ההשפעות הרגשיות והנפשיות של לידה בניתוח קיסרי על היילוד

The Emotional Ramifications of Being born in a Caesarean Delivery 

by Amy Lauren Shapira

Introduction

Caesarean deliveries are the number one major surgery in the United States, where the rate has gone from 2 to 3 percent in the 1970s (Verny, & Weintraub, 2002) to 31.1 percent in 2006 (Yabroff, 2008), exceeding the recommendation by the World Health Organization (WHO) that caesarean deliveries should make up less than 15% of all births and less than 9.5% in wealthy, westernized nations. Around the world, rates of caesarean sections are soaring as well. In 2004, caesarean delivery rates were as high as 90% in some private clinics in Brazil (Song, 2004).

Interest in the experience of childbirth has increased enormously in the United States since the 1970s. Much emphasis has been placed on having an optimal childbirth experience and on early parent-infant bonding (Affonso, 1981). Still, the process of birth has never been so medicalized as well as regulated by state legislation, insurance companies, and other bureaucratic systems (Noble, 1993).

The emphasis in the obstetrical health team has long been on the physiological outcome of caesarean childbirth both for the mother and the newborn (Affonso, 1981). Groups such as the VBAC (Vaginal Birth After Caesarean) movement and C - sect have, for several years, been addressing the mother's perspective and the question of the politics of too many caesareans (English, 1994). Though caesarean deliveries save the lives of mother and child, little attention and respect have been given to the baby and the baby's emotional well-being by the obstetric health team (Oliver, 2000).

In this paper I will review the prenatal and perinatal research literature on the emotional ramifications of being born in a caesarean delivery. The first section will describe the perinatal experience of the caesarean born, the second will discuss how this experience has been shown to affect a caesarean born personality and relationships later on in life and the last part will talk about how modifications in the "routine" can humanize caesarean delivery for the newborn, the mother and the father to meet both the goals of caesarean delivery and family-centered childbirth.

Literature Review

In this section I will review the literature on the emotional ramifications of being born in a caesarean delivery. There are two kinds of caesarean deliveries: those done before labor starts and those done, often in emergency conditions, after some labor. Since the usual medical terms, elective caesarean and non-elective caesarean, focus on the doctor's and the mother's experience, and this paper focuses on the child's experience, I will use Jane English's (1985) definitions of the two kinds of caesarean born: "non labor caesarean" defines the child who is born in an elective caesarean and "labor caesarean" defines the child who is born in a non-elective caesarean.

Evidence of birth memory, especially associated with trauma, has been reported frequently in the last seventy years (Noble, 1993) and the importance of the birth experience in formation of self image and world view has been documented in works by Feher and Grof (English, 1994). Freud was the first to propose that birth can be remembered and that it can influence personality (Feher, 1981; Verny & Weintraub, 2002). Rank believed all neurotic anxieties were repetition of the physiological phenomenon of birth (Feher, 1981). Leslie Feher (1981) in her book The Psychology of Birth: Roots of Human Personality, states that "all patterns in life are metamorphic re-enactments of birth" (p. 68). Feher, who is a psychotherapist, claims that studies of case histories, work with patients and broader surveys have all led her to believe that certain personality structures relate to specific birth experiences. Feher admits that much of this material can be considered hypothetical and that there is a need for large controlled trials to scientifically validate her observations and assumptions.

Verny and Weintraub (2002) in their book Tomorrow's Baby, stress that although a cause-and-effect relationship between mode of birth and personality is not suggested, there is a consensus among the findings of clinicians working in the field of prenatal and perinatal psychology, that prenatal and perinatal factors create a predisposition that may be exacerbated and adversely affect one's personality. As they discuss the influence our birth can have on our life they eloquently state, that "birth is a transformative psychological event, a psychic pacemaker that unconsciously motivates our subsequent life. How we enter this world plays a crucial role in how we live in it" (p. 70).

In light of these works it is essential to examine what it is like for the child to be born via a caesarean. How do the caesarean born individuals differ in their basic personality, life attitudes and strategies, and interpersonal relationships from vaginally born individuals? Do caesarean-born individuals have distinct personality traits that are associated with the way they entered the world?

Jane English (1985) was one of the first to address these issues in her book Different Doorway: Adventures of a Cesarean Born. In her book, English, an artist, translator, and photographer who has a PhD in sub-atomic particle physics, describes her ten year journey of self discovery and exploring the personal, social and spiritual implications of having herself been born non-labor caesarean. In her journey, English followed practices such as mindful meditation, rebirthing, Gestalt therapy and more. Her book consists of excerpts from her journal offering dreams, imagery, and insights into being caesarean born as well as informative interviews she had conducted with other caesarean born individuals.

Prior to this book, most of the literature on caesarean birth viewed it as being abnormal, pathological, or unfortunate (English, 1994). English (1985) indicates that her intention in her book was to show that a caesarean birth is neither more nor less intense than vaginal birth but that it is simply different. In Different Doorway, English has sketched the first map of caesarean-born experience but stresses the fact that the material presented is anecdotal rather than scientific and that the map is not intended to categorize all caesarean birthed people but to offer a conceptual framework.

The Perinatal Experience of the Caesarean Born

English (1994), in her article Being Born Caesarean: Physical, Psychosocial and Metaphysical Aspects, presents a map describing the perinatal experience of the non-labor caesarean outlining each step of the caesarean delivery and how these could be subjectively experienced by the baby being delivered. She then explains how this experience of being delivered by caesarean differs from the experience of being born vaginally which could account for distinct habits, expectations and personality traits in the caesarean born.

Before any procedure is begun, English (1994) describes the subjective experience of the unborn child as "primal oceanic union" with the mother. This union is disturbed by general anesthesia used in surgery which could be experienced by the unborn child as poisoning and being attacked (when regional anesthesia is used there may be less sense of aloneness as the mother's consciousness is still present). The next procedure is the incision made in the mother's abdomen and uterus. This, English states, could be shocking to baby who is still unified physically and psychically with the mother.

The obstetrician then abruptly pulls the baby, who is still very much in a state of cosmic union, out of the womb (English, 1994). Noble (1993) states, that the non-labor caesarean is physiologically not ready for delivery at this point, since his systems, have not gone through the hormonal changes which prepare them for birth. In addition, the baby may experience lack of oxygen as he is lifted up above his blood supply (Noble, 1993; English, 1994). Delivery of the baby is followed by cutting the umbilical cord (English, 1994).

English (1994) believes it is necessary to include the encounter with the obstetrician as part of the birth. The encounter, she states, consists of a struggle with the obstetrician who suctions the baby's airways (because the amniotic fluid is not squeezed out of the lungs, as in vaginal delivery) and then forcefully stimulates the baby's breathing. But the encounter, according to English also includes an experience of bonding with the obstetrician which is the first to touch the baby and make eye contact with him. However, this new bond is soon broken as the baby is taken away to the nursery (English, 1994) and could be separated from the mother for as long as 24 hours (Noble, 1993).

It should be noted, that this experience may be different for caesareans being delivered more recently as some hospitals' caesarean protocols may be advanced. For example, some hospitals may use regional anesthesia enabling the mother to be awake during the delivery. Some may permit the father to be present in the operating room and so forth. The experience is also partially different for the labor caesarean, who experiences some labor before being delivered by caesarean section. 

Caesarean Personality and Relationships

Personality traits of the caesarean born have been described and addressed by numerous authors (Feher, 1981; Ray & Mandel, 1987; Verny & Weintraub, 2002, Noble, 1993). These authors link caesarean born personality traits to the perinatal experience of the individual born in caesarean delivery. Feher (1981) states that the caesarean born encounter difficulty dealing with complications leading to goals since they never experienced the conflict of birth as the vaginally born do. According to Feher, the caesarean adult expects things to be handed to him and needs the help of others to accomplish anything. In case of failure, the caesarean will blame others for not helping enough.

Feher (1981) says the caesarean born have difficulty understanding processes in general, having missed experiencing the transitional phases during contractions. This makes frustrations and responsibilities difficult to deal with. Feher adds that caesareans in general have problems in learning.

Having missed out on the initial massage the walls of the birth canal provide at birth, the caesarean born craves physical affection (Ray & Mandel, 1987; Verny & Weintraub, 2002). If one doesn't get it as a child, they may still need what seems like an excess of caressing as adults (Ray & Mandel, 1987). Not experiencing the high pressure squeezing of contractions and the journey down the birth canal, non labor caesareans have a different learning experience in terms of personal space. They may not have a strong sense of boundaries and limits and they tend to continuously test limits and boundaries. Many caesarean-born are "put in place" over and over, and are told not to be intrusive by people who expect them to have an inborn sense of limits (English, 1994).

Verny and Weintraub (2002) state the caesarean born tend to get into difficult situations and hope to be rescued. Caesareans tend not to know how to push through barriers, as their birth script is often looking for a savior because that is what happened during birth (Noble, 1993). Because the baby is separated from the mother's womb very abruptly in a caesarean birth, a procedure which sometimes involves an emergency operation accompanied by much fear and tension, caesareans are prone to be hypersensitive about issues of separation and abandonment (English, 1985; Noble, 1993; Verny & Weintraub, 2002).

When a birth doesn't happen naturally, the baby doesn't feel responsible for it. This may set up a need to find someone who will constantly "give birth" to them (Noble, 1993). English (1994) points out that caesarean birth is not limited in time to the removal of the baby from the mother, but continues for years. English (1985) writes, "'Birth' on the physical level for a caesarean is much quicker than for the vaginally born. But paradoxically, caesarean birth also can be seen as taking much longer. Many physiological, psychological and maybe even spiritual processes that occur in labor and delivery for the vaginally born happen for caesareans, if they happen at all, in their encounters with the world and with people" (p. 59).

In their book Birth & Relationships (1987) Sondra Ray and Bob Mandel discuss how birth influences the dynamics of relationships. Relating to caesarean relationships they write,

A caesarean's relationships tend to be characterized by conflicts of will, changes of heart and mind, and constant disruptions... usually they are looking for someone outside the relationship to tell them which way to go in life, then resenting it and doing the opposite. If one partner is caesarean and the other is not, the latter can be set to be the obstetrician - which happens in many relationships (pp. 83-84)

English (1985, 1994) talks about caesarean born relationships as being colorful, abrupt, and intense, characteristics which are related to the caesarean's different sense of time and space learned during delivery. She describes them as having an "all or nothing", arrow like quality rather than a wave like quality of contraction and expansion that would be learned in vaginal birth. Like Feher (1981), she addresses the little sense of process in the caesarean born, which is manifested in relationships in a tendency to expect that a relationship either exists and doesn't need to be nourished, or doesn't exist and is impossible.

English (1985) points out some positive aspects of being born caesarean,

I think there is also a sense of pioneering and leadership among caesareans ... A certain strength comes from living outside the mainstream ... Caesarean birth is an ideal structure for allowing something new to come through into the world. It sets aside some deep patterns that have been common to all human culture. We begin to realize that we don't have to do some things the way people have been doing them for thousands of years" (p. 130)

English (1994) believes the caesarean born have easy access to transpersonal awareness. Feher (1981) too, appreciates the positive qualities of caesarean personality stating that a caesarean-born can be enthusiastic, spontaneous, and artistic.

Discussion

Caesarean rates are soaring in the United States as well as around the world. There has been much concern about the medical complications related to the caesarean procedure both in the mother and the newborn. The emotional impact of undergoing a caesarean section on the woman and the impact on maternal - infant bonding have been studied and addressed as well (Affonso, 1981).

Evidence from the pre and perinatal literature suggests that we are conscious sentient beings prior to physical life (McCarty, 2004). Unborn children remember the experience of gestation and birth and these memories become the foundation for feelings and behaviors throughout life (Verny & Weintraub, 2002). Jane English's research, although subjective and anecdotal, represents a pioneering venture as she has been the first to sketch a map of caesarean-born experience and personality patterns. Further studies are needed to scientifically validate the suggested correlations between behavior and personality patterns and birth experience.

In an era when one in three babies is born by caesarean delivery it is imperative that society consider the emotional implications of being born in a caesarean delivery and strive to create changes in hospitals' caesarean birth protocols to humanize the experience for the child, the mother and the father. Dr. Robert Oliver (2000), an obstetrician, in his article The Ideal Caesarean Birth, claims that the new models of optimizing the childbirth experience have eluded caesarean delivery, where little respect is given to the baby and the baby's wellbeing.

Oliver (2000) believes it is crucial the obstetric team understand the metaphysical and transformative aspects of labor and spiritually welcome the baby through prayer and meditation. He suggests numerous ways in which caesarean birth could be humanized even in an emergency circumstance when the obstetric team has less than ten minutes to deliver the baby.

In the case of an elective caesarean, when the mother and baby are healthy, Oliver (2000) suggests to allow labor to start before performing the surgery which can ensure fewer complications for mother and baby. By using regional anesthesia the mother can be conscious throughout the delivery and breastfeed and bond with her baby after he is born. Oliver recommends a transverse incision so that the mother has the opportunity in the future for a vaginal birth and that the amniotic sac not be ruptured until after the baby's presenting part is elevated gently. The nose and throat can be gently aspirated if needed and the rest of the body is then delivered but not by the pulling of the head.

The baby could be gently compressed by the hands of the obstetrician to simulate vaginal passage, and can be covered with more warm, wet hands or towel while waiting for fetal circulation to stop. The cord should be clamped only after it stops pulsating and the baby is then given to the mother and the father while the pediatrician judges the condition of the baby and decides whether gentle stimulation of breathing is needed. The obstetrician completes the delivery of the placenta, awaiting its delivery instead of jerking it out, and closes the uterus and abdomen Oliver (2000).

Oliver (2000) believes that this ideal is possible but that there will have to be a tremendous awakening of the medical community to the need for this caesarean birth. Apparently, Dr. Oliver's vision of humanizing caesarean delivery is shared as well as practiced by other obstetricians. According to an article published in The Guardian (Moorhead, 2005), Professor Nick Fisk, an obstetrician at Queen Charlotte's and Chelsea hospital in west London, practices what he calls "a 'natural' caesarean section" which is performed quite similarly to Dr. Oliver's recommendations.

Professor Fisk (Moorhead, 2005) states: "... while couples having normal deliveries have been given more and more opportunities to be fully involved in childbirth, very little has been done to see how we could make the experience more meaningful for those having caesareans" (Morrhead, 2005, para 5). He also states that caesareans are done a certain way because that is how they have always been done, when in fact they could be done differently - and in a way that parents feel better about. Jenny Smith, a midwife who works closely with Fisk, describes the benefits of performing a "natural caesarean": "the parents feel more involved, which gives them a better start to family life, breastfeeding is easier to establish, and one can see how much calmer the baby is".

Dr. Chris Gunnell, an Australian obstetrician, has just started performing "assisted caesarean" deliveries, a procedure that allows the mother to be the first to hold her child, with her hands guided into the womb by medical staff (Dowling, 2007). "Assisted caesarean" is unlikely to become mainstream procedure as Dr. Gunnell states, "Speaking to a lot of women and talking about this, many of them are actually grossed out about the idea; they don't like the concept of helping" (Dowling, 2007, para 14). Dr. Gunnell adds that there are still a lot of things to work on before "assisted caesarean" becomes standard, if at all. For example, the risk of infection needs to be addressed.

It is evident that, not only does the medical community need to become aware of the need to humanize caesarean birth, but future parents need to be educated about this subject as well.

References
Affonso, D. (1981). The Impact of Caesarean Birth. Philadelphia: F.A. Davis.
Dowling, J. (2007). Delivered safely by caesarean with his mother's hands [Electronic version]. The Age. April 15th.
English, J. B. (1985). Different Doorway: Adventures of a Caesarean Born. Point Reyes Station, CA: Earth Heart.
English, J. B. (1994). Being born caesarean: Physical, psychosocial and metaphysical aspects. The Journal of Prenatal & Perinatal Psychology & Health, 7(3), 215-229.
Feher, L. (1981). The psychology of birth: roots of human personality. New York: Continuum.
McCarty, W.A. (2004). Welcoming consciousness: supporting babies' wholeness from the beginning of life - an integrated model of early development. Santa Barbara, CA: WB Publishing.
Moorhead, J. (2005). Every bit as magical [Electronic version].The Guardian. December 3rd.
Noble, E. (1993). Primal connections. New York: Fireside.
Oliver, R. (2000). The ideal caesarean delivery. The Journal of Prenatal & Perinatal Psychology & Health, 14(3-4), 331-344.
Ray, S., & Mandel, B. (1987). Birth and relationships: how your birth affects your relationships. Berkley, CA: Celestial arts.
Song, S. (2004). Too posh to push [Electronic version]. Time Magazine. April Issue.
Verny, T.R., & Weintraub, P. (2002). Tomorrow's baby: the art and science of parenting from conception through Infancy. New York: Simon & Schuster.
Yabroff, J. (2008). Birth, the American way [Electronic version]. Newsweek. January Issue.