By Pamela Vireday
“Remember, no effort that we make to attain something beautiful is ever lost.” – Helen Keller
Today we conclude our three part 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. Two days ago, Pamela examined the limited research available on CBAC births in part two. Today, Pamela will provide information on how to support CBAC women in the absence of published research. There is also great set of resources in the post to share with the families you work with or include in a CBAC Resource packet you provide after birth. 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 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
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 was 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 is 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 health care 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.
- http://cbac-support.weebly.com/ – ICAN’s CBAC website
- http://www.ican-online.org/product/when-vbac-doesnt-happen/ – link to ICAN’s new CBAC brochure (for new CBAC moms)
CBAC Support Groups
- https://www.facebook.com/groups/cbacsupportgroup/ – ICAN CBAC Support Group
- https://www.facebook.com/groups/111066659056348/ – Unplanned CBAC and Birth Trauma Facebook Support Group
General Birth Trauma Support Organizations
- solaceformothers.org – support for women with traumatic births
- tabs.org.nz – Trauma and Birth Stress
- birthtraumaassociation.org.uk – Birth Trauma Association, U.K.
- ptsdafterchildbirth.org – info on PTSD after childbirth
- pattch.org – Prevention and Treatment of Traumatic Childbirth
- http://improvingbirth.org/trauma-toolkit/ – Improving Birth Trauma Toolkit
Articles on CBAC Recovery
Birth Trauma Articles
- Rebounding From Childbirth by Lynn Madsen, 1994
- Ended Beginnings: Healing Childbearing Losses by Claudia Panuthos and Catherine Romeo, 1984
- Cesarean Voices– ICAN, 2007
Beck CT, Watson S. Subsequent childbirth after a previous traumatic birth. Nurs Res 2010 Jul-Aug;59(4):241-9. PMID: 20585221
About Pamela Vireday
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.