The Physical Impact of Cesareans

by Pamela Udy

© 2008 Midwifery Today, Inc. All rights reserved.

[Editor's note: This article first appeared in Midwifery Today Issue 88, Winter 2008.]
Photos provided by the author

On April 14, 1912, the mighty Titanic hit an iceberg. The boat’s structural design and weight made sinking inevitable and swift. Over 1500 lives were lost.

Our maternity health care system could be compared to the Titanic, which, even with warning, is headed for a disaster.

We’re seeing only the tip of the iceberg in regard to the impact of cesareans on women and their families. The reality is that the impact is far larger and deeper than we know. As the cesarean rate increases, so does our glimpse into the reality of the immense proportions of the epidemic and its impact on our lives.

Cesarean surgeries have an impact on the health of both mother and baby, both short- and long-term. Cesareans have an impact on the workplace, because the time off needed by mothers—and fathers—is lengthened. The International Cesarean Awareness Network (ICAN) has recently been tracking a trend among health insurance companies to deny coverage, charge high premiums or even ask for proof that a woman has been sterilized to prevent future pregnancies before they will cover women who have had a prior cesarean. This will have both a financial and a health effect on families. Cesareans affect how many children a couple will have, a woman’s self-image, and relationships among all family members. I make no judgment on the necessity of the cesareans in this article. I use the examples of real women to show the impact of cesareans in their real lives.

Physical Recovery for Moms and Babies

One of the earliest family relationships we see strained by a cesarean is that of the mother and baby.

Jennifer Block says, “The most common reason why babies are not put to the breast within the first hour is the cesarean section; and cesarean babies are more likely to be given milk substitutes in the nursery while the mother is recovering.”(1)

Mothers who have cesareans are less likely to breastfeed, for many reasons. Often mother and baby are separated, which means a delay in getting baby to breast. The mom is dealing with pain, fatigue, possibly stress, and even trauma. The incision itself causes the mom difficulty in finding a comfortable position in which to nurse. The baby may have respiratory issues.

Let’s look beyond that to see how this disruption of the breastfeeding relationship may affect the family. The State of the World’s Mothers report asserts that “Immediate breastfeeding is one of the most effective interventions for newborn survival.”(2) I submit that, rather than an intervention, breastfeeding is the normal biological extension of pregnancy and childbirth. It also provides many advantages to mom and baby.

Breastfeeding provides the baby with good immune system protection, gut protection, protection against obesity and short- and long-term disease protection.(3) Breastfeeding also helps the mom. Her uterus returns to normal size more quickly after birth if she breastfeeds. She is less likely to experience postpartum depression.(4) She is less likely to have brittle bones later in life.(5)

Studies indicate that women need two years (over a lifetime) of breastfeeding to lower their risk of ovarian cancer. Every six months of breastfeeding cuts down a woman’s breast cancer risk.(6) She also is more likely to space her children in a physically healthy way. Without the norm of breastfeeding, the mother is clearly at long- and short-term risk.

There is more at stake here than what the baby has to eat today or how she gets it. Whether a mom breastfeeds her baby—or not—can affect the lifelong health of both.

Midwives can inform moms and work with local hospitals to encourage them to become baby-friendly establishments that encourage and actively work to get baby to breast within the first hour of life, regardless of what mode of delivery is used.

Attachment

Attachment can be a touchy subject for moms. Because moms who’ve had a cesarean have to focus on their own recovery, they may have difficulty focusing on the baby. Babies who were born through a non-labor cesarean don’t receive the helpful hormone rush that helps them to be alert, feed and bond. They also aren’t likely to be placed on mother right away, negatively contributing to the problem. Research has shown that mammals whose babies are born by cesarean sometimes reject them.

Because we human mothers have the ability to think, we usually don’t totally reject our babies. We do, however, have to work harder at bonding. Michel Odent explains, “In the hour following birth, in physiological conditions, the high peak of oxytocin is associated with a high level of prolactin, which is also known as the ‘motherhood hormone.’ The maternal release of morphine-like hormones during labor and delivery is now well documented. We have also learned that the baby releases its own endorphins in the birth process. The primary purpose of these hormones is to induce states of ‘dependency’—or attachment—to develop.”(7) He continues, “It is clear that all the different hormones have a specific role to play in the later interactions between mother and baby.”(8)

Cesareans lead to a bypassing of this hormone production, which means that mothers have to work harder to gain attachment to their baby.

I had a scheduled cesarean at 38 weeks with my first baby. The epidural didn’t work very well. I had a window of pain on my left side. I complained and they gave me more drugs, to the point that I don’t remember my first baby’s first 24 hours. I have video—my eyes are rolling and I certainly am not “present.”

The day after surgery, my son’s second day, they brought him to me. I looked at him and didn’t recognize him. I told them, “This isn’t my baby.” They took him back to the nursery, and after double-checking everything, brought him back, insisting that he was mine. I took care of him, but I kept feeling my belly, looking for my baby. I’ve watched the video enough times that I’ve started to believe those images are my memories. The reality is that they aren’t. I lost something that I can’t reclaim.

What about the baby’s attachment to her mother? Michel Odent states: “It is well-known that the baby has its own survival mechanisms during the last strong contractions and releases its own hormones. The visible effect of this hormonal release is that the baby is alert at birth, with eyes wide open and dilated pupils. Human mothers are fascinated and delighted by the gaze of their newborn babies. It is as if the baby was giving a signal, and it certainly seems that this human eye-to-eye contact is an important feature of the beginning of the mother and baby relationship among humans.”(9)

If moms and babies miss this experience, it can mean a more difficult struggle for both.

Recovery

Most moms are surprised by the recovery process after a cesarean. They’re told horror stories about labor, but nothing about what cesarean recovery means. A cesarean is major abdominal surgery. The anesthesia can make some women nauseated. It’s also unsettling to the body to have internal organs taken out and then placed back inside. Add to that drugs to relieve pain and you have moms who are sick to their stomachs.

It’s also normal to have extensive bruising around the incision. The entire abdomen can turn black, yellow, purple, red and blue. It’s startling to look at an incision and see tape, staples or both holding it together. Some moms wonder whether that can really hold their body together.

Moms who have had a cesarean lose more blood than moms who deliver vaginally. As a result, extreme exhaustion from anemia is common. In addition, air often is trapped inside the body during abdominal surgery. This can cause a form of transferred gas pain—leading to incredible shoulder pain. It does pass eventually (at which point a woman can start eating real food again!), but often food is withheld until a mom can pass gas.

She can’t roll over, sit up or get out of bed without help. She’s afraid to cough or laugh because it feels as if her insides will come out. Holding a pillow, blanket or stuffed animal to press on can help with that feeling. She doesn’t feel that she can stand up straight. She can hardly walk. She’s prodded to do so almost as soon as the anesthesia has worn off, since it really is the best thing she can do. If she can’t walk, she should have someone massage her legs to prevent blood clots. She’s told to lift nothing heavier than her baby, and she feels can barely lift him.

In January 2008, two celebrities had babies at the same hospital on the same day. One went in while in labor, delivered vaginally and went home later the same night. The other had a scheduled cesarean, citing convenience and fear of pain. She didn’t leave the hospital for five days.(10) News reports stated that she was “surprised” by how hard the recovery was.(11)

Medical reports often note that a woman “tolerated surgery well,” no matter what her experience, unless she experiences clear and significant complications.

Complications

We talk about complications as if they were a list of remote possibilities. Something that is possible, but not probable. Mothers think: That won’t happen to me. I’m not going to have a cesarean! Regardless of the fact that one of every three women in the US has a cesarean—mothers still don’t believe it will happen to them.

When a woman has a cesarean, she is immediately at increased risk for short-term complications, including excessive blood loss, blood clots, infection, anesthesia mistakes, injury to bladder, bowel or adjacent organs, pulmonary embolism and death. All of these complications (except death) require treatment and probably a longer hospital stay or re-hospitalization.

She’s also at increased risk for long-term reproductive problems including infertility, ectopic pregnancy, miscarriage, placenta accreta and placenta previa. It’s interesting to note that although these are always listed as complications for the mother, each has risks for the next baby or may even prevent future babies from either beginning or completing their journey here.

Effects on Babies

Vaginal birth is often said to be risky, while cesareans are touted as being absolutely safe for the baby. Women are told that cesareans might have some risks for mom, but the risks associated with vaginal birth are greater for baby. The implication is that moms are selfish if they risk their baby’s life by having a vaginal birth.

Meanwhile, hospitals are building expensive NICU wings due to the rising cesarean rate. Cesareans are risky for babies. Some babies die from respiratory problems after a cesarean. Some die because of uterine rupture, too. There it is: uterine rupture. It’s the unbidden fear of moms and the manipulation card of doctors. How can we say that we’re afraid of uterine rupture when we have a 30%, 40% or even 50% cesarean rate in our hospitals? I want to make it very clear: Uterine ruptures occur because of cesareans. They aren’t caused by VBAC attempts, but because of that first cesarean.

Later in life, babies born without labor have a higher chance of having asthma (12) or diabetes.(13)

If a mother has postpartum depression, the infant is also affected, often exhibiting developmental or behavioral problems. Many studies have shown that “maternal depressive symptoms are related to adverse care-giving and health-related behaviors, which in turn influence children’s health and development.”(14) Depressed mothers are less likely to read to, sing to, smile at and play with their babies—all vital activities for their rapidly growing brains and maternal-child bonding.

If you don’t have a healthy mom, can you have a healthy baby? We say to moms, “At least you have a healthy baby.” I submit that you cannot have a healthy baby unless you have a healthy mom. A mom who just had a cesarean is in recovery—she is in the process of physically healing. She just had major abdominal surgery. You don’t have a healthy baby because mom can’t respond to that baby’s cry in the same amount of time that she could if she wasn’t recovering from surgery.

You don’t have a healthy baby because mom can’t hold the baby without pain and, therefore, is likely to hold her baby less than a mom who isn’t in pain. You don’t have a healthy baby because mom can’t breastfeed the baby comfortably. She struggles to breastfeed at all. If she can’t—then the baby isn’t healthy.

What if the baby isn’t healthy? What if baby has respiratory problems and is getting treatment? What if baby is premature and is struggling? What if baby was cut by the surgeon’s knife and is having to heal that wound?

We say to moms. “At least you have a healthy baby.” I challenge this statement. A cesarean doesn’t guarantee a healthy baby. Cesareans have risks for babies that may jeopardize their growth—and even their lives.

Childbirth professionals—educators and doulas especially—have spent the last decade putting a positive spin on the experience of a cesarean—no matter what happened during the labor and “birth.” This has contributed to the lie that all that matters is a healthy baby. This spin devalues the mother and doesn’t allow her to grieve her loss—whatever that means for her.

Many women think that they’re the only ones who feel that loss. They need to know that it’s okay to be unhappy about the disappointment or bad experience. Those feelings don’t make them bad mothers; they just mean that the arrival of their baby—whom they love—was a much different experience then they had expected. It doesn’t matter that they were afraid for their baby’s life or their own life. Moms are expected to celebrate, regardless of the pain they are in or the trauma they just experienced. Maybe they just need someone to give them permission to grieve, along with an acknowledgement of their pain. Sometimes that’s all we need, so we can begin our journey of healing.

Perhaps we’ll find that the birth happened the way it did for a good reason. Maybe we’ll reach a different conclusion. Either way, our cesareans have had an impact on us—as real women with real lives. We’re not just a number, one of a percentage. We are talking about our lives and our children.

The top 10% of icebergs show above the water. Once that top of the iceberg was spotted, the Titanic couldn’t maneuver around it quickly enough to avoid hitting it. We can do better. We can prevent a collision by using the midwives’ model of care.(15)

Pam Udy is an expert on the impact of cesareans by virtue of personal experience, having had two cesareans followed by three vaginal births. As a member of ICAN’s Board of Directors since 1999 (with a one year hiatus in 2005), she has experience supporting, educating and encouraging moms, both those who are recovering from cesareans and those who are planning a vaginal birth after cesarean (VBAC).

References:

1. Block, J. 2007. Pushed: The Painful Truth about Childbirth and Modern Maternity Care. 141. Cambridge, Massachusetts: Da Capo Press.
2. Save the Children. 2006. State of the World’s Mothers 2006 Report. 27. Westport, Connecticut: Save the Children.
3. United States Breastfeeding Committee. 2002. Benefits of Breastfeeding (issue paper). Raleigh, North Carolina. www.usbreastfeeding.org/Issue-Papers/Benefits.pdf. Accessed 9 Sep 2008.
4. The New Hampshire Breastfeeding Task Force. 2007. A Breastfeeding-friendly Approach to Depression in New Mothers. www.nhbreastfeedingtaskforce.org/nhbftf-ppd-curriculum.pdf. Accessed 8 Sep 2008.
5. USDA/ARS Children’s Nutrition Research Center at Baylor College of Medicine. 2001. Breastfeeding Remodels Moms’ Bones. In Nutrition & Your Child. Houston, Texas: USDA. www.kidsnutrition.org/consumer/nyc/vol2-01.htm. Accessed 15 Oct 2008; Blaauw, R. et al. 1994. Risk factors for development of osteoporosis in a South African population. S Afr Med J 84(6): 328 –32.
6. Phipps, A.I., et al. 2008. Reproductive and hormonal risk factors for postmenopausal luminal, HER-2-overexpressing, and triple-negative breast cancer. Cancer 113(7): 1521 –26.
7. Odent, M. 2002. The First Hour Following Birth: Don’t Wake the Mother. Midwifery Today 61: 9–11.
8. Ibid.
9. Ibid.
10. www.foxnews.com/story/0,2933,322310,00.html. Accessed 16 Oct 2008.
11. www.imnotobsessed.com/2008/02/15/christina-aguilera-talks-about-her-scheduled-c-section. Accessed 16 Oct 2008.
12. Sullivan, M.G. 2003. Asthma associated with planned cesarean. OB/GYN News 38(10): 8.
13. Queen’s University, Belfast. 2008. Caesarean Babies More Likely To Develop Diabetes. ScienceDaily. www.sciencedaily.com/releases/2008/08/080826080810.htm
14. Ayers, S., and A.D. Pickering. 2001. Do Women Get Posttraumatic Stress Disorder as a Result of Childbirth? Birth 28(2): 111 –18.
15. For a description of the Midwives Model of Care (trademarked by the Midwifery Task Force), see: MANA (www.mana.org) or Citizens for Midwifery (http://cfmidwifery.org/mmoc/define.aspx)

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