“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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