Fathers' feelings and thoughts when their partners require an emergency cesarean section: Impact of the need for surgery
Naomi Yokote, Department of Nursing, College of Life and Health Sciences, Chubu University, Matsumoto-cho 1200, Kasugai-shi, Aichi 487-8501, Japan. Email: email@example.com
Aim: This study sought to identify fathers' feelings and thoughts about their partners, babies, and medical staff when an emergency cesarean section (c-section) is required. Information was gathered on fathers' reactions when they first learned of the need for surgery, during surgery, and on first seeing their babies and partners post-surgery.
Methods: Japanese men whose partners delivered a live baby by emergency c-section, without having planned to, at a private maternity hospital were interviewed. The men had semistructured interviews within 1 week post-partum, alone or together with their partners, according to the couples' wishes. The interviews were recorded, transcribed, and analyzed both descriptively and inductively.
Results: All participants had their first babies with their present partners. The indications for a c-section were classified into two groups: a fetal distress group and a prolonged labor group. Although the fathers understood the need for surgery when the decision was made, they were anxious and felt that the lives of both their partner and baby were at risk. Moreover, they were frustrated that they could do nothing. In general, they also tried to remain calm so that their partners would not become agitated. The indications for surgery seemed to produce different feelings among the fathers and research interviews with the couples might provide a better opportunity to review and share birth experiences.
Conclusion: Midwives who care for women prior to surgery must be aware of fathers' complex feelings and needs in emergency c-section cases. Knowing their reactions to this type of surgery might help to strengthen the support from fathers and facilitate an understanding of couples' concerns and needs.
Cesarean sections (c-sections) can be divided into planned c-sections and emergency c-sections; many of the latter are unexpected before the event. Even if a woman prefers a natural birth, she might require an emergency c-section for her safety or that of the baby. While most studies have stressed the need for emotional support to the woman during and after an emergency c-section, the involvement of fathers has been largely ignored.
Emergency c-sections are often described as being related to negative feelings (Cranley, Hedahl & Pegg, 1983; Fawcett, Pollio & Tully, 1992; Marut & Mercer, 1979) and low levels of satisfaction regarding the birth experience (Waldenström, Borg, Olsson, Sköld & Wall, 1996). One descriptive study revealed negative feelings caused by the great shock of disappointment, inevitable fear, and responsibility as a mother when an emergency c-section was required (Yokote, 2002). Recent studies have revealed that some women experience traumatic fear for both their own life and that of the baby and that many women exhibit acute posttraumatic stress symptoms (Ryding, Wijma & Wijma, 1997; Yokote, 2004, 2005).
In this critical situation, a woman who is helped by her partner during the decision to undergo emergency surgery is encouraged by and appreciative of his support (Yokote, 2002). Meanwhile, according to Czarnocka and Slade (2000), the perception of weak support from a partner during labor is predictive of posttraumatic stress symptoms. Although fathers now attend childbirth more frequently in Japan (Aono et al., 2005), they usually are required to leave the operating room if the woman requires an emergency c-section. A midwife cares for the woman prior to surgery and must perform preoperative procedures. She is very occupied with the safety of the mother and the baby and thus might have little opportunity to learn the father's feelings and thoughts during this critical situation.
Two studies in Japan reported that fathers' negative feelings in cases of emergency c-section were stronger than in cases of planned c-section and natural delivery (Sakajo et al., 1996; Tanaka, 1999). However, these studies were limited by the use of questionnaires and a lack of details about the fathers' feelings and thoughts. To strengthen a father's support in cases of emergency c-section, and from the standpoint of family care, midwives need to understand fathers' feelings and thoughts when this critical situation arises.
This study sought to identify a man's feelings and thoughts about his partner, baby, and medical staff when an emergency c-section is required. The father's reactions when he first learned of the need for surgery, during surgery, and on first meeting his baby and partner after surgery are characterized. In this study, “emergency cesarean section” means a c-section that was not planned in advance and includes several indications for surgery.
Japanese men whose partners delivered a live baby by emergency c-section in a hospital setting, regardless of age or indication for surgery, were recruited. The mothers were all Japanese women and those with psychosis and severe postoperative or post-partum complications were excluded.
The setting was a private maternity hospital that is often used by low-risk expectant women, located in southern Japan. The cesarean rate was ∼8% and half of those were emergency cases. The father's attendance in the operating room was acceptable if the couple requested it as part of a planned c-section. However, in emergency cases, such as fetal distress, the father was generally not allowed to stay, even if the mother received lumbar anesthesia.
Procedure and data collection
To gain access to mothers and their partners for this study, I requested the cooperation of a hospital, which was thought to be the proper setting for the study. The director of the hospital and the head of midwifery both gave permission. This study was conducted at the same time as an investigation of women's emergency c-section birth experiences; initially, I identified women who met the inclusion criteria in the postnatal ward. I then contacted midwives and nurses through fieldwork and obtained new information about the potential female participants.
On the day after surgery, each potential female participant was first informed of the purpose of this study in an oral interview and through an information sheet that explained what participation would involve. It was organized thus because of the fact that the woman is at the center of the birth event, although the birth is also a very important event for a partner, and it was thought that she might lose valuable time spent with her baby if she participated during the research interview with the father. In addition, as the woman might indeed be present during the interview with the father, in the event that she knew nothing about this research interview, the possibility existed that she might take offence. Therefore, after the mothers had agreed to participate and to invite their partner, the fathers were also invited.
The participating fathers were interviewed in a semistructured manner within 1 week post-partum, alone or together, at the couple's request. The interviews were tape-recorded with their permission and transcribed. The interviewer (the author) also made field notes on non-verbal communication, such as facial expressions, eye contact, and physical expressions.
The data were analyzed descriptively and inductively. First, descriptions regarding the fathers' feelings and thoughts about the emergency cesarean birth were extracted from the raw data. Second, these descriptions were classified and integrated for relevance to the following three phases: when the father first learned of the need for surgery, during surgery, and on first meeting his baby and partner after surgery.
In the analytical process, I assessed the validity of the observations through discussion until agreement was reached among three researchers, one of whom was a father. In addition, a father whose first baby was born via emergency c-section but who did not participate in this study was shown the results and he did not find them to be unreasonable.
The information sheet clearly stated the participants' right to refuse or withdraw from the study at any time. Even if the couple refused to take part in this study, it was assured that the woman and her baby would not be at any disadvantage in the hospital. Furthermore, the participants were assured anonymity and confidentiality, and that I would exclusively handle all data and use these data only for the purposes of this study.
Although 22 women agreed to participate, it proved very difficult to arrange the interviews with the fathers. Some fathers initially consented to participate in the study, but subsequently cancelled because they were busy at work and the timing of visits to their partners and babies after work was uncertain. Six fathers agreed to participate in this study and be interviewed.
The fathers who participated ranged in age from 28–39 years. Five couples were married and one was not, but all of the men had their first baby with their present partner. The participants' situation and the obstetric data on the partner and baby are shown in Table 1. The indications for surgery were classified into two groups: a fetal distress group, which included participants 1–3, and a prolonged labor group, which included participants 4–6. Each group comprised three possible cases. Interviews with five of the fathers were conducted together with their partners by request.
Table 1. Participants' then situation and obstetric data of the partner and baby
|1||29||–†||Telephone||39||Fetal distress||6 h 45 min||21 min||8||–|
|2||31||+||Directly||41||Fetal distress||40 min||22 min||8||–|
|3||30||+||Directly||32||Premature rupture of the membranes, fetal distress, breech presentation||–||97 min‡||8||+|
|4||28||+||Directly||39||Induction failure, toxemia of pregnancy||39 h 8 min||71 min||9||–|
|5||37||+||Directly||40||Unreassuring Fetal heart rate pattern||28 h 50 min||60 min||9||–|
|6||29||+||Request§||41||Cephalopelvic disproportion||42 h 25 min||61 min||9||–|
Fathers' feelings and thoughts about their partner and baby
Although all of the fathers understood the need for an emergency c-section when the decision was made, they had complex feelings and thoughts during the aforementioned three phases (Table 2). Particularly at the first and second phases, the indications for surgery seemed to produce different reactions. For the first and second phases, the categories are described for both the fetal distress group and the prolonged labor group. The comments made by the fathers are translated with minimum editing and quotations are given as examples. Their identities are noted by the number in brackets (e.g. P1 is participant no. 1).
Table 2. Fathers' feelings and thoughts about their baby and partner before, during, and after an emergency cesarean section
|When the participant first learned of the need for a cesarian section||Fetal distress||No choice is involved if the baby and mother are in danger and are saved|
|Prolonged labor||Best option considering her stamina and willpower|
|During surgery||Fetal distress||Anxiety and feeling of powerlessness|
|Prolonged labor||Lack of time to consider the options|
|On first meeting his baby and wife after surgery||Both groups||Feelings for the baby:|
|Relief on seeing a healthy baby for the time being|
|This is our baby|
|Feelings for the partner:|
|Appreciating her hard work and giving thanks|
|Relieved by the successful surgery|
|Fear during the recovey period after surgery|
When the father first learned of the need for surgery
No choice is involved if the baby and partner need to be saved. It was sudden notice for the fathers, as well as for the mothers, in the cases of fetal distress; however, they felt that they had no choice but to trust the doctor because the doctor was the only person who could save the mother and the baby, and a c-section was the only safe method:
When I saw the monitor and got the doctor's explanation, I had no choice, even if only our baby was saved. Also, I thought it [surgery] should be done as soon as possible in order to avoid an after-effect to our baby (P2).
Best option considering the mother's stamina and willpower. In cases of prolonged labor, fathers felt exhausted and irritated because they were unable to assist and facilitate progress. In addition, they realized that their partner was limited both mentally and physically. Therefore, they thought that a c-section was the best way for the mother and the baby, and some of them anticipated that the doctor would make that recommendation:
Since attending to her after entering this hospital, I realized she already had limited stamina and willpower. I thought that, “a cesarean section may be suitable for her before either she or the baby weakened further” (P4).
When the father could no longer stand to see his partner's pain, they both requested surgery:
It seemed to me that I witnessed “hell” during her labor. . . . I also asked the doctor because she kept repeating “I need surgery!” (P5).
Anxiety and feeling of powerlessness. After consenting to surgery, although the fathers were very anxious about the safety of the mother and the baby, they could do nothing for them. In spite of their anxiety, they tended to try to appear calm so that their partners would not become agitated. The waiting time during labor must have seemed very long to them:
When I saw a midwife running to the operating room, I again realized that we were in a pinch. So, I was very anxious for her and the baby. You know, the cord is the lifeline for a baby! (P1).
Lack of time to consider or worry. In the case of prolonged labor, fathers felt that the time from the decision for surgery to the birth was unexpectedly short in contrast to the long labor period:
It was so quick once the operation started, and I was disappointed to find that the operation time was so short (P5).
On first meeting his baby and partner after surgery
For this phase, because no clear trend was seen upon the indication for surgery, the entire experience of the participants is described.
Feelings for the baby
Relief on seeing a healthy baby. When the baby was taken to the neonates' room, the new father could see his “healthy” baby with his own eyes and was clearly relieved. Although this was most conspicuous in cases of fetal distress, all of the fathers described this feeling of relief:
My son was fluttering his arms and legs, and I was so relieved (P2).
This is our baby. Although the fathers were very happy to see their babies, some felt that it was not really happening. This feeling was related to being first-time fathers, rather than the need for surgery. When they talked about first meeting their babies, their faces lit up and they became excited upon remembering that event:
He was very big! I thought, “This had been inside her!” Then, all of a sudden I was exhausted (P5).
Feelings for the partner
Appreciating her hard work and giving thanks. The fathers showed respect and thanked their partners for experiencing hard labor and/or emergency surgery to have their lovely baby:
I said to her, “Well done!” . . . And I was moved to tears (P1).
Relieved by the successful surgery. Although the fathers understood the need for surgery to save the baby, they worried about their partner's health because the surgery was urgent rather than elective. They were therefore very glad to see that both the mother and the baby were well:
I felt relieved because I had been so anxious for both my baby and my wife. It would have been impossible to deal with losing either of them (P4).
Fear during the recovery period after surgery. In the case of complications due to toxemia, the father was extremely anxious about postoperative progress because he had been informed that his partner would still be at high risk after giving birth:
As soon as I saw our baby, I wondered, “Will she get well after this?” because we had been told about the risk with toxemia, even after the operation (P6).
Acknowledgments of and requests to medical staff. The fathers also described their acknowledgment of and/or requests to medical staff, rather than their feelings or thoughts in this respect (Table 3). In particular, those in the fetal distress group were thankful for the early recognition of distress signs and the rapid preparation for emergency surgery. The prolonged labor group appreciated the close observation of the delivery's progress and supportive care by the midwives, such as providing the mother with massage and encouragement during the long labor period. However, a few of the fathers confessed that they felt exhausted under so much stress and almost became depressed staying with their partner for such a long time. Thus, they wanted some advice, for example, on how to rest during labor:
Table 3. Fathers' acknowledgments of and requests to medical staff before, during, and after an emergency cesarean section
|When the participant first learned of the need for the surgery during labor||Fetal distress||Thanks to early recognition of distress signs and the rapid preparation for emergency surgery (A)|
|Prolonged labor||Thanks to the close observation of the delivery's progress and supportive midwifery care (A)|
|Need for advice on how to take a rest during labor and its timing (R)|
|During surgery||Fetal distress||Need for advice on how to wait for surgery and what he can do for his wife and baby (R)|
|Both groups||Happy to be informed about the safe arrival of the baby and his wife's condition in the operating room (A)|
|On first meeting his baby and wife after surgery||Fetal distress||Better understanding, with particular explanation by the doctor of the final diagnosis and the present condition of the baby (A)|
|Both groups||Thanks for letting me touch/hold the baby (A)|
I think that a midwife is a special person to a woman in labor. I wondered, “Could I stay here [in the labor room]?” . . . Having been there [in the labor room] the whole time, I was distressed and exhausted. So, I wanted to ask a midwife for advice, for example, “She is stable now, so could you come out and take a rest?” (P4).
As all of the fathers had to wait outside the operating room without being able to help, they felt extremely anxious. Some of them wanted to know how to wait and what they could do for their partner and baby:
After my wife was brought to the operating room] and I was left there [in the waiting room] alone, I wondered, “What should I do?” I couldn't sit still, but I couldn't do anything for them either (P1).
Every father in the waiting room was happy to be informed of the safe arrival of their babies and of the stable condition of their wives in the operating room.
Couples' reactions during the interview. In the interviews with couples, I observed specific reactions and I took field notes. As their memories were muddled by the sudden change in plans and/or fatigue, they attempted to connect a certain memory with a particular situation and feeling. It was as if they were solving a puzzle together. Some couples were able to recall each event during those days and they were sometimes moved to tears.
This study showed that fathers have complex feelings and thoughts when their partners require an emergency c-section. The fathers understood the need for surgery, but felt anxiety for the safety of the mother and the baby and great frustration as partners and new fathers. This suggests that the need for an emergency c-section is a crisis not only for the woman, but also for her partner, who can be under great stress. Therefore, the fathers' feelings and thoughts were complex and a positive or negative classification of reactions would have been inadequate.
A limitation of this study is the small sample. Although 22 women agreed to take part in this study, only six fathers participated. This is related to satogaeri-bunben, which is the Japanese custom whereby the woman goes back to her parents' home after delivery to learn parenting skills. Moreover, Japanese fathers are usually unwilling to take time off work for a birth, despite their legal right to child-care leave. As the fathers in this study came to see their partners and babies on short notice, it was very difficult to arrange research interviews with the fathers. For this very reason, another researcher gave up trying to obtain interviews and used a questionnaire instead (Tanaka, 1999). The present data collected from face-to-face interviews with fathers are rare and, thus, valuable. Another limitation is the mother's presence during the interviews with the fathers. Although it helped in that they were able to recall memories and to share their birth experiences, the mother's presence might have influenced the findings.
The indications for surgery seemed to produce different feelings among the fathers when they first learned of the need for surgery, as well as during surgery. Those in the fetal distress group felt that they had no choice but to trust the doctor, but they were very anxious during surgery. When the baby was diagnosed with fetal distress, although the women could undergo emergency surgery to fulfill their responsibility as mothers, despite their mounting fear and anxiety (Yokote, 2002), the fathers knew they could do nothing else to save their babies. The prolonged labor group of fathers felt exhausted and irritated because they were unable to assist. Thus, there was a similarity between the two groups in that the fathers felt powerless as partners and fathers. Tanaka (1999) reported that many fathers in emergency c-section situations had missed out on a joyous birth experience because they felt anxiety, confusion, and guilt caused by disappointment during the delivery process. Knowing the trends of fathers' feelings as regards the need for surgery might be useful in practise when quick assessment is required.
The fathers tended to try and remain calm so that their partners would not become agitated, despite their fears and anxieties. Chandler and Field's (1997) study concurs, supporting the tendency among races that the father hides his fear so as not to upset the mother. Furthermore, as the present participants were concerned for the safety of their partners and babies and their fear was beyond measure, the effort required to not let this show was probably very great. This is one reason why midwives should be more aware of fathers' feelings and needs.
Most fathers feared for the baby's life or sequelae, as did the mothers. This is a contributing factor in traumatic experiences resulting from emergency c-sections (Yokote, 2005). In particular, the prolonged labor group described the difficulty of seeing a loved one in terrible pain over a protracted time. This indicates the possibility of trauma from witnessing a partner and baby in mortal danger. Fathers now attend childbirth more frequently in Japan. The potential effects on the father require careful consideration and additional study.
Although fathers might not stay with their partners for long periods and might find the distressing scenario difficult, sharing the labor experience until surgery contributes to understanding its necessity and to feelings for their partners and babies after surgery. Sakajo et al. (1996) reported that men whose partners delivered by emergency c-section had a poorer understanding of the need for it, a lower evaluation of their partner, and lower enjoyment of paternity than men who experienced other delivery styles. They suggested that hospital staff should have enhanced the mothers' efforts before surgery and supported a birth review, including an explanation of why emergency surgery was required. In contrast, our participants understood the need for surgery and realized their partners' courage as women and new mothers. This was linked to respect for their partner. A high evaluation of their partners was expressed by most of the fathers who stayed with them in labor and witnessed their great effort. Moreover, each made early contact with their baby by holding it or viewing it as soon as possible and the “rooming-in” system and nursing support in the postdelivery ward advanced their attachment. This characteristic of the hospital setting might have elevated the fathers' feelings.
Research interviews with couples together might provide a good opportunity to help them to share their valuable birth experiences. As all of the couples had a live baby, they had to quickly begin to learn parenting. Although this is a very happy time, some might lose the chance to look back on the birth experience and share it because of their relief in getting a healthy baby and the time and care that a new baby requires. Through the interview process, a couple can review their birth experiences and fill in the “missing pieces” (Mercer, 1981). The benefit of a birth review is well-known and such a review is probably even more meaningful for couples such as those in this study, who sometimes tend to have negative feelings about the birth. Moreover, this variable in a couple's experience can affect their relationship. More study from the viewpoint of the family system is needed in the future.
Most of the fathers' requests to medical staff were linked to midwifery, as found in Chandler and Field's (1997) study, which reported that fathers needed advice from the midwife about taking a rest or meal during their partner's labor. In addition, the fathers in the present study needed more explanation from the midwife regarding the condition of the mother and the baby during labor and what they could do for their loved ones during and after surgery. The fathers recognized that the midwife was the expert on birth and was the most intimate and supportive person for the couple during the experience, even in the case of an abnormal delivery. The fathers also appreciated not only the speedy preparation for emergency surgery but also the supportive midwifery care during labor. Women's perceptions of sensitive midwifery care in labor affect the overall birth experience (Waldenström et al., 1996), and the same might be true for fathers.
What a midwife can do for a couple during an emergency c-section might be limited by time and personnel constraints. Nonetheless, a midwife can enhance a couple's birth experience by reviewing and evaluating their efforts and, in turn, strengthening their relationship as a couple and as parents.
I thank all of the study participants and the staff at the hospital. I also thank Professor Yoshito Tanaka and Ms Kazuko Takenaka of the Graduate School of Health Sciences, Hiroshima University, who supported all stages of this study. Finally, I wish health and happiness to all of the babies and families who participated in this study. This study was presented at the 27th International Confederation of Midwives Triennial Congress, Brisbane, Australia.