Recently, we have been talking about Cesarean Birth After Cesarean, or CBAC (some people prefer Cesarean Surgery After Cesarean, or CSAC). This is when someone wants and works for a VBAC but doesn't have one. Usually it means that she labored but ended up with a repeat cesarean, but sometimes it can involve an
unwanted planned repeat cesarean that was done for medical indications or because of unsupportive providers. It is the unwanted aspect of it that is most important.
As we have discussed, everyone celebrates a VBAC but many CBAC mothers feel alone and unsupported, both in their physical and emotional recovery. This needs to change.
As part of our CBAC emphasis this past month, I shared
my CBAC story a few weeks ago, as well as the
CBAC support website I created to discuss the many feelings that a CBAC can involve and some ideas for working through them. I also wrote a 3-part series for the Science and Sensibility blog that discusses how birth professionals can better support people who have had a CBAC:
- Part One - CBAC: A Unique Grief
- Part Two - CBAC: The Forgotten Mothers
- Part Three - CBAC: Supporting Women When VBAC Doesn't Happen
For the
International Cesarean Awareness Network (ICAN), I wrote a
brochure on CBAC so birth professionals have something to give the CBAC mother immediately afterwards to help support her emotional journey. And I will be recording several webinars for ICAN about CBAC as well.
For my last posts in this series here on this blog, I'd like to focus on physical healing after a CBAC, what you might be feeling after a CBAC, and some things you might do to help in your emotional healing as well. As always, take what works for you and leave the rest behind.
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 healthy. 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 set-backs 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 afterwards, 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 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.
More on emotional recovery in the next post in the CBAC series.
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.
