What to expect when you're unsuspecting

Eight years ago, Rachel Somerstein was wheeled in for an emergency c-section. "I felt that!" she called out, with the first slice into her abdomen. But no one listened.

A few years ago, I was invited up to SUNY New Paltz to give the 2021 Ottaway lecture. Earlier in the day, as part of my pre-lecture responsibilities, I taught several classes of students, one of which was normally taught by Professor Rachel Somerstein, who told me about her ongoing research into the c-section. What was there to know, I wondered, about the most common surgery in the world, other than the fact that it has saved many a baby and mother’s life?

A lot, as it turned out. And, like most things related to women’s health, not enough. But Somerstein was determined, after her own traumatic c-section—when she felt every slice and tug into her abdomen, but her pain was dismissed and ignored by her surgeon—to use her skills as a journalist to find out as much as she could, both for the 1 in 3 mothers who’ve already had c-sections and for those yet to come. How did the c-section become so ubiquitous? What are the longterm health issues and risks for those who’ve undergone them? And why weren’t those of us with uteri informed about any of this before going into labor? The result, Invisible Labor: The Untold Story of the Cesarean Section, was just published last month. I have asked Rachel to write a guest essay to summarize her findings.

-Deborah Copaken, author of Ladyparts

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By: Rachel Somerstein, guest essayist

When I got pregnant for the first time at 33, I believed that I’d have a vaginal birth. My mother and grandmothers had had vaginal births; my pregnancy was healthy. In fact, I was so certain I’d have a vaginal birth that I didn’t bother reading the parts of the pregnancy books about c-sections. My plan, such that I had one, was to labor without an epidural. That seemed right because I thought of myself as a “natural” person: I did a lot of yoga, was in touch with my body, meditated. I was a vegetarian! (mostly). I bought the “healthy” chips, the health-food-store deodorant. I couldn’t have expressed this at the time, but I believed—erroneously—that the way I birthed reflected something essential about my character, rather than the characteristics of the hospital where I had my baby or the skills of the people taking care of me. 

When I went into labor, I was almost immediately rocked by monster contractions from my baby’s head hitting my tailbone. This excruciating pain is produced by back labor, and it’s not uncommon among people shaped like me: short torso, small stature (I’m 5’2”). I was in tremendous pain, but didn’t really have a plan for how to cope with it. So I got an epidural—though the anesthesiologist had to redo it multiple times. At 1 in the morning, I started to push, and a nurse turned on the baby warmer. I was about to meet my baby! It was her due date, which felt cosmically right, particularly for a person like me, who’s chronically running behind schedule. But then my daughter’s heart started to dip after the contractions—which can indicate that she wasn’t tolerating labor, and needed urgently to come out—and the midwife taking care of me said it was time for a c-section.

And so, because c-sections had been beyond my field of vision throughout pregnancy, I didn’t learn what happened during one of them until I was in the operating room for my daughter’s birth. Scared, and exhausted, it’s not exactly the optimal time to learn the steps: you’re basically naked, the OR is freezing-cold; you sit on the edge of the gurney, back humped, so the anesthesiologist can insert a spinal; you lay back beneath the enormous weight of your belly. 

But then things went wrong. The anesthesia did not work. Perhaps the worst part—and there is a worst part, even in this nightmare scenario—is that though I told the OB, “I felt that,” when he started to operate, he did not stop.

“You’ll feel pressure,” he assured me.

 “I felt that,” I told him again.

He continued to cut, though as he later put it in his notes, my pain was evident to everyone in the OR—I was kicking my legs “quite a bit,” he wrote, and screaming from the pain.

After her birth, the anesthesiologist put me under general, then sewed me up. I don’t remember my daughter’s birth, that great moment of face-to-face, There you are! This loss matters more to me now, eight years after her birth, than it did at the time. That’s because I’ve dealt with the trauma, and have also since had another baby—both experiences that allow me to measure what I, and what my daughter, lost irretrievably.

Rachel and her daughter after the traumatic delivery.

When I tell someone this story, they generally react in one of two ways. One: they’re horrified and shut down the conversation. Two: they express shock, outrage, anger. Then—especially when I’m talking to a woman—they say, you know, I can actually see how that might happen. Because probably every woman has been there there’d by a professional: the IUD insertion shouldn’t hurt that much, you’re exaggerating. Or, the symptoms are all in your head—when really it’s your thyroid or perimenopause or some other condition causing the heart palpitations, the rage, the anxiety. This is particularly true when it comes to pain, which studies show people underestimate for women beginning in childhood—following surgery, according to one paper, girls are less likely to receive opioid pain medication than boys.

On a national level, we’re witnessing this refusal to listen to women speak about their bodies’ needs play out in the wake of the Dobbs decision, which revoked access to abortion. There are countless stories of people forced to continue with pregnancies that they say they don’t want—even ones that threaten their lives. What better evidence is there that when it comes to women’s bodies, and their reproductive health in particular, we won’t listen? In this way, what happened to me is exceptional, and also, too common. It’s the stakes of a c-section, and the consequences—missing out on my daughter’s birth, developing PTSD, feeling unsafe in my own body—that made such an everyday event so serious, so life-changing. 

In recovering from my cesarean, I made a study of surgical birth. I wanted to understand not only how what happened to me could have happened, but also, how c-sections came to be the world’s most common operation, comprising 1 in 3 births in the US. What I’ve come to see, since publishing my book Invisible Labor: The Untold Story of the Cesarean Section, is that c-sections share something essential with other aspects of women’s health: like peri-menopause, menopause, postpartum mental health disorders, endometriosis, hyperemesis gravidum—the list goes on—cesareans are under-researched, underestimated, and under-discussed in the public culture.

Some of what we don’t know about c-sections is devastating for mothers. For instance, they’re associated with secondary infertility—they can make it harder to conceive again—and miscarriage. We don’t yet know why this might be. These answers are likely discoverable—we simply haven’t prioritized researching them. Because while researchers have long known that c-sections are associated with having fewer children, they assumed that was because mothers who’d had a cesarean didn’t want to have more kids. An NIH-funded study by Kris Kjerulff showed that wasn’t the case—that actually, mothers who’d had a c-section had unprotected sex more often than mothers who’d had vaginal births. But to no avail, in some cases; after 8 years, in her research, 42 percent of c-section moms had had only a single live birth, compared with 33 percent of mothers who’d birthed vaginally.

Rachel and her daughter today

C-sections also raise the likelihood of needing a hysterectomy later in life, the second-most-common surgery for women in the United States (preceded only by c-sections), and make it more likely that that hysterectomy will be complicated. What’s more, as multiple pelvic floor physical therapists explained to me, if you don’t restore the peritoneum, which contains abdominal organs, you can develop back pain and urinary incontinence years later. Adhesions can also cause chronic pain. All news to me until I did my research, and developed pain in my abdomen. (“Could be adhesions,” a gastroenterologist told me; “What??” I asked, incredulous, the c-section seven years in the rearview.)

There’s also little public conversation about how hard c-sections are on mothers. We say they’re for people too posh to push, the easy way out—like putting on a band-aid, Keisha Goode, a sociologist at SUNY Old Westbury, told me—but recovery from a cesarean is long and painful. One mother I talked to likened her incision to a fiery dog collar of pain. Yet even as we under credit how tough they are, we treat them like a second-class way to birth, artificial, inauthentic—something I believed too, until I had one. As if the mothers who’ve had them failed to want vaginal birth strongly enough—as if a c-section is some failure of character, or of will.

None of this is to stigmatize the operation—quite the opposite—but to invite all of us to look closely at the cascade of consequences that surgical birth can set in motion. Few mothers know about these possible outcomes until they personally experience them. It’s unacceptable that more people believe that Caesar was the first c-section baby (he wasn’t) than know c-sections are associated with future pregnancy complications, hysterectomy, miscarriage, and infertility.

In the course of reporting my book, while interviewing families about their experiences, one father whispered to me while his wife was in the bathroom: can c-sections cause miscarriages? The couple had been struggling for years to have another baby; his wife couldn’t keep a pregnancy, and they were nearly ready to give up trying, though they wanted another child very much. No one had told them that her first surgery could be a reason for their ongoing trial. I was both honored and saddened that he would ask me—that there wasn’t anyone else they felt they could ask, and that no one else had bothered to tell them.

But like birth trauma, none of these downstream consequences is linked, in public data, to c-sections—in the sense that, they wouldn’t be evident from perusing national data about c-section complications.

C-sections save lives; in the countries where providers don’t do enough of them, mothers and babies die preventable deaths. And. We need to look more directly at them to better appreciate, research, and understand the ways that they impact mothers’ health long after birth.

There’s a lot we can do about this. First—as a lactation consultant I interviewed told me—“There’s at least a 30 percent chance you’re having one. And no one fucking talks to you about it until you’re in there.”

So. Let’s talk.

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