourage CBAC mothers to be careful about whom they seek support from. Many well-meaning people say hurtful things like, “Just be grateful you got a healthy baby,” or “You’re just lucky you didn’t die!” CBAC mothers need to find support that will not inadvertently trigger or hurt them more.

Acknowledge Unique Circumstances

Each CBAC is unique, and each may carry its own particular color of pain.

Some women had CBACs because their providers suddenly withdrew support for VBAC at the end of pregnancy or during labor. Some faced so many interventions and conditions during their labors that a CBAC seemed almost inevitable. Some experienced mistreatment and abuse during their experience.

On the other hand, some women had very supportive providers but still ended with a CBAC. Others felt they had a “prudent CBAC,” a difficult but sensible choice because of fetal distress, poor fetal position, rising blood pressure, or other complications. Some had an “empowered CBAC,” where there were powerful learning and healing to help balance the disappointment.

Some women have multiple CBACs, each with their own emotional resonance. Some have a VBAC and then a CBAC, which has its own particular pain. A few have had the bitter experience of having lasting physical and emotional damage from their CBAC, including uterine rupture, hysterectomy, or loss of their baby.

As always, each person’s experience is different, and each CBAC mother needs their unique experiences honored.

“Try on” a CBAC

“Trying on” a CBAC can help birth professionals have a deeper empathy for the unique grief of a CBAC mother.

Consider what it might feel like to have a CBAC. Let yourself feel what it might be like to hope and dream for a VBAC and then not have one, to have to tell everyone afterwards that you didn’t VBAC after all, to listen to the naysayers who believe your body really is broken and who tell you that you should have just scheduled a cesarean section, to listen to other women’s easy birth stories and feel envious all the time.

Walking in someone else’s shoes for a while gives people a better appreciation for the difficulties and the bittersweet feelings surrounding disappointing life events. More empathy for CBAC mothers is definitely needed in the birth community.

Contact the Mother Periodically to Check-In

CBAC is a bit of an emotional rollercoaster and feelings will change over time. The way the mother feels immediately after a CBAC will probably not be the same as a few months or a year later. Check in with her periodically to see how she is feeling about everything and whether there is any way you can support her further. This is especially important for CBAC mothers who have experienced a major trauma.

It’s not unusual for CBAC mothers to experience emotional upset around the six-month mark, on the child’s first birthday, or even later. A quick check-in can affirm that someone remembers and cares about what she is going through.

Discuss Future Pregnancies

Another common point of emotional crisis for CBAC mothers is when the mother considers having another child. At that time she revisits her fear and trauma from past births, decides whether to have more children and if so, may be torn over whether to choose a repeat cesarean or another VBAC trial of labor (TOL).

Although conventional medical wisdom holds that once a woman has had a CBAC, she has shown she cannot birth vaginally, the reality is that a number of CBAC women go on to have a VBAC in future pregnancies, and the American College of Obstetricians and Gynecologists (ACOG) is supportive of VBAC after two cesareans. Women who choose a TOL in this situation may need particularly strong emotional support as they work through their fears and concerns from both a primary cesarean and a CBAC.

However, it’s also important to remember that sometimes a VBAC is truly medically contraindicated, the woman is done having children, or does not wish another TOL. Although VBAC is no longer an option, that doesn’t mean these women are at peace with past or future CBACs. They may still need support too. Little research has been done on how to support this group as they integrate their experiences into their lives. In particular, information is needed on how to support women who experienced significant emotional trauma during birth (Beck and Watson, 2010).

Believe That Healing Can Be Had

Life gives us all disappointments and sometimes these remain bittersweet forever. As with other griefs, you never truly “heal” from a CBAC; the disappointment and loss of that birth are always there, and it never goes away. However, birth professionals need to communicate that – with time and distance – women often come to some sort of peace with the experience.

If given the chance to process their feelings thoroughly, women eventually have enough distance from it to not grieve as sharply, to find lessons or growth in the experience, and to be able to integrate the disappointment of it into their lives.

Some transform the power of the CBAC experience into advocacy, becoming healthcare workers themselves or advocates in birth-related fields. Others practice micro-advocacy by informally helping birthing women they encounter in their personal lives.

Women don’t have to ever be grateful for their CBACs, but in time they can recognize that good things can spring from difficult things, and that great trauma can lead to great growth. The process is not quick or facile, but it can happen. And birth professionals can be a vitally important part of that process.

“My joy [in my births] has gradually returned. I am learning now to honor my experiences…We are not failures, we are no less brave than the women who accomplish the VBAC goal. I keep reminding myself that I will never climb Mount Everest, either, and will probably not accomplish some of the other things I think I want in my life. Maybe this missed childbirth opportunity is just that ─ another missed opportunity ─ and maybe we can find some other accomplishments/ life experiences to compensate. Maybe.” -K

“Today, 12.5 years after my first CBAC, I can honestly say how much growing and learning came from it and for that I am grateful.” -Teresa Stire

“My CBAC made me the compassionate advocate I am today.” -Melek Speros

Resources for CBAC Mothers

Here are a few select resources that may be helpful to CBAC mothers. If you know of more, please add them in the comments section.

CBAC Resources

CBAC Support Groups

General Birth Trauma Support Organizations

Articles on CBAC Recovery

Birth Trauma Articles

Books

References

Beck CT, Watson S. Subsequent childbirth after a previous traumatic birth. Nurs Res 2010 Jul-Aug;59(4):241-9. PMID: 20585221

Permission to repost given by Pamela Vireday. Read more on her blog.

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