By Pamela Vireday

'CBAC mothers have powerful lessons to teach, if you are willing and able to hear us.' - Melek Speros

We continue our current series on Cesarean Birth after Cesarean, written by Pamela Vireday, who is an occasional contributor to Science & Sensibility. In this series, Pamela examines the topic of women who experience a Cesarean Birth after a Cesarean. This is when families are planning for a vaginal birth after a prior cesarean, but the birth does not go as planned. The experiences of women who have a CBAC are often negated and their emotional and physical well-being given short-shrift by both professionals and their social community of friends and family. The research on this topic is slim and begs for exploration by qualified investigators. Last week, Pamela discussed the unique grief that CBAC women may experience. Today, Pamela examines the limited research available and part three (on Thursday) will provide information on how to support CBAC women in the absence of published research. We will also conclude the series with a useful resource list to share with the families you may work with who find themselves in this situation. You can also read a companion piece of Pamela's own personal story, 'Cesarean Birth after Cesarean, 18 Years Later' on her own website.- Sharon Muza, Community Manager, Science & Sensibility.

In Part One of the series - Supporting Women When a VBAC Doesn't Happen, we discussed how women who work for a VBAC but end up with a cesarean have a unique grief that is different from that of a mother who has a primary cesarean or who chooses to have a repeat cesarean.

There is a pressing need for better support for CBAC mothers, but often birth professionals and family members have no idea how to go about offering this support. Does research have any insight on improving CBAC support to these women?

CBAC Research

Unfortunately, there has been very little research done on CBACs. Most VBAC-related research deals with VBAC rates, complications, cost-effectiveness, or the woman's decision-making process. Women who choose VBAC but don't end up with one are largely ignored in academic studies.

However, there are a few studies with implications for the CBAC mother, including those that address physical recovery and a few that address emotional recovery.

Physical Recovery

Most CBAC research focuses on physical morbidity, which can certainly have an influence on how a woman feels after a CBAC.

Although most CBAC mothers recover just fine, women who have a trial of labor cesarean do have higher rates of infectious morbidity, postpartum hemorrhage, hysterectomy, blood transfusions, and neonatal morbidities (El-Sayed 2007, Hibbard 2001, Durnwald and Mercer 2004).

One study found that 2.1% of women with a trial of labor experienced major maternal morbidity (Scifres 2011). How much more complicated is emotional recovery if the mother is also dealing with the aftermath of a serious infection, a sick baby, surgical injuries to nearby organs, anemia from a major hemorrhage, or heaven forbid, a uterine rupture, hysterectomy, or stillbirth?

The lesson here is that some mothers will be dealing not only with the disappointment of CBAC, but also with significant physical fallout afterwards. This can greatly complicate emotional processing, but sadly, these are often the mothers who receive the least emotional support afterwards. It's as if their complications have made them toxic to the birth community because their experiences represent the rare worst-case scenarios no one wants to acknowledge.

The first step in helping a CBAC mother is to help her focus on her physical recovery, especially if there have been complications, even as you help her explore her emotions around the CBAC.

Emotional Recovery

There is only a small amount of research available on the emotional impact of CBACs. How do women feel about the CBAC experience? Do they regret having tried for a VBAC? Would they want to try again? What can be done to help women process the experience emotionally?

One study surveyed CBAC mothers.(Chigbu 2007) Not surprisingly, they found CBAC mothers, particularly those with no previous vaginal birth experience, often had feelings of:

• Dashed expectations
• Inadequacy as a mother
• Frustration of experiencing the pain of both labor and surgery

Some women experience long-lasting trauma from birth. Although many people have written about Post-Traumatic Stress in childbirth, it is unclear from the research what the most effective approach is for dealing with PTSD in birth.

Some research indicates that Eye Movement Desensitization and Reprocessing treatment (EMDR) can be helpful (Sandström 2008, Stramrood 2012). However, research trials have been extremely small and limited in the childbirth field.

A recent Cochrane review (Bastos, 2015) concluded that there was little high-quality evidence for or against using debriefing interventions to prevent psychological trauma after childbirth. Still, many women find counseling helpful after a traumatic birth, and EMDR helpful if flashbacks are frequent or intrusive.

From anecdotal evidence, anger is a common theme among some CBAC mothers. They may be furious with care providers who let them down, with the seemingly random nature of birth fortunes, or with their bodies for 'not working right':

It was very important to me that someone recognize and validate my anger. I was SO FREAKING ANGRY!!!!! And I needed to hear, 'You have every right to your anger!' - Jer

This kind of anger is uncomfortable for birth professionals to hear. We want women to have happy endings and just be enthralled with their babies. But denying anger doesn't make it go away; it just makes it burrow down more destructively. Helping a mother speak her anger without taking it personally vents it and takes away some of its toxicity so that healing can start to take place.

Many CBAC mothers deal with a strong sense of shame and failure, of feeling broken. Health care providers make this worse when they blame women by telling them their pelvises are 'too narrow,' their cervix is 'horrible,' or that they have 'too much soft tissue' around their vaginas. Health care providers must be careful in issuing judgments such as these because many women told these things have gone on to have vaginal births. More often it's a case of 'this baby, this birth, this time' didn't work, not that the woman's body is defective.

Some CBAC mothers obsess over the 'what-ifs' of birth decisions or spend a lot of time analyzing what went wrong. This can be a way of asserting a sense of control over what feels uncontrollable. Analysis can sometimes be useful, but it also can lead to a never-ending rabbit hole of self-blame. Sometimes we just don't know why birth turns out the way it does, and it can help when health care providers and birth professionals share this.

'Pregnancy/childbirth is one of the most unfair endeavors I've encountered. Realizing that has set me free in a way. If something as commonplace as childbirth has so many variations even despite what is actively chosen/done, then how can anything else in our lives go the way we want if we just. work. hard. enough. Life isn't fair. Childbirth, the ease for some, the struggle for others, just isn't fair. And that's been liberating for me.' - L

Common Recovery Arcs

Recovery from a CBAC can be an emotional roller-coaster. Many women experience ambivalent feelings and these feelings can change considerably over time.

Immediately after a CBAC, some women are so traumatized that they need to process it immediately. Yet the people around them may feel threatened by any negative feelings around the birth; they don't understand that women can love their babies but still feel upset about how the baby arrived.

Some CBAC women find a place of temporary peace about the experience. They may be reconciled to its necessity, or may simply need to focus first on the baby and put aside any other feelings. It may only be later that more ambivalent feelings rise up and must be dealt with.

Sometimes right after the birth, women wish they had just chosen a planned repeat cesarean. However, with time, this feeling changes for many CBAC women. One study found that, while women were disappointed at not having a VBAC, 92% of CBAC women 'were pleased that they had attempted a vaginal birth' (Cleary-Goldman, 2005). The authors concluded that 'Although the most satisfied patients were those who succeeded at vaginal birth, most women valued the opportunity to attempt a vaginal birth regardless of outcome.'

This result was also found by Phillips (2009). Indeed, Chigbu (2007) noted, 'This survey revealed that most women still would prefer to be delivered vaginally after 2 previous cesarean deliveries.'

What few surveys have been done show the emotional impact a CBAC can have, but the topic is glaringly understudied. More research is urgently needed on the experiences of CBAC mothers and what can be done to help support them.

In the absence of research to guide us, we must trust what CBAC women tell us they need. More on that in Part Three of the series on Thursday.

References

Bastos MH, Furuta M, Small R, McKenzie-McHarg K, Bick D. Debriefing interventions for the prevention of psychological trauma in women following childbirth. Cochrane Database Syst Rev. 2015 Apr 10;4:CD007194. doi: 10.1002/14651858.CD007194.pub2. PMID: 25858181

Chigbu CO, Enwereji JO, Ikeme AC. Women's experiences following failed vaginal birth after cesarean delivery. Int J Gynaecol Obstet 2007 Nov;99(2):113-6. PMID: 17662288

Cleary-Goldman J, Cornelisse K, Simpson LL, Robinson JN. Previous cesarean delivery: understanding and satisfaction with mode of delivery in a subsequent pregnancy in patients participating in a formal vaginal birth after cesarean counseling program. Am J Perinatol. 2005 May;22(4):217-21. PMID:15906216

Durnwald C and Mercer B. Vaginal birth after Cesarean delivery: predicting success, risks of failure. J Matern Fetal Neonatal Med 2004 Jun;15(6):388-93. PMID:15280110

El-Sayed YY, Watkins MM, Fix M, Druzin ML, Pullen KKM, Caughey AB. Perinatal outcomes after successful and failed trials of labor after cesarean delivery. American Journal of Obstetrics and Gynecology 2007 Jun;196(6):583.e1-5; discussion 583.e5. PMID: 17547905

Hibbard JU, Ismail MA, Wang Y, Te C, Karrison T, Ismail MA. Failed vaginal birth after a cesarean section: how risky is it? I. Maternal morbidity. American Journal of Obstetrics and Gynecology. 2001 Jun;184(7):1365-71; discussion 1371-3. PMID: 11408854.

Phillips E, McGrath P, Vaughan G. 'I wanted desperately to have a natural birth': Mothers' insights on Vaginal Birth After Caesarean (VBAC). Contemporary Nurse 2009 Dec-2010 Jan:34(1):77-84. PMID: 20230174

Sandström M, Wiberg B, Wikman M, Willman AK, Högberg U. A pilot study of eye movement desensitisation and reprocessing treatment (EMDR) for post-traumatic stress after childbirth. Midwifery. 2008 Mar;24(1):62-73. Epub 2007 Jan 12. PMID: 17223232

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

Stramrood CA, van der Velde J, Doornbos B, Marieke Paarlberg K, Weijmar Schultz WC, van Pampus MG. The patient observer: eye movement desensitization and reprocessing for the treatment of posttraumaticstress following childbirth. Birth. 2012 Mar;39(1):70-6. doi: 10.1111/j.1523-536X.2011.00517.x. Epub 2011 Dec 19. PMID: 22369608

About Pamela Vireday

Painting by Mary
Cassatt, 1844-
1926. (public
domain) Image from
Wikimedia
Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 20 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.

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