“Pulled Apart And Put Back Together” {A Cesarean Section Procedure}

by Birth Without Fear on April 9, 2013

[Warning: This post describes and illustrates Cesareans sections with graphic detail.]

The Cesarean section is often described as simply “an incision in the abdomen”, or variations to that effect. Usually you’re told it’s “straightforward” or “simple” or “virtually risk-free” or even “the easy option”. But what is it, really? I’ve heard stories where the muscles are cut, and stories where the muscles are pulled apart from the middle, and stories where the uterus is taken out of the body… So what do they do and how do they do it?

sarah

The anaesthesia:

Many women are given regional anesthetic: an epidural or spinal anaesthesia for a Cesarean section. And yes, there is a difference between them.

And epidural procedure involves inserting a needle into the epidural space of the spine. First, a local anesthetic injection is given to numb the area and minimise discomfort of the large epidural needle. The epidural needle is inserted into the epidural space, and a catheter is threaded through the needle and into the space. The catheter is taped into place on the skin, and an anesthetic liquid is pumped through the catheter and into the epidural space. The anesthetic can be continuously pumped through the catheter (known as Continuous Infusion), or can be administered periodically as needed (known as Patient Controlled).

Spinal anesthetic is a similar procedure, but the needle is inserted beyond the epidural space and into the spinal cord. Anaesthesia in injected into the spinal cord, and a catheter is not placed. At any time, you may be put under general anesthetic if an emergency situation arises.

For detailed (and graphic) images of an epidural being performed, visit Patti Ramos Photography | Epidural Procedure

A general anaesthesia is not often the first choice for Cesarean sections, for medical and emotional reasons, but is sometimes necessary. During this procedure, anaesthsia is injected into a vein, and you might also be asked to breathe in gas – these will stop you from feeling pain or being conscious during the procedure. You will be intubated – a tube is put down your throat and into your windpipe – because you cannot breathe on your own.

Once you have been given the epidural, spinal or general anesthetic, you will have (if you don’t already have the following in place): a cannula inserted into a vein, catheter in your bladder, a cuff around your arm to continuously monitor your blood pressure, an oximetre clip will be placed on your finger to measure your blood oxygen levels, an electrocardiograph will be connected to patches stuck onto your skin to monitor your heart while under anesthetic, a possibly an oxygen mask if your oxygen levels indicate that you need it.

Once you are lying on the table in the operating theatre, the nurses will usually hang a sterile blue drape above your neck/chest area. This is done primarily to keep the abdomen and incision sterile, although some people also appreciate not being able to see the details of the operation. Nurses will often wrap your neck and chest area in a blanket or warm you with a heater/fan, as operating rooms are kept very cool, around 20 degrees Celcuis (68 degrees Fahrenheit).

The cesarean section procedure:

A Cesarean section is not ‘a simple cut’. It is an extremely involved major abdominal surgery.

The first incision is made with a scalpel into the skin. The cesarean scar used to span from ‘hip to hip’, however these days the incisions are smaller for aesthetic reasons. This limits the amount of space the surgeons have to work in, and recovery can be more painful because the limted space means there is more stretching, pulling and bruising.

This incision can be in a number of places, however the most common incision, the one that leaves a scar across your ‘bikini line’, is called a Pfannenstiel incision. Other less common incisions are horizontal Maylard and Supraumbilical incisions, and the vertical Midline incision. It’s important to note here that the placement of this incision (and the subsequent scar left on the skin) does not necessarily indicate the placement of the uterine incision.

Surgeons must then navigate through the skin and fatty tissue, being careful to avoid the major superficial arteries present in the area. The skin and tissue are held apart with clamps or the hands of surgical assistants.

The connective tissue (known as the fascia) that surrounds the rectus abdominis muscle is cut down the middle with scissors and pulled towards the respective side of the body. The rectus abdominis muscles (your ‘abs’) are not cut, instead they but pulled apart from the middle outward towards the sides with the fingers.

The peritoneum, which is the connective tissue that encases the internal organs, is then cut with scissors and lifted and pulled aside.

A layer of tissue, known as the Vesicoperitoneum pouch, encases the bladder, uterus and some of the intestine, and a loose portion of the pouch needs to be pulled upwards, cut with scissors, and pulled aside.

A retractor is placed along the lower edge of the incisions, and pulls the opening down (in the direction of the feet). Clamps or surgical assistants hold the skin, muscle and tissues aside, allowing a large opening. At last, the uterus is visible! A baby (or babies!) will soon be born!

The incision made now determines the ‘type’ of Cesarean you are having. The most common type of incision is a transverse lower uterine segment (LUS) incision – an incision going from one side of the abdomen to the other, of a lower section of the uterus. Depending on the circumstances of the surgery, the surgeon might choose to perform a classical incision (up and down), an ‘inverted J’ or ‘inverted T’ incision. After a small initial cut is made, the uterus is then either cut with scissors or pulled apart with the fingers.

The surgeon inserts a hand and/or forceps into the uterus, and carefully manoeuvres the baby out and into the world, usually with some pushing or force placed on the fundus of the uterus while also attempting not to rip the uterine incision further. In a mother-assisted Cesarean, the mother may reach down and assist in birthing by helping to lift her baby from the uterus.

Hooray! A baby!

cesarean post

The baby’s umbilical cord will be cut, and then the baby will moved away from the abdomen. In many cesarean births, the baby is taken to a warmed bassinet to be checked and wrapped, and then brought over to meet their mama. Some mothers ask for immediate skin-to-skin contact once the baby has been birthed, but unfortunately this practice is not standard, and needs to be negotiated with the surgeon.

But it’s not over yet.

At this time, the uterus may be left ‘in situ’ (in situation, or within the abdomen) or ‘exteriorised’ (removed from the abdomen). The placenta is removed, and the surgeon begins the task of ‘putting it all back together’.

The area is washed, and the uterus is stitched closed. Many birth plan examples suggest asking for a ‘double-layered suture closure’ rather than a ‘single-layered suture closure’, and this just means that the uterus is closed with two layers of stitches rather than one. Some studies suggest that this decreases the risk of uterine rupture and increases the chance of a successful VBAC, which may be because doctors are more open to allowing mothers a TOLAC if the uterus has been closed with a double-layer suture.

Surgical retractors and clamps are removed and depending on the surgeon, the peritoneal may or may not be sutured closed – it was once standard to close to however some recent research suggests that it can be left open without adverse effect so some surgeons are trialing or have adopted this technique.

The skin is closed with stitches and/or staples. The area is washed, and occasionally the vagina may be irrigated. And yes, you will bleed after a Cesarean section. Most of the bleeding after any form of birth is from the ‘open wound’ that is created when the placenta detaches or is removed from the uterine wall and slowly heals.

 The mother is moved from the operating theatre to the recovery room, and depending on hospital policy, her baby may or may not be allowed in with her. Depending on her response to the surgery, she will be taken back up to her room quickly, often within an hour of the surgery ending.

cesarean group pics

[Warning: These clips include extremely graphic video footage of a cesarean section birth. It is a real cesarean. It is really graphic. And before anyone asks, the baby is alright, you do hear crying in the background further on in the surgery.]

Cesarean Section Video: Part 1 | Cesarean Section Video: Part 2

After my cesarean birth, I felt the best way to describe the feeling was that I was ‘pulled apart and put back together’ and it’s no wonder. Cesareans are not a walk in the park, and are hardly the easy way out. The body has so much healing to do – it has been cut, moved, pulled, pushed and ripped apart. But we are strong. We have not failed.

For Cesarean section procedure pictures, visit  Cesarean Section

References:

Hema, K. R., & Johanson, R. (2001). Techniques for performing caesarean section. Best Practice & Research Clinical Obstetrics & Gynaecology, 15(1), 17-47.

Lanneau, G. S., Muffley, P., & Magann, E. F. (2004). Gynecology and Obstetrics, Chapter 74: Cesarea Birth: Surgical Techniques. Retrieved on April 4, 2013, from http://www.glowm.com/resources/glowm/cd/pages/contents.html

Morgan, P. J., Halpern, S., Lam-McCulloch, J. (2000). Comparison of maternal satisfaction between epidural and spinal anaesthesia for elective Cesarean section. Canadian Journal of Anaesthesia, 47(10), 956-961.

Ng K. W., Parsons J., Cyna A. M., Middleton P. (2012).Spinal versus epidural anaesthesia for Cesarean section. The Cochrane Collaboration, 4.

Tabasi, Z., Mahdian, M., & Abedzadeh, M. (2013). Closure or Non-Closure of Peritoneum in Cesarean Section: Outcomes of Short-Term Complications. Archives of Trauma Research, 1(4), 176-179.

Tully, L., Gates, S., Brocklehurst, P., McKenzie-McHarg, K., & Ayers, S. (2002). Surgical Techniques Used During Caesarean Section Operations: Results of a National Survey of Practice in the UK. Obstetrical & Gynecological Survey, 57(11), 725-726.

University of Maryland Medical Center. (2011). Epidural Series. Retrieved on April 4, 2013, from http://www.umm.edu/presentations/100195.htm

University of Maryland Medical Center. (2011). Spinal and Epidural Anaesthesia. Retrieved April 4, 2013, from http://www.umm.edu/ency/article/007413.htm

University of Washington, Department of Medicine. (2013). Cesarean Section. Retrieved on April 4, 2013, from www.fammed.washington.edu

World Health Organisation. (2013). Alternative techniques and materials for Cesarean section. Retrieved on April 3, 2013, from http://apps.who.int/rhl/pregnancy_childbirth/childbirth/Cesarean/eacom3/en/

And a big thank you to Australian midwives Harmony, Manda and Fiona for ‘fact checking’ my information! 

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{ 18 comments… read them below or add one }

Leah R April 9, 2013 at 1:12 pm

I am a nursing student and just watched a ceserean as part of my OR clinical. You are spot-on except in the one I watched, after they finished the last layer of staples, they massaged the mothers uterus and removed clots from her vagina. Great description!

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Alisia Cameron April 9, 2013 at 1:46 pm

Thanks for the feedback Leah – and yes, you’re right! I didn’t mention staples as an option instead of sutures.

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Megan Casey April 9, 2013 at 2:09 pm

GOD BLESS CS Momma’s!!! Oh man I never thought it was easy but WHEW after reading this I think my pit induced no pain meds birth was NOTHING compared to Momma’s who need this operation. I can only imagine when its emergency its done a lot faster harder and with slightly less care .
I had 4 children, all vaginally. Yes it was hard work but with an epidural for 1st 2 I had ZERO pain. Now #3 I had pain in epidural site and refused it for #4 even though I was again given pitocin. That was God awful, I think pit is an evil drug. However I would do it again 10 times over before consenting to doing a CS w/o serious need.
CS Mommy’s are my hero after reading this. Especially those who had long labors first! How sore one must be after I cant imagine. I would think a long labor just adds to the soreness. Thank you BWF for sharing what a section invoves

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Still Healing... April 9, 2013 at 8:35 pm

Imagine pit, almost 20 hours of labor and then add a c-section. It’s double the recovery, emotionally and physically…

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Jessica March 31, 2014 at 9:15 pm

Thank you for this post! I ended up having a c section after 20 hrs of natural labor at a birth center, 5hrs natural at the hospital, followed by pitocin which led to 3 hrs of pushing…but a swollen cervical lip was blocking baby at nearly 9cm and we were nearly 2 days in at that point! I have been hesitating to look up the exact procedural steps of the surgery because I knew it involved so much pulling apart, according to my husband and the movement I felt. I have my 2 week follow up appt tomorrow and am glad I read this first so I can ask some more detailed questions about my experience. Definitely not how I wanted to deliver, but baby boy was healthy and is very happy, so our goal was realized. Thank you again, as no other post online that I found was this detailed and made me wonder why the he!! I felt so much pulling if it was so “simple”.

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Krista April 9, 2013 at 6:28 pm

After 40 hours of labor, I had to have an emergency c-section with my son. It was a scene out of a movie when I was being rolled to OR. I had general as they didn’t have time to give me an epidural. Very interesting to know what happens because I definitely didn’t hear much from my Drs after the fact. I’m curious though, in emergency c-sections, are the abs cut? I have two scars, one on the surface (skin) and one just below the skin that I can feel if I massage the area. If there isn’t time to pull back the muscles, would an incision be faster?

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Janie Moreno April 9, 2013 at 8:27 pm

I’ve had two Cesareans 5 years apart. Because of Severe Preeclampsia complications with blood pressures of 200/95. I was very sick so had emergency c-sections. First at 32 weeks of pregnancy and my second at 29. We’ve had two babies in the NICU. So I AM STRONG!

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Rosemary Vorih April 10, 2013 at 4:57 pm

Very good info. I had three c-sections with a spinal. That was 51-50&49 years ago. My how times have changed. I was awake (my request) saw part of the births through the OR lights. I walked the same day, unheard of in those days, nursed all three, two at the same time. The first two are a year and nine days apart. The older one was brought to the hospital to be nursed. Left on vacation when the youngest was ten days old. Yes I was pulled apart and put back together without problems. A lot of it depends how one faces the birth (how strong the mom is) and the emotional support one has around them. The first daughter is an certified nurse midwife, has her own business delivering babies at home and has a full woman’s health office.

Rosemary Vorih

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Jessica April 10, 2013 at 10:18 pm

As a midwifery student in Australia I have seen 2 cesarean birth and they are brutal. I think if every women was shown the procedure from the surgeons end they would be hesitant to request an elective C/S. But I do say we are so lucky to have this life saving procedure when it is necessary I just wished women were more informed before they signed those consent form.

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R.M. April 16, 2013 at 9:18 am

I wholeheartedly agree! I know someone who chooses caesareans, having never laboured, and likes to pick the dates too. Which can be the ideal for some women, but if the risks are not clearly explained, it simply is not true informed consent..

I have been blessed to keep 3 of our babies, my firstborn was a posterior labour, natural birth but very tough. Second was a preterm classical incision with a microprem (25 weeks, surviving twin pregnancy) and my last babe was thankfully a beautiful VBAC, another natural birth where I was able to deliver my baby into my own hands, squatting in the shower in KEMH. Not only were my birthed babies able to benefit greatly with the hormones, gut flora, respiratory systems etc that vaginally birthed babies enjoy, I was also able to reap the benefits of going home hours after my first and the following day with my last (required emergency surgery after both my births, lost a lot of blood with the last bub so stayed as a precaution overnight). I could get on with being a mum with minimal recovery, and the amazing feeling of having laboured and birthed. The trauma of delivering my preemie via preterm classical was really quite significant, so much that my VBAC birth was very healing.

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Becky April 16, 2013 at 5:39 am

I have had 2 c sections first one after having a full labour but baby’s heart rate dropping , was given a general I found the recovery very slow , second baby my scar ruptured it was the worst pain every by the time they realised what was happening I had gone through the whole labour again and was starting to push , it was only the massive blood loss that alerted them that something was wrong , even though I had complained about lots of pain in my scar area throughout my pregnancy , I wish I had been more insistent when telling them my scar hurt instead of just accepting the that’s normal response I was given each time , the thought that I was lying in bed at home then less then one later , I was laid on a operating table after fully labouring , pushing and my body tearing apart scares the hell out of me but seven weeks on I am starting to feel physically well

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Nadene April 19, 2013 at 7:19 am

Hi, great story about a healing birth. I’m a midwife who has also been an OR nurse> I have seen the full gamut of the CS journey from elective CS to emergency. Ive been there as an anaesthetic assistant, Ive scrubbed for CS and been there in the midwifery role to receive the baby before taking it to the parents to hold while the surgical procedure is finished. I disagree with above comments that CS is “brutal”. Its simply isn’t. Birth via forceps is more brutal than any CS Ive seen, and Ive seen the full GA crash induction sceanario when mum and bub lives were on the line. Any surgeon that treats a surgical procedure such as a CS with disrespect is only asking for trouble. No surgeon will be deliberately brutal during a CS, and Ive seen a baby born via CS in an emergency situation that took 7 minutes from anaesthetic induction to delivery of the babe….both mum and bub were fine post birth. Which is the outcome we all want right? Any mother who has had to or chooses to give birth by CS should not be made to feel she has ‘failed”….no way. She has grown and birthed that babe as good as any earth mother who delivered in a pool under a willow tree. CS mums need extra care to recover, they need extra care and attention to help the breastfeeding relationship, and to manage their pain in the days after. In fact, some of the MOST inspirational women I have seen are the ones who have had long difficult journeys through labour, then had an emergency CS, often with post delivery complications connected with pregnancy rather than the CS itself. these women have tramped the long road of birth and needed assistance…they have not failed. I have seen these women struggling with their own post op pain but still held their arms out to feed their baby and more than once Ive held their baby to their breast while they slept from pure exhaustion as the baby fed, seen them struggle to get out of their beds to pick up their infant and still beam with pride….and two to three days later they look like a different woman, having shed all the “trimmings and appendages” of a surgical procedure, they’re up and parenting that baby. Any other surgical patient would be still laying in bed pressing their pain relief buttons. CS women birth their babies with assistance, but its still birth. Whatever form it takes, birth should be an empowering experience for women, and no one has the right to deny the CS mum that feeling.

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Mrs. BWF April 19, 2013 at 9:03 am

While forcep birth may be brutal, it does not mean major surgery is not. Having had 2 cesareans myself, this article is accurate. Not saying other births can’t be ‘brutal’. This is an informative post on what a cesarean truly is. Now, if you would like, you can read the rest of the blog or follow our FB page and you will see that this post does not mean we do not support cesarean birth. We have shared birth plans, positive cesarean stories and a lot of information on family centered cesarean birth. We are not anti cesarean. We are pro informed choice. Pro supporting the mother in her choices. That we can agree on. :)

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AMBER July 22, 2013 at 3:12 pm

This brought me to tears.

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Melissa Barron April 19, 2013 at 9:49 pm

My son was born by C-Section after 25 hours of induced labour. I went 22 hours with just a shot of Demerol, then got the epidural. I was fully dilated and pushing. I pushed on my back and on my side but he was NOT coming. We were given the choice to wait it out or have the c-section. After discussing it with my husband we decided to go with the section. We didn’t know at the time but this was likely a life or death decision. At that point, I went into complete shock. I remember little from the actual surgery, apparently my son was too big (9lbs 7ozs) for me. He was completely stuck in my pelvis and they had to pop him back before they could extract him through the incision. There was no way I would have naturally delivered him. The one thing the still rings crystal clear during the surgery was the surgeon saying “Is ‘it’ alive”. After that I was on pins until I heard him cry. To add insult to injury, while I was in recovery the nurses gave him formula twice. This set breastfeeding back by weeks but we fought through and nursed for 8 months.

Both of his sisters were VBAC even though DD1 was scheduled to be a c-section

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Christina May 25, 2013 at 2:32 pm

I had a c-section (not planned) 4 months ago. Reading this makes me happy that I was totally not aware of what was happening. I always thought it would be great to have a mirror set up so I could see it all happening next time if I ever have another one (and don’t VBAC) but never mind to that. I could not handle seeing that happening to myself. I seriously felt pain in my belly reading what happened to all my insides. Thank you for the description though. I am glad to know what all went on in there. A lot more happens then I previously thought.

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heather August 6, 2013 at 12:15 am

I was 41 weeks pregnant when I went in to be induced. I got 20 hours of pills to soften my cervix cause I was not dilated, only got to 2cm, then I got a fully tube and only got to 4cm, then I was given the pitocin, and still only managed to get to 5 cm, after that I stopped dialling, so they broke my water, by the way this is my 3rd day by now in the hospital, anyway, they broke my water and I started contracting, the only problem was my body would not release, my baby was stuck, my oxygen was low and her heart beat not right. Doctors gave me a epidural and sent me to get a c section, the tugging, and scared feelings I had was horrible, but after seeing my baby well worth it.

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Marlies August 9, 2013 at 3:22 am

Hi there,

Nice article. To make it even more accurate, I would add that spinal anesthesia involves injecting anesthetic into the spinal canal, not into the spinal cord. Also, the needle is withdrawn after injecting, it is not left in place.

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