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

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

[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?


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


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

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

University of Maryland Medical Center. (2011). Spinal and Epidural Anaesthesia. Retrieved April 4, 2013, from

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

World Health Organisation. (2013). Alternative techniques and materials for Cesarean section. Retrieved on April 3, 2013, from

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

A Hospital VBAC with a Doula, ObGyn, Residents and Nurses

A Hospital VBAC with a Doula, ObGyn, Residents and Nurses

Two days overdue with my second baby, I woke up at 7am with a stomach ache, like I ate something bad and needed to go to the bathroom. Around 8am I finally got out of bed to go to the bathroom and I had a contraction.  It felt like the normal Braxton Hicks that I’d been having for the past month.  Less than 10 minutes later, I had another one. This one was a bit stronger and I wondered if this was going to be “it,” but then I thought back to my labor with my first baby.

With my first baby, in 2010, I went right into active labor with intense contractions from the start at 12am and I went right to the hospital. There was no question as to whether or not I was in labor.  By 7am I couldn’t take the pain of the contractions and I opted to have the epidural. I hated the feeling and had them shut it off around 12pm. By 2pm I was ready to push and I could feel everything by then.  2 1/2 hours into pushing and suddenly an army of doctors and nurses came flooding in and told me that baby’s heart rate was not recovering between contractions. And even though she was just about crowning, my hospital records reported that she was a “failure to descend.”  I was wheeled into the OR and she was born minutes later. I hated every minute of the C-section. I threw up on myself, I was shaking, asking the OB if everything was okay without any response from him. I was alone because my husband was gone with the baby, etc.  We all know the difficulties of what a c-section are.

I researched everything I could on VBACs and spent the last couple of months of my pregnancy reading only success stories.  It was just a month before my due date that I finally freaked out and decided that I needed to have a doula to help with the pain. I hated that epidural because it made me feel out of control and I knew that I could not deal with the pain without something or someone to help me through it. Although it was last minute, I found a doula and began to work with her right away.


So, back to this labor.  I was having contractions that were fairly strong less than 10 minutes apart. From 8am until 1pm I breathed through them, but constantly asking myself whether or not this was the real thing.  My sister-in-law was visiting and helping my husband and I.  At 2pm, my daughter came home from pre-school and my contractions stopped completely.  Between 2pm and 6pm, I had nothing. In that time, my parents came into town and my house was full.  I called my doula and she suggested that I make a nest away from everyone and just relax.  I first went on a power walk and then sat with everyone at 6:30pm for dinner.  I was bouncing on an exercise ball and suddenly, one bite into my hamburger, I had a contraction so hard that I fell off the ball!

Contractions were immediately less than 5 minutes apart and fierce.  My husband called the doula at 7:30pm and she was at our house at 8pm.  I asked my doula if she thought it would be too optimistic to have the baby by the morning. She didn’t show total confidence, but was very good at staying neutral! By 9pm, I was in excruciating labor pain and asked to go to the hospital.

Arrived to the hospital by 9:30pm and this is where a lot of my VBAC education paid off.  Immediately I was asked to be in the triage bed and I refused except to be checked by OB when they arrived. Two residents arrived, I got on the table and while my cervix was being checked by resident #1, the other (while checking her hair and lipstick in the mirror) asked me if I understood the risks of a VBAC. I managed to exclaim, “yes, and I also understand the benefits.” This shut her up, but she wasn’t pleased.  Resident #1 announced that I was 7cm! 7CM! We celebrated and screamed in happiness. The unmedicated laboring was so difficult, but at 7cm, there was an end in sight.

I was immediately assigned a nurse who came in and told me that I was getting an epidural in place. No! I refused this. So, she insisted that I get a HEP lock. I also turned this down and she began to argue, at which point I asked for a new nurse.  I remembered reading that you can always ask for a new nurse, one that you find is compatible with you. New nurse was Lisa and she rocked! At 10pm I was wheeled into a laboring room. At 10:15pm, with a major contraction, my water broke while Lisa was trying to get my blood (I was standing up). It broke all over the nurse, all over myself, all over the floor!

Lisa practically lifted me off the floor and onto the bed and exclaimed, “the baby is coming!” It was a very slow night at the hospital and I had about 15 people from the hospital rushing into the room to watch me push. It became very chaotic fast. All together it was 2 residents, 1 attending OB, a plethora of nurses and such, plus my husband, sister, and doula. Everyone was telling me how to push, and I didn’t know where to look or who to listen to.  I asked if everything was okay because so many people were there and it was just incredibly chaotic. I remember asking to push in a different position, but the attending OB told me I “had to” push on my back.  (Just like last time!) I pushed for 30 minutes and again, the heart rate dropped and they freaked out. Baby had already crowned.  They told me I would have to get her out in one more push or else I would have to go for an emergency c-section. I pushed like no other and while I was pushing (contractions right on top of each other), they gave me a SURPRISE episiotomy without telling me–all that mean resident said was, “sorry honey, I have to do this.” With that cut, the baby came right out.

Successful VBAC

2nd degree tear and just 18 hours in the hospital. My baby was in my arms almost immediately and was happy and nursing right away! I just kept crying and crying and everyone in the room was celebrating and yelling in joy.  Conversely, the attending OB, who was very obviously NOT pro-VBAC, reminded me that what I did was risky because “history tends to repeat itself medically.” She added at the end, “But you changed your history tonight.” Her words stuck with me. I thought they were unfair and untrue. The rate of successful VBAC is quite high, which would actually indicate that history does NOT repeat it self often.  Quite the opposite!  And she was such a Debbie Downer during my most celebrated time. It was such juxtaposition between the 2 residents, the attending OB and the rest of us.

I can’t say that the physical healing time from the UNVBAC is shaping up to be any easier than the c-section, but the emotional healing time was almost none!


Cesarean Birth Matters

Cesarean Birth Matters

You know, I have see this picture of an apple shredded up and the statement about how only a healthy baby matters. It’s making the point that it’s not OK when people say that your birth and your body don’t matter. I AGREE with that statement. Birth DOES matter. HOWEVER, I completely disagree with the picture (related to cesarean birth only). I have seen it passed around to try and make cesarean moms feel bad that they did not have natural birth.

Having had 2 cesareans and 3 VBA2Cs (two of them at home, unassisted), I do not find a picture regarding a cesarean mom ripped to shreds, appropriate. I understand the point trying to be made, but this approach can be seen as offensive to many cesarean mamas.

I DO think birth matters, but with that, cesarean birth matters too and they are not all horrible experiences.

That would be the same as someone making a picture like this regarding women who have vaginal births and what it does to their vaginas.

All types of birth *can* be informed and empowering experiences. Birth Matters, Healthy Baby Matters, YOU Matter…regardless of how you birth.

Now, here are some REAL examples of cesarean scars from BWF mothers.

Here are some lovely BWF moms (and dads) with their babies after their cesareans.

So please, be supportive and thoughtful to our cesarean mamas and babies, too.

All photos belong to the parents. Do not copy or use. Last picture captured by Mae Burke Photography.

Cesarean Birth Video

Cesarean Birth Video

I have seen many cesarean birth photos, but never a video like this one. It is from Birth Without Fear mother, Christina. She received and has given much support throughout her pregnancy, labor, birth and post partum. They were able to catch the c-section on video and it’s nothing short of amazing. If blood and surgery make you squeamish, you may want to skip it. However, if you can look past that, it is still a miraculous birth of a baby!!!

Shared with permission.

Here are a few still pictures as well. Unwrapping the cord (3 times)…

Being born…

Welcome earthside little one…

Christina was 40 weeks 5 days pregnant and her son was born 7lbs 2.5oz and 21 inches.

3 weeks old signing ‘I love you’ to the boob…he looooves him mama milk and as of a few days ago (at 5w6d), he’s up to 11lbs8oz! Grow, baby, grow!

Processing 2 Cesarean Sections: A Twin Cesarean Birth and A C-section Due to Placental Abruption

Processing 2 Cesarean Sections: A Twin Cesarean Birth and A C-section Due to Placental Abruption

I know people hear a lot of negative birth stories that are over inflated. I’m not sure why people do this. I try to refrain from sharing these two experiences with expectant moms, because I don’t want to instill any fears or insecurities in them.

I had a very normal, uneventful pregnancy with the twins until 35 weeks. April 27th I went to bed a little crampy. I didn’t think anything was really happening. I was up and down all night. My back was hurting but I paid no attention to it. It always hurt. In the morning I started feeling sick and threw up a few times. I decided I didn’t feel good enough to take my older to school so I called the neighbors. She called my husband and he came home to check on me.

We went to the doctor to get checked out. I was apparently having some nice contractions and dilated to almost 5. Baby A was well, but Baby B was having some problems. My urine protein levels were +4 and my blood pressure was staying in the range of 160’s/120’s and we went for an emergency c-section. Baby B was Frank Breech.

When I got to the hospital everyone was rushing to get things going. I was wheeled to the OR within 30 minutes despite having just eaten. Once I was on the OR table staff was doing things to me like inserting a catheter, cleaning me, and spreading my legs to the point I was becoming concerned about what was happening because no one was telling me.

The anesthesiologist began giving me a play by play of what was happening. When my doctor came back I felt relieved, because he kept talking to me and kept my mind off what was happening. Baby A emerged from my abdomen screaming. He was held up and I was in shock over how big he was. The NICU team began to check him out. When they were going after baby B it felt like they were digging in my chest. When she was pulled from my stomach there was silence. They held her up for a split second and I saw a large baby girl. Her hands and feet were black and I thought “I didn’t know they did the foot prints in here?”

It didn’t take long to figure out her skin was not inked. She was turning black. They were bagging her to get her breathing. They took her to the NICU. They lifted me off the table onto a bed and took me to another room. Baby A came with me. I was moved again about an hour later.

About an hour after my final move, a nurse was trying to make me get out of bed and walk. She said I had 12 hours to do it. I told her to come back in 12 hours. I was unmedicated after the birth by choice. I was in so much pain when I did get up I began to feel dizzy from it.

Baby B spent 4 days in NICU for respiratory distress but checked out of the hospital with us. I remained in horrible pain for 2 to 3 weeks after the c-section. It wasn’t long and I began to question why they did nothing to maintain my blood pressure. I don’t feel the c-section was money motivated, because I was only charged for a vaginal birth.

About 12 weeks later I was pregnant with an unexpected pregnancy. While it was unexpected, it was not an unwanted pregnancy. I was afraid I would have to have another c-section. My OB said I was a great candidate for a VBAC. So that was the plan. I opted out of nearly all testing. The ultrasound at 20 weeks was the only real testing done. We chose to discover gender at the baby’s birth.

The pregnancy was normal with the exception of c-section site pain. I was due 5/18 according to my doctor. My calculations were closer to 5/11. On 5/1/2010 I began having contractions, but since we had moved 70+ miles from the hospital, I wanted to wait it out a little longer so I would not be sent home. I decided maybe some primrose oil capsules orally might help move things along nicely. So I took two and went to bed.

At 3 am I woke up in some real pain. I used the restroom and got back in bed. I laid there for about an hour in a lot of pain. I don’t know why I didn’t get up sooner. I rolled over and felt like maybe my water had broken and was getting ready to leak. Since one of the twins was in bed I woke my husband up so the baby wouldn’t fall out of bed when I got up. I got up and hurried to the bathroom. Three steps into the bathroom there was a big gush, but it was not amniotic fluid, it was blood. It was such a forceful gush that it splashed so forcefully through my underwear that there were blood splatters on the walls and cabinets.

I called to my husband and told him to put the kids in the car. When he appeared in the door way and was panicking over the blood told him not to worry. I told him that this was just the bloody show and it was OK. I knew it wasn’t, but didn’t know what was happening.

On the way to the hospital I was in so much pain, but couldn’t let on that anything was wrong because my kids were in the car and I didn’t want them to be scared. I was very worried because I couldn’t remember if I had felt the baby move recently. Blood was gushing still. It seemed like it took forever to get to the hospital. Hubby took me in and left me to drop the kids off at my friends house down the street.

I left a blood puddle in the elevator and bloody foot prints to the maternity ward. I was examined and told my placenta was rupturing and we needed to get the baby out asap. The babies heart rate was between 40-60 beats a minute and would fall into the 20-30’s. The nurses were moving me into different positions trying to see if it would help, but it wasn’t. I’m not sure why, but they were putting IV’s in my arms and legs and squeezing the IV bags.

I was wheeled off to the OR and the anesthesiologist said if there were any issues with the spinal that I would be put to sleep. My husband wasn’t there and I was very upset and crying. A nurse took pictures, otherwise I would have none. My daughter was born a few minutes later. My husband was brought in the OR a few minutes later.

The OB on call told me that when she began to inspect the placenta it more or less fell off the inside of the uterus. The placenta was discolored, mushy and was falling apart as she held it. They sent it to pathology to see if they could figure out what went wrong. They never figured it out. Our baby never had any issues resulting from any of this. They said Zazi may be mentally disabled, blind, etc but she is absolutely perfect in every way. She is a beautiful baby with a wild spirit.  In my medical records it says “repeat c-section”.

I feel the first c-section could have been prevented. I’m angry about it. The scars might be all better, but I’ve certainly not healed.

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