Cesarean Section and Birth Trauma

Pregnancy, birth, and the postpartum period are milestone events in the continuum of life. These experiences profoundly affect, women, babies, fathers, and families, and have important and long-lasting effects on society.

For many women childbirth is a joyous, fulfilling and empowering experience. For others it can be one of the most traumatic events of their lives. Memories of childbirth can be vivid, deeply felt, and last many years perhaps even a lifetime. Women who express a long-term satisfaction with their births feel a sense of accomplishment. They have positive memories of their caregivers. They feel they were in control of their birth and their experience contributed to their feelings of self-confidence and self-esteem.

Other mothers have long-term memories of a childbirth gone awry. An experience that left  them feeling distressed, confused, and angry. Although much is now known about the physical health risks associated with a cesarean delivery formal knowledge about the psychological impact of a cesarean birth is beginning to gain ground. 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.

Many new mothers are familiar with the common symptoms of the Baby Blues which may last for a week or two. The sadness, anxiety, mood swings, difficulty sleeping, trouble concentrating and not feeling like oneself. Increasingly we are learning about the frequency and impact of depression during or after pregnancy. One in eight new mothers in the U.S. suffers from postpartum depression. A condition  that can develop anytime within a year of childbirth. Remarkably, current research tells us that some women experience childbirth as a traumatic event and up to 6% meet the clinical criteria for post-traumatic stress disorder (PTSD).

Childbirth can be an extremely painful experience, sometimes associated with feelings of being out of control so it is understandable that some women may experience the birth itself as a psychological trauma. Women who have a “normal” vaginal delivery can also experience birth as traumatic.  Unwanted, invasive and painful interventions together with a perception of inadequate care are also risk factors for a traumatic birth. British researchers found that 3% of women who had an uncomplicated hospital birth displayed clinical symptoms of post-traumatic stress at 6 weeks postpartum and 24% displayed at least one of the three components of PTSD.

Researchers have also identified feelings of numbness, lack of mobility from epidural anesthesia and not being involved in making decisions regarding their care, as risk factors for a traumatic birth. Invasive procedures such as vaginal exams, use of IVs, and bladder catheters can also trigger a traumatic response from survivors of early childhood sexual abuse and women who live with domestic violence. Women who may lack support from their partner or family, who have an unplanned pregnancy or a previous history of stillbirth are also more vulnerable.

How Women Feel About Their Cesarean Birth Varies Widely

A cesarean section, although not an uncommon procedure these days is an invasive procedure which is often initiated unexpectedly at some point in the process of labor or birth. Emotional reactions and adjustments to a cesarean birth vary widely. Some women recover quickly from a cesarean. They resolve and integrate their cesarean birth as one step towards becoming a mother. Other women, especially mothers who had an unanticipated cesarean perhaps after long hours of labor, can experience sadness, disappointment, loss of self-esteem guilt, and anger. A woman’s experience of her cesarean birth and her perceptions of the event, are influenced by multiple complex factors: 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; 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.

That birth by cesarean can have an adverse psychological impact on some mothers was already a concern in the mid-seventies and early 1980’s as the cesarean rate in the United States was climbing rapidly. Research, anecdotal reports and personal testimonies helped to increase awareness about the negative psychological repercussions that some women experience following a cesarean birth.

More than a decade ago social scientists already recognized that birth by cesarean can have a powerful negative psychosocial impact on some women The effects were significant and far-reaching . Birth by cesarean can impact self-esteem, mother-infant attachment, spousal relationship, and the new mother’s ability to respond to her newborn’s needs.  The risk seemed to be greater when women had an “emergency” cesarean, had general anesthesia, or were separated from their newborns after the birth.  A negative experience of a primary cesarean birth may last years and affect a woman’s future pregnancies. A difficult first birth that leads to an emergency cesarean or an instrumental birth can be so terrifying that some women in a subsequent pregnancy would rather have a cesarean delivery rather than experience labor again.

Cesarean Delivery and Post-Traumatic Stress

Women who have a surgical birth are more likely to experience feelings of loss, grief, personal failure and lower self-esteem.  Cesarean section is major abdominal surgery and often the emotional impact of a cesarean is misunderstood, dismissed or overlooked. The outcome of the pregnancy and birth, the new baby, is validated, but not the process of the birth nor the negative feelings the mother may have experienced. Some women who experience a cesarean especially if was not a anticipated can suffer from post traumatic stress. Current evidence suggests that the incidence of post-traumatic stress disorder after childbirth ranges from 1.5%  to 6%.

Phyllis H. Klaus, CSW, MFT, is a psychotherapist and international consultant who specializes in medical and psychological concerns of pregnancy, birth, the postpartum period, trauma, and abuse issues. She explains,  “Events are traumatic and create feelings of powerlessness when they are dangerous. When they are actually or appear to be life-threatening to oneself or a loved one. When they are sudden (the situation changes quickly from “normal” to dangerous), they are experienced without explanations, and when the situation appears overwhelming. There is no time to prepare, no way to plan an escape or to prevent something from happening. A number of events during labor or birth such as an emergency, unexpected or unwanted interventions, serious problems in the mother, physical damage, a sick or compromised infant and separation from the baby, can be classified as traumatic, with a capital T. Major trauma for a woman occurs in childbirth when she has inordinate fear and is in a situation where she has no control. Other aspects of trauma are more subjective and relate to how a woman is treated. How she perceives her experience, and how she feels about the experience. These experiences are often man-made and cause shame, humiliation and stigma.”

Some mothers experience their cesarean as a physical assault and a form of institutional violence. For some mothers the surgical birth is experienced as a rape.  A growing body of psychosocial literature and increasing personal testimonies from mothers themselves in books, on e-lists, websites and personal blogs also suggest that some women suffer from Post Traumatic Stress Disorder after their cesarean section. They experience the same physical and psychological symptoms as those experienced by combat veterans, major disaster victims, or plane crash survivors.

The symptoms of birth-related PTSD may emerge weeks, months, or years after the event.Post-traumatic Stress (PTSD) is a diagnostic category used to describe symptoms arising from an emotionally traumatic experience. It may involve an actual or perceived serious injury or actual or perceived threat to the physical integrity of oneself or others. Individuals with post-traumatic stress experience feelings of intense fear, helplessness, or horror in response to the traumatic event.  PTSD is also well-known  reaction to other medical experiences such as open heart surgery or cancer. Women who suffer from a post-partum hemorrhage or a preterm birth and women who undergo infertility treatments may also suffer from PTSD. When symptoms occur in the first 30 days of the traumatic event it is called an acute stress response. The diagnosis of PTSD is made when the clinical symptoms persist.

  • 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.

Women with clinical symptoms of post-traumatic stress re-experience the birth and the emotions associated with it in dreams or thought intrusions. They avoid places or people that remind them of the event. Mothers will also exhibit symptoms of hyperarousal, such as difficulty sleeping or concentrating, irritability, and an excessive startle response. Untreated post-traumatic stress often leads to clinical depression. A traumatic birth of any kind can leave a woman feeling disempowered, violated, or betrayed. While experiencing such clinical symptoms, depending on their individual condition, mothers are more likely to have difficulty tolerating their infant’s vulnerability and establishing an emotional closeness. Their capacity for feeling tender and warm towards their infants and people close to them is directly affected. Mothers who feel fearful, sad, and withdrawn will have difficulty with the process of mother-infant attachment.

Breaking the Silence – The Importance of Supportive Communities

Research and experience strongly suggest that providing women with the opportunity to make sense of their traumatic birth is vital for their emotional well-being. Penny Simkin, PT, co-author with Phyllis Klaus CSW, MFT of When Survivors Give Birth counsels many women who have had a traumatic birth. She tells us,

“The childbirth experience lives on in the new mother’s thoughts and emotions as she integrates her prior expectations with all the rewarding, challenging, painful, frightening, exhausting, and demanding aspects of it. She needs to make sense of her childbirth by reconstructing it and putting into words to understand what happened and how she felt. Of course, if she feels triumphant, powerful, and fulfilled by her child’s birth, having a chance to recall the details and relive the joy will reinforce the positive aspects, enhance her self-esteem, and deepen her satisfaction. Negative or mistaken impressions, however, do not go away if they remain unresolved; in fact, they tend to fester and grow. If the birth was traumatic for her on her baby, early processing and reframing may even prevent later Post-Traumatic Stress Disorder or Postpartum Depression. If she is angry at or disappointed in herself, in people who were there, or over the events that occurred, she will benefit from a caring, empathic listener who acknowledges and validates her feelings. When the time is right, this person can help her to a more comfortable or positive perspective.”

Since the late seventies and early eighties women have created their own safe and supportive communities to help them make sense of  a traumatic birth.  A place where mothers can openly share their feelings of their cesarean birth validates their experience. Supportive networks that address birth trauma issues, websites and warm lines where mothers can write or phone in and talk about their birth, have formed in several countries including the U.S., Britain, New Zealand, and Australia. Peer self-help support groups provide emotional support and a non-judgmental place where mothers can feel understood and respected. A place to express  their grief, confusion, disappointment, guilt or anger about their cesarean births. It gives mothers an opportunity to reconstruct the events around their cesarean birth, and hopefully to eventually integrate their experience in the context of their lives. They are also a source for community resources, education, and counseling services. Support groups above all provide mothers with a safe place where other mothers with similar experiences can affirm that having those feelings is normal and does not make them bad mothers. These supportive communities also testify to the need for a better understanding of the impact of the medicalized model of care on women’s psychological well being and consequently on their ability to care for their babies.

Sharon Storton, MA, LMFT has worked extensively with women who have experienced birth trauma. She tells us, “Our culture can give women the clear message that discussing these experiences aloud is shameful and unacceptable. Women often report that any emotion other than gratitude or joy is silenced. Social and family pressures tell women, “just get over it and move on. Sometimes moving on requires understanding what happened, mastering the story and the experience, and even breaking the silence about what occurred. At times, a woman is ready to take these steps toward healing immediately after her delivery. For some individuals, this process can come years after the experience. Challenging childbirth can have a sense of “freezing in time” until the silence can at last be broken.

Are Some Women Being Forced to Repeat the Trauma?

Currently in the United States more than 90% of women who had a prior cesarean have a repeat operation. Some hospitals and care providers support women’s choice for a planned VBAC, but thousands of other women are basically having a forced repeat cesarean because hundreds of hospitals have decided they cannot or will not for financial or malpractice reasons meet ACOG’s controversial recommendations (issued first in 1999) for a planned VBAC.

How have these guidelines affected women’s mental health?  To date we have no information on the impact of that policy on the thousands of women who had no choice but to repeat a major abdominal surgery they most likely didn’t need. Medical societies, policy makers, researchers, employers, mental health professionals, and the media have yet to investigate the ethical, moral, legal, financial and health issues regarding forced repeat cesareans in the United States.

Mothers’ Feelings about Their Cesarean Birth

Mother’s feelings about how they experienced their cesarean originated from support group websites and newsletters from the U.S., Great Britain, Australia and Canada.

“ …Because I had a previous c-section…a c-section was arranged…As I was wheeled away…I felt like I was an animal led to the slaughter with no mind of my own and doing as I was told…No real consideration was given to how I felt. I was lying there having the epidural inserted, screaming out inside, why, why, I don’t want this…”

“I signed papers giving them permission to do the caesarean. …I felt sacrificial. I was crying and holding my partner’s hand and telling him that I loved him. I felt lost. I remember staring up at the glare of the quadruple-headed theatre (operating room)  lamp that seemed to sear its clinical, alien rays across my cut-open body. I remember the light’s protruding handle becoming covered in my blood from the surgeon’s glove.”

“When my son was three years old I was nine weeks pregnant…I became terrified: terrified of doctors, hospitals, everything. I hadn’t seen a doctor; I was too scared to get shafted again. The terror and pain came back to me. I began to relive the experience again…”

“Recently, I was the victim of date rape: afterward I started having flashbacks of the last few minutes of consciousness before my daughter was delivered by cesarean section. Finally, it became crystallized for me what those awful indescribable feelings were since the c-section. …I hope that other women can get in touch with those feeling or rage, betrayal, loss, etc. and start the healing process even if it comes three years after the assault like it has in the case of my c-section, or should I say, their c-section.”

Inadequate anesthesia-my epidural wore off during surgery and the anesthesiologist didn’t believe me. It was dosed high enough pre-op but started wearing off towards the end. I could feel the stitching and then the stapling. Finally, to stop my screaming, the anesthesiologists pretty much put me completely out, but only because the surgeon told him to. I still have nightmares-six years later.

“What bothered me the most about m y sections was the way they were acknowledged by the rest of the world I guess. I mean, yes, I had a wonderful baby, and wasn’t I happy, and the answer was no. I actually felt assaulted and violated and out of control. Also with both sections, even though they were 10 years apart, I didn’t feel there was anything out there really to help me deal with getting it together psychologically. To most of my family and friends it is like, it happened, it’s over, get on with it, and I have…twice, but there is sadness there and I think there needs to be someway of addressing and handling that.”

“Despite my rational mind recalling the surgery, and a memory of the perfect baby’s lustily-wailing reality, my body and heart are giving me a different message. No child came from my body. There is no child. Wait—there IS a child? I am confused. I am hallucinating. I am grieving. For the next several weeks, my heart stops whenever there is a knock on our apartment door, because I am irrationally convinced that  it’s the newborn’s real mother, the one who birthed him, who has come to take him home. It has taken me months, years, to overcome my body’s messages of a missing child.

Before my son was born, I was unaware of the underbelly of grief and anger associated with the unwanted, and often unnecessary surgical extraction of our children. I was amazed to find many women who felt the same way about their cesarean birth experience. It is kept quiet not only by the medical community, but by the mothers as well. Many women think that the feelings they have after a cesarean are wrong and they are afraid to share them with others, even loved ones. It has inspired me to create a place where these women can vent, share poetry, artwork, cesarean and VBAC birth stories and anything else that helps them through those painful feelings.

“What is so bad about c-sections? They are not as nature intended for women to give birth. They take so much away from healthy women, and brand us for life. Anytime we become pregnant again, anytime we write down any medical information, we will have to write down c-section. We are branded as ‘broken’ by the medical community and often by ourselves. I feel like my scar is like a cattle brand. Look at me, I couldn’t do it. Well, I could have! I just didn’t have all the support I needed and information necessary to. Next time, I will not make that mistake.”

This section is  based on  Chapter 6 of  Understanding the Dangers of Cesarean Birth: Making Informed Decisions. The chapter includes 58 references.

Support Groups For Women Who Experienced a Traumatic Birth

Solace For Mothers

Trauma and Birth Stress – PTSD After Childbirth, New Zealand

Birth Crisis Network, Great Britain

Birth Trauma Canada

CARES, South Australia

Updated, January 4, 2014.

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