Cesarean Recovery: What to Expect

Welcome to Pampered Pregger & Beyond! Tonight, Cesarean Society hosts Cesarean Recovery: What To Expect presented by Jennifer Mossholder. Through this chat, you will get the real scoop on what it is like to recover from a c-section: mentally and physically. Even if your section was medically necessary there will still be feelings you never thought you'd have. Physical recovery varies mom to mom and we'll go through some typical (and not so typical) things to expect. Q&A follows at the end of the session. Please save your questions til the end. Jennifer (Jenn) Mossholder: is a "doula of all trades". She is an Antepartum, Postpartum, and Labor and Birth Doula. Jenn also provides Birth Plan Support and Breastfeeding Support. Jenn's business, "Before, During & After..." also offers The Happiest Baby on the Block, general Childbirth Classes and The Bradley Method. Be sure to check out her website at www.doulamom.com

Tiffani Lawton: Welcome Jenn!

Jennifer Mossholder: Hi! My name is Jenn Mossholder: and I am a mother of 4 daughters; 1 singleton birth and 1 triplet birth! I have personal and professional experience with vaginal, cesarean, VBAC and other types of birth as I have had both a vaginal and cesarean births and I am a Labor Doula. This presentation's topic is recovery after a cesarean section.

Women have a wide range of emotional responses after a cesarean. Some are devastated by it, some love it, some are disappointed but okay with it, some feel 'rescued' by it, and some seem fine at first only to experience delayed grieving later. There are many factors that can influence how a woman experiences and interprets a cesarean emotionally.

Planned Cesarean vs. Unplanned Cesarean

Whether or not the cesarean was planned is often (but not always) a factor in how a woman experiences her cesarean. Women whose cesareans were planned ahead of time usually have the easiest time recovering emotionally, since they knew ahead of time that it would happen and more or less what to expect. They had time to grieve their lost ideal birth ahead of time, and were able to prepare themselves mentally for the rigors of surgery and recovery. They did not have to go through the pain of labor and the pain of surgery too.

However, not all women who have planned cesareans have an easy time emotionally; some have planned cesareans because of unavoidable physical factors and/or unenlightened medical policies. Because they did not want the cesarean but were forced to have one anyway, the emotional recovery in these cases can be difficult and painful.

Women who do not plan to have a cesarean but who go through labor and still end up with a cesarean anyway generally have a hard time adjusting emotionally too. To go through the intensity of labor and then have to endure the pain of surgical recovery too is a double physical burden. To give up your fantasy of how you wanted your birth to go and face a totally unexpected outcome is a difficult emotional adjustment for many.

Those who unconsciously believed that 'this won't happen to me' (and conversely, those who were especially afraid of having a cesarean) often face the most difficult emotional adjustments of all. Rigid expectations of birth, denial of the unpredictable nature of birth, or extreme avoidance fears of possible surgery make a cesarean that much harder to deal with if it does occur.

Another factor that strongly influences a woman's experience of cesarean birth is how her labor went. If a woman experienced a relatively easy labor but a situation suddenly occurred where a cesarean became necessary, some women feel bereft and robbed of the culmination of what they had been working towards. These women tend to adjust fairly quickly and are often able to navigate recovery easily enough. They usually do not face future pregnancies or births with much fear of labor, just the fear of the recurrence of the complication recurring. Once they get past the stage where the complication occurred, they generally do very well. Sometimes they do experience the complication recurring, but with a more favorable resolution, and then they are fine.

On the other hand, sometimes women who have had a sudden cesarean due to an emergency during labor are traumatized by the suddenness of how things changed, the unpredictable nature of labor, and a sense of fear over this volatility. The quick action that sometimes must be taken because of complications often does not leave time for women to adjust emotionally; they may feel like their bodies and emotions have been hijacked. In subsequent labors, even if everything is going well, they may fear another sudden 'hijacking' by a complication, and often need a lot of reassurance that all is going well. Again, once they are past the point where the previous complication occurred, they can often relax a bit more.

Women who experienced a very difficult and painful labor before their cesarean occurred often see the cesarean as a welcome release from the pain they experienced. These are often the women who 'loved' their cesareans, as to them it was a release or a rescue from a difficult situation. To go from an immense amount of pain with little or no progress to the numbness of cesarean anesthesia may feel like a real blessing, and to have the immediate gratification of having it all over and holding that precious little one in their arms sooner rather than later is an understandable joy.

Many women in this position logically therefore see their anesthesiologist or OB as rescuer and hero. Ironically, many of these difficult labors were actually caused by the labor management policies of the doctors, who were then able to ride in on their white horse to 'rescue' the woman from the problem the doctors had created in the first place!

Women in this situation usually divide into two camps---those who staunchly keep seeing their doctors as white knight rescuers, and those whose heroes get knocked from the pedestals when they find out that the actions of their doctors may have caused their cesareans in the first place. This is a particularly difficult emotional transition. A woman may be 'fine' with her cesarean at first because she saw it as a rescue from a difficult situation or a lifesaving measure for herself or her baby. If she finds out later that the doctor actually caused or greatly added to the problem that she had to be rescued from (or even worse, put her baby's life in danger through his actions), that transition from loving the cesarean to feeling betrayed by it can be particularly bumpy. Women who are induced, have a long and painful labor, and end in an unanticipated cesarean can also have a particularly hard emotional recovery. A cesarean after a long difficult induction can be particularly challenging physically, and induction drugs often have long-term physical effects too. Pitocin, for example, can cause significant swelling and edema in the mother, which may impact breastfeeding supply, make it difficult and painful to walk, and be very uncomfortable to deal with.

Women who have been induced with Cytotec (misoprostol) often report that their labors were extremely painful and difficult to deal with. Babies who have experienced labors with lots of drugs and pain medications often are jaundiced, drowsy, and 'out of it' at first, then fussy later on. All of these physical factors tend to make emotional recovery much more difficult as well.

Adding to the difficulty of physical and emotional recovery after a difficult induction is the fear factor. Some inductions are so difficult that women develop a tremendous fear about labor. They can feel traumatized by how hard it was and how much pain they went through. Many have great anxiety about going through labor again because their only experience of labor was such an unnaturally strong and painful one. As a result, many choose an elective cesarean for their next birth in order to avoid a recurrence of such a difficult labor, not knowing (or not being able to trust) that labor doesn't have

How necessary the surgery was is also a very important factor in how women perceive a cesarean. If the surgery truly saved the life of the mother or the baby, her feelings about it will be different from a woman who was bullied into surgery unnecessarily. For some women, knowing their surgery was necessary helps them recover emotionally without a great deal of regret. Their disappointment about the cesarean may be overshadowed by gratitude that surgery was possible and available, and that they and their child are alive to tell about the experience.

However, even when surgery is truly necessary or life-saving, some women still mourn the loss of their ideal birth and the changes that had to occur due to circumstances. These women are often told "at least you have a healthy baby" and that they should be thankful for the life-saving surgery, but often find this an extremely frustrating and disempowering statement.

Of course it is true that a healthy baby is the top priority, and if the c-section was truly necessary, then we can be grateful intellectually for the procedure. It is insulting to suggest otherwise. However, even when the surgery was necessary, a woman often needs to mourn the birth she wished she could have or was not allowed to have, and to acknowledge the difficulty of having major surgery.

Having major abdominal surgery right before taking care of a needy and high-maintenance newborn is not easy! Most women would not choose to adopt a baby and bring it home on the day they had their gallbladders out, yet people routinely dismiss the physical impact of cesarean surgery on the mother. And for some women, to be told that they have no right to mourn the loss of their ideal birth in addition to the physical invasiveness and burden of surgery is insult added to injury.

If women who truly needed a cesarean can still find it distressing, imagine the bitterness and intensity of mourning in women who find out that their cesarean was unnecessary! About half of all cesareans in this country have been estimated to be 'unnecessary', and as previously noted, are often caused by the management policies of the doctors themselves.

Jennifer Mossholder: If women who truly needed a cesarean can still find it distressing, imagine the bitterness and intensity of mourning in women who find out that their cesarean was unnecessary! About half of all cesareans in this country have been estimated to be 'unnecessary', and as previously noted, are often caused by the management policies of the doctors themselves.

When a woman realizes this difficult and invasive experience could have been avoided, the anger and bitterness she experiences often makes it emotional healing difficult. On the other hand, if she is able to channel this anger into empowerment, this may also propel her into great action and healing in birth issues and in life.

How a Cesarean Can Interfere with Breastfeeding

Breastfeeding is more difficult after a cesarean for many reasons. Nursing your baby as soon as possible after birth ensures the jumpstarting of hormonal processes designed to ensure milk supply, and aids in the woman's physical recovery afterwards. Although a few women are able to nurse their babies right on the table during surgery, most have to wait until they are in the recovery room.

A few misguided hospitals still have the outdated practice that forbids breastfeeding during the mother's time in the recovery room, so their babies must wait even longer to nurse for the first time. In addition, many women are so groggy from drugs after the surgery that they are not able to nurse for many hours afterwards. This delay in first nursing definitely impacts milk supply, often delays the appearance of mature milk, and undermines a woman's confidence and desire to breastfeed.

Many cesarean babies are given bottles of formula routinely, which research clearly shows also lowers the rate of successful breastfeeding (Blomquist 1994). Because cesarean mothers' milk may be delayed in coming in, the baby may be at more risk for excessive weight loss after birth, which usually means more bottles of formula.

If the mother had pitocin during the labor, jaundice rates are higher, which may erroneously mean even more bottles of formula. The more bottles are given, the less the baby is nursing, and the less the mother's supply is stimulated. Between the delayed access for first nursing and the bottles of formula routinely given, many cesarean mothers experience a delay in their milk coming in, low milk supply at first, and difficulty nursing due to nipple confusion from bottles.

Physical factors that accompany cesareans can also interfere with breastfeeding. If a woman experiences excessive blood loss during surgery, she may experience anemia afterwards, which can interfere with milk supply significantly . If you experience dizziness, weakness, and extreme fatigue after your cesarean, strongly request that your iron levels be checked; early treatment can prevent or minimize problems with milk supply, and speed your recovery significantly.

Positioning can also be more difficult after a cesarean. The usual 'cradle' nursing position can be painful after a cesarean, since this places baby against an abdomen that has just been traumatized. Many women can still use the 'cradle' position after a cesarean by putting a pillow over their incision and putting baby on top of that pillow. Other women prefer to nurse lying down after a cesarean; women who are well-endowed or who find it difficult to nurse lying down usually find the 'football hold' the best position.

For more information on breastfeeding after a cesarean and illustrations of all these various nursing positions, read The Nursing Mother's Companion, The Womanly Art of Breastfeeding, or So That's What They're For! Breastfeeding Basics. You can also find more information and illustrations online at www.promom.org, www.breastfeeding.com, or www.lalecheleague.org.

What is the best possible way to ensure a quicker recovery?

Many women find that walking, at least within a 24 hour period after their Caesarean helps speed up the recovery process. While it may be painful to take those first steps, walking helps to begin moving gas through as well as prevent stiffness around the incision area.

When can I resume my normal activities?

Upon leaving the hospital you will be given a list of instructions on what is safe and what isn't as far as normal activities go. It is best to wait 2-4 weeks before beginning activities such as sweeping, vacuuming or anything that will require bending, stretching or stooping. A good rule of thumb is to listen to your body. If you feel as though you can perform an activity and you experience no pain or discomfort, then proceed with the activity.

How much is safe to lift after a Caesarean?

The heaviest thing you should lift for at least 2-4 weeks after your Caesarean is your newborn. Lifting anything heavier could seriously complicate your recovery.

When can I begin an exercise routine?

It is usually best to wait at least 8 weeks after your Caesarean to begin an exercise routine. When you do begin one, start out with very light, moderate exercises and gradually build to the exercises you performed before your operation. Listen to your body. If you experience pain or discomfort, stop immediately. If you experience any bleeding or oozing from your incision, contact your doctor immediately. It is important not to overdo it.

When can I begin taking baths?

It is usually okay to resume taking baths about 4-6 weeks after your Caesarean. However, if you have had problems with your incision being infected or with the wound re-opening, it is best to wait until your doctor gives you permission to do so.

What happens if my incision gets infected?

In most cases antibiotics are given orally and the incision is treated with topical medications. If the infection is serious, hospitalization may be required so that intravenous antibiotics and fluids can be administered. If an infection is present, your doctor will monitor you closely.

Is it possible for my incision to re-open?

While it isn't common for the wound to re-open, it does happen. It can occur if you begin some activities too soon after your operation. It can also occur if the incision is sutured incorrectly or if the wrong type of sutures are used. If the wound re-opens it may need to have new sutures. If additional sutures are not required, you may have to use special dressings to keep the wound covered and safe from exposure. If the wound gets infected, antibiotics will most likely be necessary. This has only happened to ONE of my clients ever.

How long will I have to use my pain medications?

This really varies from woman to woman. Some find that they only need the pain medications for as little as a few days while others may need them for a longer period.

Is my bleeding normal? How do I know if I am bleeding too much?

Even though you did not delivery vaginally, you will still experience some significant vaginal bleeding as part of your recovery. This is called lochia. The question of how much is too much is one which plagues many recovering moms. Most women will bleed heavily for at least the first two weeks of their recovery - but if you experience so much bleeding that you must change your pads every hour or pass a clot larger than a golf ball, then you should contact your doctor immediately.

How soon can I go swimming?

If your lochia (vaginal bleeding) has stopped and your scar is totally closed, you can swim. Swimming is one of the best forms of exercise for those recovering from c-sections because it puts so little stress on your body.

When can I drive a car?

The answer to this one seems to vary a great deal from doctor to doctor. Women have reported everything from 2 weeks to 6 weeks, though usually with an answer somewhere in the middle. This is another issue that depends a lot on your own body and how you are feeling. I would ask myself the following questions before getting into a car to drive again after having had a c-section:

1) Can I get in and out of the car without significant pain?

2) Can I buckle my seat belt over my abdomen without flinching?

3) Do I feel that I can turn my torso comfortably so that I am able to look over my shoulder and in all directions while driving?

When can I resume sexual intercourse?

The short answer is when you feel ready. Most doctors seem to lean towards 6 weeks. Some women are recovered enough after 2 weeks, others take 3 months before they would even think about it. On the physical side you need to consider how much pain you are experiencing in your abdomen. Is your scar healing well? Are you experiencing any sensation of pulling from your scar? Another thing to keep in mind is that there is more to this than just your physical recovery. For many women who have just had a child, sex is the last thing on their mind - and their partners need to understand that between sleep deprivation and hormones, a woman's body is a bit of a war zone for a while after delivering a baby. Each couple must work through this particular issue in relation to the physical and emotional state of the new mother. Remember that even if you are breastfeeding or your cycle seems not to have returned yet - you can still get pregnant again if you do not use some form of birth control.

Will I ever get feeling back around my scar?

Probably. It will take time. Everyone experiences some numbness and tingling in their abdomen after the surgery. There may be patches which never regain feeling. Some women report that the skin around their scar feels extra sensitive after the scar completely heals. In my case, I have very little sensation on my scar line, but it is so small, it really doesn't matter to me.

Can I still have more children?

Assuming that you have no other medical issues, there is no reason that a standard c-section should prevent you from having more children.

What is an 'elective c-section'?

An elective c-section is a cesarean which is performed at the request of the mother without any medical need. Usually scheduled to precede the mother going into labor, a date is selected and an operating room reserved for the cesarean delivery of a child. While many women with specific health issues or prior cesarean sections have long scheduled c-sections, elective c-sections have become more common in recent years. Theories about decreased risk of pelvic floor injuries and incontinence are often behind the choice.

Will I have to have another c-section if I have another child?

This is a great question - and in the United States there are two major camps right now with very different answers. On one side are proponents of Vaginal Birth After Cesarean (usually abbreviated VBAC and pronounced vee-back).

On the other are those who feel that the risks are too high and that an elective or scheduled c-section is the best option for a mother who had already undergone the procedure in the past. The risk to which they refer is uterine rupture.

Both sides have studies. Both sides have strong opinions. Add to the mix that some doctors and hospitals across the United States have instituted 'VBAC bans'. The American College of Obstetricians and Gynecologists (ACOG) published their latest guideline on Vaginal birth after previous cesarean delivery in 2004.

The line that is causing some hospitals, insurance companies and doctors to no longer 'permit' VBACs is the one which reads "Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care."

Many hospitals which do not have a surgeon and anesthesiologist on hand at all times have been choosing to say that they cannot provide 'immediate' surgery if needed - so they choose not to allow laboring moms to attempt VBACs within their facilities. There are theories that pressure from the insurance industry has decreased the number of doctors who are willing to support their patient's VBAC attempt.

If you don't want another c-section - a good first stop is the International Cesarean Awareness Network (ICAN). I especially like their paper: My hospital is currently not allowing VBAC and forcing me to have a cesarean; what are my options?

I know I just threw a ton of information out there I will gladly take questions from you!

Tiffani Lawton: Thank you Jenn! You can directly contact Jenn by visiting her profile and clicking send message under her image.

Christie: Tiffani asked me to join because of an article I wrote for Chic Galleria re: my experience with both vaginal and c-section. Vaginal with my first and elected c-section with my second.

Tiffani Lawton: Yes, I just posted Christie's article in the article section of the community under resources.

Jennifer Mossholder: I'll have to read her article! I had a vaginal birth the first time and a c-section since I was pregnant with triplets.

Christie: My first labor experience lead me to go c-section the second time. But if I am asked which I prefer...both. The first time, I had gestational diabetes and my daughter grew too big for my body. I went into labor but never dilated...29 1/2 hours not one cm!

Tiffani Lawton: Eee Gads!

Lauren: Wow.

Jennifer Mossholder: That is a loooong time! Very untypical, even for first timers!

Christie: I was about to have an emergency c-section...but I guess my daughter had other plans...I dilated 9 cm within the last hour. Long story short she got stuck and it almost was a bad thing. They were either going to have to break her collar bone or cut me in a bad way to get her out. Thankfully neither had to happen.

Tiffani Lawton: Oh my heavens!

Christie: Gory details in the article (LOL)

Jennifer Mossholder: Wow, I can see how that could color your perception of vaginal birth!

Lauren:: Yes, I can definitely understand why you wouldn't want to do that again.

Christie: Uh...yeah. Well fast forward to my pregnancy with my son and same deal...gestational diabetes and big baby on the way. My doctor and I made the decision together. Not to mention...statistically if one baby gets stuck the next one will too. Definitely did not want to deal with that again.

Jennifer Mossholder: Christie, you know, medicine has evolved for a reason. Sometimes it is a necessary intervention.

Tiffani Lawton: In your case, it sounds as though the vaginal birth experience was traumatic...

Christie: yes...and no. The labor part was the worst...the pushing was not as bad as I thought it would be

Lauren: Christie: - thank goodness the outcome of your first delivery ended up being positive and that you had a physician to work with you on your second one.

Christie: Yes... but as you read in my article... I was made to feel bad about my decision.

Tiffani Lawton: By who?

Christie: Family and friends. I was told I was a chicken and taking the easy way out.

Lauren: *sighs*

Jennifer Mossholder: Christie, as a doula I do not like it when people are made to feel bad for bottle vs. breast, epidural vs. "natural". Every case is different, every time!

Christie: I think it is so unfair.

Tiffani Lawton: It is all an independent decision....

Lauren: I hate that too Jennifer. It is one of my biggest pet peeves.

Jennifer Mossholder: I certainly have MY ideals, but that's what they are: ideals

Christie: Actually...funny thing...a MAN commented on my article...telling me I was wrong for bringing my babies into this world in a drunken stupor!!

Jennifer Mossholder: A lot of docs, midwives, doulas, friends, etc will all give input. While it can be valuable, mothers get overwhelmed.

Tiffani Lawton: As a nurse, I respect the individual needs of all people...it is about what they want and need, not what I want and need.

Lauren: My approach for peer support of other moms is to support the journey towards recovery THEY have chosen even if it wouldn't be right for me - I have to remember they need to choose what's best for them and provide them with guidance towards that end.

Christie: I think it is just important for women to trust their bodies...I learned that my body would tell me what it needed and what to do.

Lauren: AMEN to that Christie.

Christie: Exactly, Lauren:!

Lauren: Jennifer - I've had three vaginal deliveries myself but I've experienced PPD twice which has led me to provide peer support and become an advocate in that realm. A lot of the moms I come in contact with have had c-sections and being that I'm not personally familiar with them, I wanted to come tonight to gain some insight.

Jennifer Mossholder: Lauren, I knew from day one of the triplet pg I was 99.9% going to have a c-section and it still bugged me to have the section.

Tiffani Lawton: I had four cesareans...I wanted to state that the football hold is what worked best for me after my cesarean with breastfeeding

Jennifer Mossholder: I found the football hold best for me BOTH times :)

Tiffani Lawton: Jenn, I also did want to go back to a section in your presentation...If a cesarean incision opens, it is generally not re-sutured. Tiffani Lawton: Instead, it must heal from the inside out...an opened incision can never be re-sutured. If sutured, it creates a greater risk of infection..

Jennifer Mossholder: Yes, but I have had ONE client who literally was open on one end.

Tiffani Lawton: And she healed from the inside out?

Jennifer Mossholder: They opened her up and redid it the external stitching. It wasn't the uterine stitching, it was the abdomen.

Tiffani Lawton: That is usually not done...it is a risk. My last incision opened and became infected...took 8 months to heal with IV antibiotics...the whole 9 yards.

Christie: Yikes!

Jennifer Mossholder: Yes, this client was feverish and oozing....

Tiffani Lawton: Because of the delayed healing time and decreased mobility, I ended up with a pulmonary embolism that nearly killed me.

Jennifer Mossholder: Oh My! With the triplets I bled for 5 months.

Christie: Suddenly my 29 1/2 hours of labor are a cake-walk!

Jennifer Mossholder: I was too chicken to get a D&C (suggested by the doc)

Tiffani Lawton: The VBAC debate that you mentioned...you presented that very well...

Jennifer Mossholder: Thanks!

Tiffani Lawton: There are many bans across the country and you are so accurate in saying that it is because of the staffing requirements. They must have a OB surgeon, an assistant, anasthesia, and an open operating room available. Hospitals do not want to pay for that... however, it is a patient's right to have that provided.

Jennifer Mossholder: I can see both sides of the issue. When I interview birth clients I really try to give them both sides of the story. It's not always the cost too. It's where the placenta attaches for the 2nd birth, how many babies the mother is carrying, etc.

Christie: I am just curious... why would one want to have a VBAC? For the experience?

Jennifer Mossholder: Yes, a lot of women feel they were "cheated" out of a "real" birth.

Christie: Not me...from day one I was trying to go old school...knock me out and wake me when the baby's here. They didn't like that idea.

Tiffani Lawton: Christie, if I could turn back the hands of time, I would VBAC my last three.

Christie: Really?

Tiffani Lawton: I would have at least liked to have tried...and my first one, I labored 56 hours, he got stuck and I had a c-section. I felt cheated...

Jennifer Mossholder: The thing is, if hospitals allowed more mobility etc., I don't think there would be so much "babies getting stuck". Sometimes they truly are stuck, but not as much as I think it is being reported.

Tiffani Lawton: That is why they need more doulas like you!!!

Jennifer Mossholder: My website is www.doulamom.com

Lauren: My links are: www.unexpectedblessing.wordpress.com and www.postpartumdadsproject.org

Tiffani Lawton: Jenn, thank you for a wonderfully informative presentation!

Jennifer Mossholder: Thanks for having me!

Tiffani Lawton: Ladies, thank you so much for coming!