Women’s experiences of labor, surgery and first postnatal

37J. Jpn. Acad. Midwif., Vol. 22, No. 1, 2008

Original article

*Department of Nursing, College of Life and Health Sciences, Chubu UniversityDoctoral course, Graduate School of Medical Sciences, Hiroshima University

Received 26 March 2007; accept 22 February 2008

Women’s experiences of labor, surgery and first postnatalweek by an emergency cesarean section

Naomi YOKOTE*

Abstract

PurposeThis study investigated the experiences of Japanese women who underwent emergency cesarean sec-

tions (c-sections), including their experiences during labor before to the decision for surgery, during sur-gery, and during the first postnatal week.Methods

Eleven Japanese women who delivered live babies by emergency c-section at a private maternity hos-pital were interviewed in a semi-structured manner on the second and seventh postpartum days. Interviews were tape-recorded, and transcripts and participant observation in the postnatal ward assisted the interpre-tation. Data were analyzed qualitatively and inductively.Results

Eleven women (seven primiparas, four multiparas) participated in the study. The main reasons for surgery were fetal distress (n=9) and arrest of labor (n=2). The time between making the decision to per-form surgery and birth ranged from 15 to 69 minutes. Six themes were evident from the women’s experi-ences: shock of disappointed expectations, unavoidable fear and responsibility, release from pressure, re-experience of fear and pain, being “saved” by the baby, and getting out of a vicious cycle. Trying labor pain, shock, fear of their babies’ or their own deaths, and feeling powerless and guilty contributed to the women’s negative feelings about their birth experiences by emergency c-section. After surgery, however, women felt loving toward their babies, who had been born safely as a result of the surgery, and eagerly breast-fed or took care of the infants with midwifery/nursing support.Conclusions

The findings suggest that prenatal childbirth classes need to include information on and discussion of possible emergency c-section and that emotional support from midwives and nursing staff in the operating room/postpartum unit helps to decrease a woman’s negative feelings about birth experiences by emergen-cy c-section and enhance her experiences as a mother. In addition, medical staff should be more aware of the birth trauma felt by the expectant mother surrounding emergency c-section.Key words: emergency cesarean section, birth experience, postpartum experience, trauma and emotional support

J. Jpn. Acad. Midwif., Vol. 22, No. 1, 37-48, 2008

I. Introduction

The rate of cesarean sections (c-sections) in Japan has been gradually increasing since the 1980’s. In 2002, the c-section rate ranged between 12 and 18%, this rate has doubled in the last 15 years (Mother’s & Children’s Health Organization, 2006). Factors contributing to the rise

include: recent advances in neonatal care, increased safety of surgery, improvement of postoperative management as well as increased proportion of high risk expectant moth-ers who married late and are of advanced age at the time of pregnancy, all factors play a part in the steady rise of na-tion’s c-section rate (Shin, 2002). Nevertheless, this rate is still lower than that of 29.1% in 2004 USA’s rate (Medical

38 J. Jpn. Acad. Midwif., Vol. 22, No. 1, 2008

News Today, 20 November 2005) and a rate of more than 20% in the UK (BBC News Online, 13 April 2001).

Even if a woman and her fetus are at low risk dur-ing pregnancy, an emergency c-section may likely be required if there are existing maternal and/ or fetal con-ditions that are incompatible or unsafe for vaginal birth when labor begins or while a vaginal delivery is in progress. In this situation, the actual labor and delivery experience may differ considerably from the woman’s original expectations for the birth event. After surgery, despite the disadvantageous situation a postpartum woman may encounter which includes physical and mental fatigue and an abdominal wound, new mothers must face the difficult and unfamiliar task of initiation of parenting roles as well as the establishment of im-mediate and early bonding between mother and infant.

Some studies have reported that women who have experienced emergency c-sections have stronger negative feelings about their birth experiences (Marut & Mercer, 1979; Cranley et al., 1983; Ryding et al., 1998a) and poorer mother-infant interactions (Trow-ell, 1982) than women after normal vaginal delivery or elective c-section. Emergency c-sections, which represent medical intervention at the time of delivery, decrease women’s satisfaction with their birth experi-ences (Waldenström et al., 1996). These studies have emphasized the need for emotional support for women who undergo emergency c-sections, but the quantitative approaches have not revealed what aspects of the birth experience were negatively perceived by the women. Only Ryding et al. (1998b) described women’s thoughts and feelings during consecutive phases of the deliv-ery process by emergency c-section. They pointed out that women experienced fear, guilt, and anger, despite happy with their healthy babies. Ryding’s study, how-ever, did not include the intra-operative and postopera-tive experiences of women who had spinal anesthesia, because all of the women in their sample received gen-eral anesthesia. Currently in Japan, in order to increase women’s satisfaction and to reduce anesthetic compli-cations, doctors prefer spinal anesthesia, except under certain circumstances, e.g., serious fetal distress caused by grave placental abruption (Terui, 2002; Watanabe & Inaba, 2002). Customarily, women in Japan usually re-

main in hospital for more than 1 week after a c-section. There have been some Japanese studies of emergency c-sections based on loss experiences (e.g., Tono & Kondo, 1988). Currently, there no studies that describe women’s experiences in the time following emergency c-section.

Therefore, given the current medical and obstetri-cal practice in Japan, a descriptive study of women’s feelings, thoughts, and reactions of emergency c-sec-tion are needed in order to better understand the expe-riences of women who undergo emergency c-section. The study findings will enable providers to improve their care and offer individualized and appropriate sup-port to women during labor and surgery and during the postpartum period.

The purpose of this study was to investigate Japa-nese women’s experiences of labor prior to the decision for an emergency c-section, during surgery, and during the first postpartum week; all participants delivered live babies by emergency c-section.

II. Methods

Research designA qualitative and inductive design was chosen to

explore and describe the labor, surgery, and postpar-tum experiences of women who underwent emergency c-section. This design was chosen because I believed that women have individual and varied experiences during the birth and early postnatal process, and my aim was to determine what aspects of emergency c-sec-tion produce negative feelings in the women I studied.

SettingEleven patients in a private maternity hospital in

Kyushu, Japan, participated in this study. The hospital oversaw approximately 2300 births annually and the c-section rate was 8%. The numbers of emergency and elective c-sections were almost equal. Women who un-derwent c-sections usually receive spinal anesthesia in the operating room and after completing the operation; epidural anesthesia was administered for the control of wound pain for 2 days. The skin incision was vertical and sutured with a skin-stapler. Women could ‘room-

J. Jpn. Acad. Midwif., Vol. 22, No. 1, 2008 39

Women's experiences of labor, surgery and first postnatal week by an emergency cesarean section

in’ with their babies if possible and were discharged on the eleventh day if they showed good progress without postpartum complications.

Inclusion and exclusion criteriaPossible participants included Japanese women

who delivered live babies by emergency c-section were chosen at the hospital where the study was conducted, regardless of age, parity, or the reason for surgery. If a woman had intended to have a planned c-section but underwent an emergency operation, she was considered a possible participant. Efforts were made to determine whether women’s experiences differed depending on parity, the reason for surgery, and the timing of the de-cision for surgery.

However, to avoid exacerbating physical or emo-tional problems, I excluded women with heart disease, severe pregnancy hypertension syndrome, psychiatric disease prior to delivery, postoperative/postpartum complications, or poor prognosis of the newborn due to asphyxia, congenital abnormality, or any disease.

Access and ethical considerationsTo gain access to participants, I requested the

cooperation of the hospital where the study was con-ducted. The director of the hospital and the head of the nursing department gave permission for the study.

Women who met the inclusion criteria were iden-tified in the postpartum ward. I contacted midwives and nurses through fieldwork and obtained relevant information about each potential participant. Women’s perceptions of their birth experiences including satisfac-tion can change over time. The timing of the assessment for satisfaction with birth experience or care in deliv-ery, therefore, is important (Lumley, 1985). To obtain fresh and vivid feelings or memories about the delivery, participants were interviewed for the first time on the second postpartum day. A pilot study involving three women after c-section was conducted and served as the basis for the interview schedule. One of these women had an emergency c-section was included in the final sample, because the pilot schedule and pilot interview guide was maintained real interview.

On the day after surgery, each potential participant

who met the criteria received an oral explanation of the study and a written information sheet that explained the purpose of this study and what participation would en-tail. The written explanation informed potential partici-pants of their right to refuse or withdraw at any time. The women were assured that they and their babies would not be at a disadvantage in their hospital treat-ment if they refused to participate in the study. They were also assured anonymity and confidentiality. The data were handled exclusively by one researcher and were used only for the purposes of this study. Women who agreed to participate signed a consent form de-signed for this study. If any time, I recognized that the woman and/or her baby needed additional care, medical care, information or teaching, e.g., relief of wound pain or trouble with breast feeding, the woman’ concern and /or need was relayed to the medical staff for follow-up after the participant’s agreement was obtained.

On the appointed day, I reconfirmed the women’s willingness to participate based upon their physical con-dition. To minimize fatigue, the women were interviewed at their bedside for a period of no more than one hour. If they had unplanned medical procedures, or if visitors were present or the participant felt unwell, the interview was interrupted and completed at a later time.

Data collectionParticipants were given two semi-structured inter-

views (Holloway & Wheeler, 1996), which contained in an interview guide with focus on this research theme. The interviewer (author) reinforced the par-ticipants’ situation with participant observation in the postnatal ward. First interview was conducted on the second postnatal day to get vivid feeling of emergency c-section. Second one was conducted on the seventh postnatal day to get participants’ thoughts, reactions and feelings toward baby, parenting and hospital stay.

The opening question during the first interview was “Please describe your birth experience, including how your delivery began and progressed, with your feelings and thoughts at that time.” To collect the same type of data from all participants and to save time, I prepared an interview guide (Holloway & Wheeler, 1996). To reflect the current medical care delivery in


Japan, I modified the interview guide that included six phases of during the delivery process of an emergency c-section (Ryding et al. 1998b). The guide for the first interview consisted of eight phases which started from admission for delivery, before knowing about any surgery, to seeing the baby in the operating room and being transferred to the postpartum ward. If the participant initially hesitated to talk or seemed to have difficulty reflecting about her experiences, she was encouraged to describe by promoting from the inter-viewer with questions such as “Can you tell me more about your feelings at the time?” and “How did you feel about that?”

During the second interview, the participants de-scribed their postoperative and postpartum experiences in the hospital, which included the following: holding the baby and breastfeeding for the first time, seeing the operative wound for the first time, parenting, and re-ceiving support from medical or hospital staff and fam-ily.

Prior to the beginning of each interview, each participant was reminded of the objectives of the study and her rights. All participants consented to tape-record the interviews. Since all were in private rooms, their privacy during the interviews was protected.

Since the participants knew that I was not a hospi-tal staff member but a midwife, I was sometimes asked by the women for advice or opinions during interviews. But, as a midwife researcher, I was remained that it is important to refrain from influencing the responses of any potential participant; therefore, offering personal, professional or clinical opinions when conducting an interview must be avoided during all interviews (Marchant & Kenney, 2000). I maintained neutrality and encouraged participants to seek advice from the medical and hospital staff when participants had ques-tions and concerns.

Birth is a very individual and private event; thus, the extent to which participants are willing to talk about their experiences with a researcher is influenced by the relationship between the two. To create a rapport with participants and to delve into the interpretation of the descriptions of their experiences during the inter-views, I acted as a “participant-observer” (Holloway &

Wheeler, 1996). When women or babies required im-mediate care during the observations, e.g., support of breastfeeding or parenting at the bedside, I helped them in context and then reported the incident to the nursing staff. I also noted other data than formal interview to field notes after the dialogue with the participant and/or observation.

Data analysisA qualitative and inductive method of analysis us-

ing the KJ method (Kawakita, 1967) was chosen for this study. The KJ method, which is used in fieldwork in social science, aims to explore main elements, fac-tors, or concepts, and the relationships among these concepts, and to find general order from individual chaotic phenomena with no preconceptions, pre-exist-ing theories, or “wishful thinking” (Kawakita, 1991). Hence, this method was consistent with the aim of this study.

During the analytic process, I obtained consensus regarding validity through discussion until agreement was reached with three researchers including: a uni-versity professor, a midwife, and a nurse with at least a Master’s degree. All were familiar with the KJ method. To increase validity, midwives and nurses at the partici-pating hospital checked the results, and no staff mem-bers objected. To obtain reliability, I refrained whether interview process and my response was correct, using field note. I also feed backed my interpretation of par-ticipant’s talk and got a confidence or made a correc-tion.

III. Results

ParticipantsEleven Japanese women who met the eligibil-

ity requirements were invited to participate in this study, and all consented to participate. The participants included seven primiparas and four multiparas and ranged in age from 20 to 43 years old (mean=31 years old). The main reasons for surgery were fetal distress (n=9) and arrest of labor (n=2). The time between mak-ing the decision to have surgery and the birth of the baby ranged from 15 to 69 min. When the decision was



made to have surgery by the doctor, seven women were without family attendance; only one had her partner present in the operating room. All women received spi-nal anesthesia. Two babies were premature (32 and 36 weeks), but they were not transferred to a special unit, and all babies showed good progress.

Women’s experiences of emergency c-sectionSix themes emerged from the women’s experiences

of emergency c-section: shock of disappointed expecta-tions, unavoidable fear and responsibility, release from pressure, re-experience of fear and pain, being “saved” by the baby, and getting out of a vicious cycle.

—Relationship between the themesAs shown in Figure 1. When the decision was

made to have an emergency c-section during labor or after emergency admission, women experienced shock and disappointment about their expectations. At the same time, they inevitably experienced fear and a sense of responsibility; therefore, they chose to trust the med-ical staff and undergo the surgery. At the time of the birth, they were released from pressure immediately. After the birth, they re-experienced fear and pain, but in different ways than before surgery; however, they felt that they were mentally “saved” by their babies. By 1 week after the birth, almost all subjects felt that they were able to escape the vicious cycle of positive and

negative feelings as a result of being in good physical and mental conditions (both mother and baby), that they can care for their babies, discuss the birth experi-ence, and receive emotional support from their partners and/or the midwives and nursing staff.

—Contents of six themes of women’s experiencesThe following describes each theme with selected

quotes; the participants’ identity is noted by the num-bers in brackets (e.g., P1- participant 1).

Shock of disappointed expectationsWomen had consistently expected to have “natural”

deliveries and “healthy” babies through late pregnancy and the first stage of labor, and had not suspected that they would abruptly require surgery instead of expe-riencing a natural delivery. Some women had been anxious about whether they could have their babies by vaginal birth because of difficult in coping with labor pain and/or having a prolonged first stage. However, they had believed that they would be capable of hav-ing a successful vaginal delivery with the care and en-couragement from midwives. Therefore, they had been coping with their labor through non-pharmacological methods such as using breathing and relaxation tech-niques and applying massages for pain relief until just before the doctor explained the need for emergency c-section.

being good condition(both mother and baby)

Receiving emotionalsupport from

partner/midwives

positive/negativefeeling

TimeBirthDecided emergency cesarean

section in labor/admission

NOTE: One-way arrow shows time order. Two-way arrowshows conflicting relationship. Reversal arrow showsopportunity of escaping from a vicious circle.

Shock ofdisappontedexpectations

Unavoidablefear and

responsibility

Releasefrom pressure

Being saved bythe baby

Re-experiencesfear and pain

Escaping from a vicious circle

Caring forthe baby

Discussingbirth experience

(first postnatal week)

Figure 1 Women’s experiences of labor, surgery and first postnatal week by emergency cesarean section


My labor pain was very difficult, but I had been doing my

best to keep it as natural as possible. So when the doctor

explained [about the c-section], I thought, “What was the

point of all this time I spent here?!” (P7)

When she had noticed the need of surgery, women were very confused and deeply shocked. They could not believe that the situation necessitated an emergency c-section and felt that “this can’t be true!” Despite the shock, however, they had to make an immediate deci-sion or risk the baby’s life. Some women who had ex-perienced satisfactory progress during pregnancy had not considered that they might need a c-section; thus, they were quite shocked. For example, in one case of fetal distress:

I was so upset because in my mind I had only prepared

for a natural delivery. I thought, “Do I absolutely have to

have surgery now?” and actually asked a midwife that

question. She was surprised at the question. The doctor

further explained to me that a c-section was the better

way for us because it involved less stress for my baby. The

midwife encouraged me to do this “for your baby” ; I then

consented to the surgery against my will. (P2)

Two women who had extreme emergencies caused by placental abruption similarly indicated that “the doctor and midwives suddenly took me to the operating room.” Two other women thought that they had come to see their doctors only for a check-up. In these cases, the events happened too suddenly for the women to truly comprehend the need for immediate surgery.

Unavoidable fear and responsibilityUnder the circumstance, the only thing the women

in this study, thought they could do, was to take re-sponsibility as mothers by entrusting themselves to the medical staff. However, they were equally afraid of the uncertainty of their own survival and that of their babies, and the women were overwhelmed by the quick action of the staff and the tense atmosphere in the oper-ating room.

Since I heard my baby’ s heartbeat was going slowly, I

remembered that another mother’ s baby [in a book or on

TV] was handicapped or stillborn because of a danger-

ous vaginal delivery. So I decided, “I don’ t have time to

hesitate about surgery!” ...Then, although I had agreed [to

the surgery], everything was like a flash...(P8)

However, women felt reassured with support from their partners and the medical staff. In particular, when it became necessary to make an immediate decision, they needed support from their partners. All of the women appreciated emotional support from the mid-wives and operating nurses, such as frequent explana-tions about what was happening and the act of hand holding by the provider.

I was very scared of the surgery; my body was shaking

before I had anesthesia. Somebody... maybe a midwife? ...

had taken my hand. When I noticed it, I tightly held her

hand. I was empowered by her hand and felt reassured.

(P2)

Release from pressureAs soon as the women confirmed the safe arrival

of their babies, they felt relieved and were released from the feeling of intense and pressure of responsibil-ity as expectant mothers. For multiparas, it was im-portant that both the baby and the mother herself were safe, because these women already had children.

Some women willingly watched their babies be-ing removed from their abdomens and this experience very empowered her. For example, one primipara said in excitement:

I had just seen my baby come out! The doctor said, “Now

you can look at the baby’ s head,” and I looked at the baby

... At that moment, I thought “He’ s alive!” ...because I

was afrraid that my baby might die. (P4)

After the baby’s birth, the women appreciated that the midwives supported them by showing them their babies during the procedures after the birth, allowing them to touch the baby, and providing some explana-tion of the baby’s general condition. These steps al-lowed the women to confirm the baby’s safe arrival and feel that the delivery was complete. However, one primipara felt anxious all over again after seeing her small, premature baby, and another woman who had only 15 minutes from decision to birth lost her compo-sure because the events had happened too quickly and because she was not able to see her baby, who needed medical attention and oxygen administration.



Re-experiences of fear and pain Three primiparas experienced flashbacks re-

lated to the birth experience during several postnatal days and they experienced fear again. The flashbacks involved violent labor pain while being taken to the operating room in a wheelchair; images of enduring prolonged labor in a dark room, and imagining being undergo a sense of undergoing surgery as well as hear-ing the sounds of surgical instruments.

All women suffered from pain resulting from the operative wound or uterine contractions after birth. The degree of subjective pain differed for each woman. Some women thought that they would never want to have a baby again because of the difficulties that they experienced before and after birth. For example, a primipara who had surgery because of arrested labor stated:

I had severe wound pain and uterine contraction, so I re-

ceived painkillers by injection, but they didn’ t work well.

Furthermore, I had to have an I.V. drip...I had a healthy

baby, but every day was full of pain! (P3)

When they saw their skin-stapled incision for the first time, many women were surprised that it looked “like a remodeled human.” They were anxious about wound dehiscence or the removal of the staples. Thus, they re-experienced some fear and pain, but this was a different nature than before birth. Their surprise, anxi-ety, and pain were increased by inadequate explana-tions by the doctor and/or midwife of what prompted the abrupt surgery.

Being “saved” by the babyAll of the women showed strong affection for their

babies because they were born safely despite the dif-ficulties during the birthing process, and all of them experienced unconditional peaceful feelings from see-ing and being with their babies. Many women claimed that they forgot their difficulties when they saw their babies. In addition, the participants perceived and ap-preciated that the midwives supported them according to their own pace and postoperative/postnatal condi-tion. Support promoting breast feeding or parenting strengthened the bond between mother and baby.

When I had trouble with breast-feeding, the midwife told

me, “You have very good secretion of milk. All your baby

needs is timing.” I felt that she spoke for me. She cared

for me emotionally. Not only her, every staff member, even

the cleaning ladies, often talked to me. I felt a special at-

mosphere in which everyone supported me. So I have to

keep trying, even if it’ s hard! (P 8)

The women roused themselves to care for their ba-bies and attempt to breastfeed. This resulted in a more positive outlook, a feeling of reality, and enhanced self-confidence as mothers. However, some primiparas had feelings of guilt that they had not been able to endure the labor pain through the last stage. Consequently, even if they were suffering physically, they tried to compensate for the guilt by caring for the baby.

To be honest, when I was in labor, I was centered inside

myself. Then I opted for the c-section...I felt sorry for my

baby. So even if I’ m having a hard time, I’ d like to give

this baby my breast milk. (P3)

Escaping from a vicious cycleAlthough the women started caring for their

babies, they continued to have various feelings and thoughts about their birth experiences, including both positive and negative feelings, e.g., “It was the right way to save my baby.” “But I had to give up natural birth.” “I underwent surgery, so the baby and I are healthy now.” “Still, I couldn’t deliver my baby the same way as other mothers.” They felt conflicted and alone because deep down, they felt that they couldn’t have vaginal deliveries like other mothers.

When women were spoken to gently by the nurs-ing staff or being helped with breastfeeding by the midwives, they felt peace of mind, with thoughts like “I am always protected by the staff.” Thus, a peaceful atmosphere became a foundation for the gradual im-provement toward their positive attitude. Also, discuss-ing their birth experience with a third person and listen-ing to others’ experiences helped the women to escape from feelings of isolation.

The women who overcame the conflicts and feel-ings of isolation thought that the delivery mode was unimportant and remarked.

In the nursery room, I talked with some mothers about

the birth experience. Then, a mother [multipara] said,


“Oh! When I had first baby, I had a cesarean section,

too!” ...Now, I really feel that each birth is different. (P5)

This helped to alleviate their reservations about natural birth. The opportunities to escape from the vi-cious cycle differed among the participants; escaping the cycle was more difficult for women who had pre-mature babies or those who had faced extreme emer-gency situations.

—Women’s reaction at interview and postnatal ward

When the participants talked their experience at interview, they evoked their feelings and thoughts of those days. These reactions were written down the field note and showed that their experiences of emergency c-section are very strong.

For example, when a primipara talked about her great shock that the doctor explained her need of sur-gery, she became angry and expressed her disappoint-ment by crying and punching the bed mattress, even though it was beginning of first interview. Also, when many women talked their fear and responsibility before surgery, they became nervous and rigid. But the story changed to baby birth and parenting, they had soft eyes and smile. The women who watched the scene of baby birth were very excited and full of confidence. Furthermore, they were glad to see the reaction of their partners, who loved their babies and were relieved that their partners had given birth to live babies despite un-expected surgery.

During the first interview, primiparas seemed to have suffered from that they could not have natural birth, regardless of the reasons for surgery. And they felt guilty and inferior to other mothers who had natural birth. Research interview gave an opportunity that she reviews her experience of labor and surgery, and at end of interview, some women brightened somewhat up.

[On the second postnatal day] I’ m sorry...I cried

again...but it wasn’ t hard for me to talk about my birth

experience. Never mind. I’ m glad you listened to me

because I was able to clear the delivery experience from

my mind. ... [After 5 days] I don’ t mind delivery mood.

I am in the middle of changing my negative feeling to

positive...but I didn’ t aware it until I said my feeling. (P8)

IV. Discussion

This qualitative study explored experiences of la-bor, surgery, and the first postpartum week among Japa-nese women who gave birth to live babies by emergency c-section. Six themes emerged from the women’s expe-riences: shock of disappointed expectations, unavoid-able fear and responsibility, release from pressure, re-experience of fear and pain, being “saved” by the baby, and escaping from a vicious cycle. Although this study was based on a small sample that consisted of eleven women who had healthy newborns and smooth recover-ies, the detail of woman’s feeling at critical situation of emergency c-section. In addition, although longitudinal study period at postnatal was short, the length of this study covered the usual period of hospitalization after a c-section in Japan. Therefore this finding is very impor-tant on practice.

Multiple factors contributed to negative feeling of emergency c-section. First was shock of disappointed expectation, which was caused lack of awareness that perhaps herself might have c-section. When the learned knew that they would require an emergency c-section, they were deeply disappointed, since this type of birth did not meet their expectations; they were shocked and confused physically and mentally. Ryding et al. (1998b) reported women’s feelings of disappointment when they realized that they had to give birth by c-section instead of vaginally. Participants in this study who had experi-enced satisfactory progress during pregnancy could not easily adjust to the idea of abrupt surgery. Furthermore, even two multiparas who had a history of previous c-section and two primiparas who had received expla-nations regarding the possibility of c-section because of existing for complications were disappointed and shocked as they had been eager to delivery vaginally. The study results suggest that woman’s perception of a possible c-section differ from those of medical staff and most women will be shocked to some degree by the necessity for an emergency c-section.

Second, fear and responsibility became very press-ing just before surgery. Until deciding to consent to surgery, the women felt frightened about the uncertain outcome for themselves and their babies. To save the



baby’s life, however, they could not change the reality of the situation and could only entrust themselves and their babies to the medical staff. Despite having just faced a crisis, almost none of the women were given any time to consider their situation, and most did not have their partners present because of the unexpected emergency. According to Cranley et al. (1983), more positive perceptions among women having c-sections are associated with greater participation in decision-making and the presence of their partners during the delivery. In reality, a woman facing an emergency c-section may have little opportunity to participate in decision-making, and frequently, her partner may be absent. In this way, the multi-faceted influences such as disappointment, anger, fear, lack of essential decision-making power, and absence of partner—contributed to women’s negative feelings and sense of helplessness about having to undergo emergency c-section.

The urgency of the surgery affected the women’s experience during emergency c-section. After making the decision to have surgery, the women were overwhelmed by the quick action of the staff and the taut atmosphere in the operating room. The women experienced acute fear during the abrupt surgery, and its quality and intensity was quite different from that of an elective procedure. The lack of prior mental preparation and the shortage of explanation of how a c-section is performed and what happen to the mother and baby further increased the women’s shock, fear, and anxiety. In particular, for those women who had experienced normal pregnancy thought that they were less likely to require a c-section and had received little information about it in parenting classes, during check-ups, or from information in maternity jour-nals. However, some women were given frequent ex-planations by midwives or nurses before their c-sections about what was happening in the operating room and were given updates on the baby’s condition, as well as having opportunities to hold hands with a staff member, and to actually see and touch the newborn. They very much appreciated the emotional support and thoughtful-ness provided by the staff.

Regarding re-experience of fear, it is worth special mention that three women experienced flashbacks dur-ing several postnatal days. This result, together with

the findings of Ryding et al. (1997), suggest that after emergency c-section, women may show some stress reaction-related “adjustment disorder” or “acute stress disorder” (American Psychiatric Association 1993). It is important to observe whether a new mother has a stress reaction in the early postpartum days, because these stress reactions may disturb the woman’s sleep and physical recovery, as well as the relationship with her baby.

Women experienced psychological conflict about not having been able to deliver normally at the stage of escaping from a vicious cycle postpartum. According to Marut and Mercer (1979), women’s psychological conflicts after c-section are linked to social stigma. The participants may have had stronger conflicts caused by the general low rate of c-sections in Japan and the Japanese ideology regarding birth. Japanese women are usually ashamed to cry or panic about labor pain. That is, in order to become mothers, they value being patient and uncomplaining, and are expected to endure labor pains during contractions which gradually increase in intensity and frequency. During the first interview, most of primiparas seemed to have suffered from this cultural expectation, regardless of the reasons for sur-gery. Therefore, some primiparas who had surgery for fetal distress in the early first stages felt that they had an incomplete labor experience, while other women who opted for the c-section after prolonged labor felt guilty.

Despite their negative feelings about labor and surgery, all of the participants expressed overwhelming love toward their newborns. Caring for the baby and receiving adequate support from their partners and the midwives enhanced the women’s postpartum experi-ence as mothers. Midwifery care at postnatal ward very contributed to the theme of being “saved” by the baby. In particular, primiparas gradually became confident regarding breast feeding and parenting with support based on the woman’s pace and postoperative condi-tion.

At many hospitals in Japan, the policy for a wom-an who has had a c-section, the length of the hospital stay is about one week or more (Hattori, Sano, Sato, et al., 1996). While this period is longer than in Western


countries, e.g., 4 days in the USA (Agency for Health-care Research and Quality, 2002) and 5 days in the UK (National Childbirth Trust, 1996), this was very valu-able for participants in this study. By having peaceful time with babies, they recognized that their babies were the result of successful surgery, which could not have achieved without their decision-making and patience. Since their mental recovery and acceptance after emer-gency c-section require the passage of time, midwives should make use of these days of hospitalization.

V. Implication For Practice

This study investigated the experiences of Japanese women who underwent emergency c-sections, includ-ing their experiences during labor before the decision for surgery, during surgery, and during the first postna-tal week. Experiencing labor pain before the c-section, the shock of disappointed expectations, fear regarding their babies’ or their own deaths, and feeling powerless and guilty and reexperiencing the fear and pain in the early postpartum days contributed to women’s negative feelings.

The women’s shock of disappointed expectations was related to shortage or lack of knowledge about c-section. Cesarean birth is no longer a minor delivery mode in Japan. Prenatal childbirth classes given mid-wives need to include information on and discussion of the maternal and fetal factors contributing to possible emergency c-section. Expectant parents need to have that knowledge in order to understand the reason for surgical delivery in the event they encounter such an emergency situation.

Emotional support in operating room can decrease woman’s fear and responsibility just before surgery. A woman who undergoes emergency c-section needs fre-quent explanations from midwives or nurses about what is happening and requires updates on the baby’s condi-tion. If possible, emotional support such as holding the woman’s hands, showing the mother her newborn that is cared by midwifery and/or pediatrician. And the op-portunity for her to touch the newborn in order to allays her fear and anxiety. These small but thoughtful acts by the hospital staff will give rise to mother’s feelings of

joy, satisfaction and contentment over the safe arrival of her baby.

In the postnatal ward, proper physical care and support for beast-feeding and parenting are essential to caring for the baby, and may be best opportunity for escaping from a vicious circle after the emergency c-section.

Finally, it must be emphasized that some women in this study expressed feelings of being revitalized after the interview, although the interview was not designed to affect the participants’ negative feelings about emergency c-section. Berg and Dahlberg (1998) suggested that the memories of women who had com-plicated births involving emergency c-section became clearer when they were given the opportunity to verbal-ize their birth experiences. A recent study regarding the trauma related to the birth event reported that midwife-led counseling interventions for women who reported a distressing birth experience were effective in reducing symptoms of trauma, depression, stress, and feelings of self-blame (Gamble et al. 2005). The participants’ at-titudes suggest that talking about their experiences with a third person and listening to other women’s birth ex-periences relieves feelings of isolation and helps them escape from the vicious cycle early in the postpartum period. As a good partner when women review their birth experiences and a coordinator when they talk/lis-ten to other mothers, midwives can act the important role.

AcknowledgmentsI wish to thank all of the study participants and the

committed hospital staff for their participation. I also wanted to thank Professor Yoshito Tanaka of the Grad-uate School of Health Sciences, Hiroshima University, who has given me unconditional support during all stages of this study. My appreciation goes to Professor Kuniko Miyazato of the School of Health Sciences, Ku-mamoto University and Associate-Professor Mayumi Nagata, of the College of Nursing, School of Medicine, Yokohama City University for their valuable advice, both as a researcher in mother and child health and as a mother. Finally, I wish health and happiness to all of the babies and families who participated in this study.



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緊急帝王切開分娩した女性の陣痛，手術および産褥1週間の体験

横　手　直　美中部大学生命健康科学部保健看護学科

元広島大学大学院医学系研究科博士後期課程

抄　　録

目　的　本研究は緊急帝王切開分娩した女性の手術決定前の陣痛体験，手術による出産体験，産褥1週間の体験を明らかにすることを目的とした。方　法　民間の産婦人科病院において緊急帝王切開で生児を出産した日本人女性11名に対し，半構成的面接を産褥2日目と7日目に行い，産褥入院中の参加観察を行った。面接内容は録音し，逐語記録を作成した。得られた記述データは質的帰納的に分析し，意味内容の解釈を補強するために参加観察によるフィールド・ノートを活用した。結　果　初産婦7名，経産婦4名，計11名が本研究に参加した。主な手術理由は，胎児仮死9名，分娩停止2名であった。手術決定から児娩出までの時間は15～69分であった。女性の体験は，【突然の裏切りによる衝撃】，【逃れられない恐怖と責任】，【重圧からの開放】，【恐怖と痛みの再体験】，【子どもがここにいることの救い】，【堂々巡りからの脱出】という６つのテーマで構成された。緊急帝王切開による出産体験に対する女性の否定的感情は，辛い陣痛，突然手術になった衝撃，胎児あるいは胎児と女性自身の両方に死が迫る恐怖，無力感と罪悪感が影響していた。しかし，術後には，女性は帝王切開だったからこそ無事に生まれることができた子どもに対して強い愛情を持ち，助産師や看護者のサポートを得ながら，母乳育児や子どもの世話を熱心に行っていた。結　論　本研究の知見は，緊急帝王切開の可能性に関する情報とそれについて話し合う機会を妊娠中の出産準備クラスにおいて提供する必要があること，手術室や産褥棟での助産師らによる情緒的支援が女性の緊急帝王切開に対する否定的感情を低下させ，母親としての体験を高めるために有用であることを示唆している。また，医療者は緊急帝王切開周辺の体験が女性にとってトラウマとなりうることに気づくべきである。キーワード：緊急帝王切開，出産体験，産褥期の体験，トラウマ，情緒的支援

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Women’s experiences of labor, surgery and first postnatal