Sharon’s Story: Cesarean Sections, PTSD, and Prenatal Care

After reading my blog post “It’s Not Your Fault,” Sharon left a comment for me on facebook, saying “good article asheya .. and thanks – nice to hear my ptsd wasnt something i was looking for!” I hadn’t realized she had experienced Post Traumatic Stress Disorder after giving birth, and I asked her if she would be willing to share her story. We met on Saturday morning, and she told me about her experiences.

Sharon is a thirty-seven year old mom of two children: almost four year old Rowan, and five month old Callum. Sharon is an elementary school teacher, and compared her maternity care experience with Rowan to the public education system. Public education is designed for mass education, teaching down the middle and trying to get everyone through. When she became pregnant she knew almost nothing about pregnancy or birth, and said that she felt like she was just going about her normal life but with a pack sack on her belly. She read a few books and attended the public prenatal classes offered for free through the health center, which she pretty much slept through as they mostly repeated what she had read in the books.

Sharon was fit, having run triathlons in the past, and ate well. She had a family doctor as her maternity care provider, who also happened to be a friend of her husband’s, and she felt she received a lot of the doctor’s time and good prenatal care. Sharon spotted blood throughout her pregnancy, and she still doesn’t understand exactly why this was. An ultrasound showed a low lying placenta, but her doctor told her that was not the cause of the spotting. Sharon said that she did not find the spotting stressful.

However, Sharon did not have a group of pregnant women or mothers to connect with, and she expressed a desire for a community of women who could have offered support and helped her prepare emotionally and mentally for birth, and who could have been there to support her after the baby was born. The only other woman she knew who was pregnant seemed quite competitive, and so instead of supporting each other it felt to Sharon like they were in competition with one another.

Sharon assumed that she would have a drug-free birth, and that she would just push through the pain like she had done in her triathlons.

Sharon went into labour on September 15, and went to the hospital. The hospital staff encouraged her to go home, and she went back again to the hospital a bit later. She dilated to five centimeters and her labour stopped. Her water had not broken, so the hospital staff sent her home.

Five days later, she went into labour again, at 10 pm. This time she stayed home, and stayed up all night without waking up her husband. They went into the hospital in the morning, but she expressed a desire to go back home, which the hospital staff allowed. She came back in again in the afternoon. A nurse was assigned to Sharon, and she stayed with Sharon throughout her labour. The nurse told Sharon that she did not encourage medical interventions, and Sharon was fine with that.

Sharon laboured in different positions, and spent a few hours in the shower. She began to experience back labour. Throughout her labour Sharon did not make any noise; she moved a lot, and her husband massaged her hips, but she was silent.

The next morning Sharon was still in labour, and starting to get exhausted. She was dilated to about 9 centimeters, and at this point she began to believe that she was going to die. She did not explicitly tell anyone this fear, but said to her husband, “I don’t think I can do this.” He tried to reassure her that she was doing great and that she could do it. Sharon felt that she should just be able to push through, like in her triathlons. She didn’t feel she could really tell anyone that she didn’t think she could handle what was happening. She thought she should be able to handle it.

Sharon received some morphine, which instantly helped her to sleep. After she woke up her labour was augmented with Pitocin and a vaginal cream. This made her contractions more intense and painful, and she requested an epidural. She still believed she was going to die.

Her labour had not progressed further, and so the obstetrician was called in. Sharon had been in labour for about 42 hours. He said that the baby was probably too big and her pelvis was too small, and he would give her four more hours to have the baby, or she could just have a c-section right away. Because Sharon was exhausted and believed she was going to die, she opted to have the c-section right away. Her daughter, Rowan, was healthy, and Sharon was lucid for the surgery. Rowan was placed on Sharon as soon as she was born. Rowan weighed 9 lbs 14 ounces.
Rowan breastfed well, even though she had been given some formula in the first few hours after birth while Sharon was in recovery and sleeping. A health nurse visited Sharon and Rowan at home a few days after they were discharged from the hospital, and at that point everything was fine.

However, as the days and weeks went on Sharon became increasingly anxious about her daughter’s health and safety. Her daughter would sleep for long stretches at night, but Sharon would lie awake watching her, afraid that Rowan would die. During the day, Sharon would sit with her baby in the living room and worry obsessively about ways that her daughter might be harmed, such as sharks eating her, feeling as if it were really happening. She would call her husband at work, crying and saying that she couldn’t handle things. Her husband tried to be supportive, sometimes taking Rowan to a different room at night so Sharon could try to sleep.

About two months after Rowan was born, Sharon went for a walk by herself down to a stream near their house. She began to think that her husband and Rowan would be better off without her, and thought about throwing herself into the cold water. Her dog began to whine and cry and wouldn’t let her go near the stream. She returned home, and two days later called her husband at work, crying and begging him to come home. At that point he suggested they go to the hospital, and she saw a doctor who recommended she take Paxel and an anti-anxiety medication. She also began counselling. Within a short while her obsessive anxiety disappeared and she was able to sleep at night again.

Sharon believes that her PTSD was caused by her cesarean surgery. Given that she believed she was going to die in labour, it makes sense that being cut open in her abdomen would be processed subconsciously as a potentially fatal wound, even though she consciously decided to have the surgery. She also believes that a supportive group of women may have made the difference for her, particularly in helping her cope after Rowan was born.

When Sharon became pregnant with her second child, she experienced a high level of stress during her pregnancy as the triple marker test showed that the baby might have some abnormalities. Her blood pressure also became high, and the doctor said that these things might indicate her body was trying to reject the placenta. The doctor was worried about another big baby, and Sharon did not want to have to go through another long labour just to have it end in a c-section. She wanted a natural birth, but she also felt that she had to admit that she couldn’t handle it. So she decided to have a scheduled c-section two and a half weeks before her son’s due date. Callum weighed 6 lbs 14 ounces when he was born.

Sharon said that the tests in her pregnancy just made everything more stressful, and didn’t actually help her to get what she was looking for. She was looking for support and nurturing, and the medical model of care really only offers tests and physical assessments, so she took what she could get. She feels that if she had received more nurturing prenatally with Rowan, things might have turned out differently.

A midwife I talked to said that almost all women will reach a point in their labour, usually during transition, so between 8-10 centimeters dilation, when they think they can’t go on. The mildest form of this is, “I can’t do this for much longer,” and the most intense form is, “I’m going to die.” It is at this point that a woman needs to be able to let go into herself, into the process, and allow what is happening to happen. Often her body will make her let go, but not always.

The midwife indicated that athletes often encounter difficulties with childbirth, because there is a belief that it will be like an athletic event. While childbirth certainly requires some similar physical endurance and effort, it is physically, mentally, and emotionally very different. Preparing mind and body for birth is very different from preparing for a marathon or a triathlon.

One of the most important aspects of the care this midwife provides is getting to know the woman prenatally. Through long appointments the midwife often gains insight into what issues might be present for a particular woman, and the midwife is able to address them in the prenatal appointments, through education on what the woman might experience and through exploring the woman’s thoughts and feelings about her pregnancy and birth. And because of the relationship the midwife has with the woman, during labour if the woman is not progressing or is encountering difficulties, the midwife will have insight into what might be helpful mentally or emotionally for that particular woman. The midwife will be able to encourage the woman to let go, to vocalize, to release control into herself and into her own body.

Unfortunately, not all mothers who want a midwife for their maternity care are able to get one, as there is high demand and a shortage of midwives. The majority of women, by choice or not, still see an obstetrician or a family doctor for their prenatal care.

Research has shown that none of the routine prenatal care we consider standard in the medical model of care actually improves outcomes for mother or baby. This includes urinalysis, ultrasounds, hemoglobin count, and the glucose test for gestational diabetes. In fact, this type of routine medical care may cause stress for the mother, creating a ‘nocebo’ effect, where the outcome of the appointments is a negative emotional effect. The only routine care that makes a difference to outcomes, such as prematurity, birth weight, and ease of birth for the mother and baby, is emotional support during pregnancy and good prenatal nutrition. The research does not even begin to examine other health outcomes and quality of life indicators, such as postpartum depression, breastfeeding rates, use of pain medication during labour, mother/baby bonding, cesarean section rates, and long-term effects on the baby.

There is evidence to support what Sharon could only guess at: being nurtured and emotionally supported during her pregnancy would have been beneficial to her and her baby. The outcomes measured in the research do not usually include mental health indicators, but it also makes sense that this type of care and support would help to mitigate or at the very least enable detection of mental health issues such as PTSD and postpartum depression. A supportive atmosphere that encourages asking for help and admitting you can’t handle what you’re experiencing makes it much more likely that mothers will ask for and receive help earlier, and feel supported no matter what they are going through.

I would like to see prenatal care in Canada changed to fit the evidence of what is in the best interest of women and babies.

Instead of monthly appointments with the doctor, and then bi-weekly and weekly visits at the end of pregnancy when there’s not much you can do if something is wrong by then anyway, create government funded prenatal education and support groups that women begin attending weekly as soon as they are pregnant. Women could even begin attending before they are pregnant if they are trying to conceive, as nutrition before conception is also very important. The government could fund doctors or nurses to provide group prenatal care, where blood pressure, heart rate of mother and baby, and belly measurements are provided, and if anything is unusual then the woman is referred to an individual visit with a doctor. The majority of the funding that currently goes to prenatal doctor’s appointments could be channeled into prenatal groups instead. These groups would be facilitated by a childbirth educator, and would educate women on prenatal nutrition, encourage exploration of beliefs and fears about childbirth, educate women about physiological birth, and provide resources and emotional support, including referral for therapy and counselling if indicated. Groups would ideally be no more than 8-10 women, and would include partners.

This kind of care might also help to improve breastfeeding rates. Currently 90% of mothers initiate breastfeeding, but only 14% are still exclusively breastfeeding at six months.

On the activity list for Mothers of Change is a pilot project for prenatal education group care. If you are involved in health care or research and have an idea of how this pilot project could be accomplished, please contact us. If you are a woman who would like to see this kind of care in your community, please contact us. Together, we can make change and improve maternity care for mothers and babies.

Macleans
Journal of Family Practice
Womb Ecology