The ins and outs of a Cesarean Section (C-section): Part 2

What to expect, what body parts are affected during a c-section, and what recovery is like

What to expect in the hospital for a c-section?

If you or the patient has to have a c-section, then you can expect that the anesthesiologist will come in and discuss the mode of anesthetic.  If the c-section is emergent, then there will be less time for discussion and questions from the anesthesiologist because of the situation.  If you have opted for a scheduled cesarean section, then you can expect the anesthesiologist to explain the process in detail to you.  

Most often, the anesthesia will be regional and is given through a spinal injection.  This means that you will still be alert and awake for the procedure, but will not be able to feel from your waist down.  To administer the medicine, the anesthesiologist will have you sit at the edge of the bed and bend forward while they place a catheter/syringe into your lower back.  Once completed, they will lay you back into the bed.  They will insert a catheter into your bladder and hook you up to an IV for fluids.  This may occur in the operating room or in the delivery room prior to being wheeled to the operating room.

Syringe with anesthetic.

Once in the operating room, they will place a drape screen; this is a drape that prevents you from being able to see from the waist down.  Your partner will be scrubbed in at this point and will most likely be near the birthing person’s head behind the drape screen.  

When the surgical team is ready, they will begin the surgical procedure.  It takes about 5-10 minutes from the time of the first abdominal incision to the delivery of your baby.  Once your baby has been delivered, they will give you the baby to hold behind the drape screen.  While you hold your newborn, it will take the team about 45 minutes to close the incision.  Expect a 3 night stay in the hospital if you have a c-section.  It is also important that despite the surgery and longer recovery time, it is recommended you get out of bed and walk the halls once the anesthetic has worn off.  As you recover, the catheter will be removed and prior to leaving the hospital, they request that you are able to urinate and have a bowel movement independently.

What parts of the body are affected during a cesarean section?

All the layers of the abdomen are affected during this surgery.  It is important to note that a cesarean section is a surgery, a major surgery.  Sometimes, this can get overlooked and is underrated.  

Most c-sections are completed with a Pfannenstiel incision (or a horizontal incision); in rare cases, the incision may be vertical. A vertical incision is more common with middle to older birthing people.

In order from the top layer to the deepest layer: 

• Skin is cut

• Subcutaneous adipose (fat) tissue is cut

• Rectus abdominis fascia is cut

• Using “blunt” dissection, the internal and external obliques are separated 

• Using “blunt” dissection, the transverse abdominis is separated

• Vesicouterine peritoneum (also known as fascia) is cut

• The uterus is exposed and the uterus is then cut and then further separated bluntly to expose the fetus 

• The fetus is removed and the cord is clamped

• The placenta is then removed from the uterus

• The uterus is then closed with sutures (stitches)

• The rectus abdominis fascia is closed, followed by the subcutaneous fat, followed by the skin.

*blunt dissection is a term used when a scalpel is not used; however, the fascia and tendons of the muscles are disrupted/separated by the surgeon and ultimately damaged despite not being cut with a scalpel.  

You can see all the abdominal structures/organs are affected by the surgery.  Therefore, recovering from a c-section is the same as recovering from a surgery.  Except, this recovery is more challenging because you have a newborn that requires constant care and attention.  Which is why a c-section is no easy feat.

Incision for c-section.

Interventions for reducing c-section

• Use of doulas

  • What is a doula? A doula is a support person present during birth that helps the birthing person and their partner during delivery.  A doula helps provide comfort measures to facilitate vaginal delivery.

• Childbirth training workshops to education increase spontaneous vaginal birth, and decrease overall anxiety and misconceptions surrounding birth

• Nurse led relaxation training programs

• Midwifery-labourist care with an OB provider oncall 

What is the recovery for a cesarean section?

It typically takes about 6 hours for the spinal block to wear off.  If recovery is going well, the patient may begin drinking clear fluids within 1-2 hours after the surgery.  Literature also shows that chewing gum postpartum can help stimulate the gastrointestinal system and decrease the time to passing gas and a bowel movement (both of which are required prior to discharge from the hospital).

Once the anesthetic has worn off, it is recommended that the birthing person begin to move around.  Pain management consists of over the counter medications and ice.  Ice often while in the hospital to reduce inflammation and to help with pain management.  Cesarean section can be associated with moderate to severe pain postoperatively.  If higher intensity of pain is felt by the birthing person, then this can delay recovery, return to activities of daily living, impair mother-child bonding, breastfeeding, and maternal psychological well being.  Historically, pain after a c-section has been undertreated, however, more recently guidelines have come out to help medical providers address pain in the hours, days, and weeks after the surgery.  Abdominal binders are also provided to the birthing person postpartum to assist in compression and approximation of the wound to help with pain management.  

Short term disability will say that recovery from a c-section is 8 weeks and this is how some/most companies determine coverage for maternity/ paternity leave.

The incision site will heal in 10-14 days postpartum.  Lifting restrictions include the weight of your baby only.  It is advised that the birthing person refrain from penetrative intercourse for 6-8 weeks postpartum to allow for healing.  

Once 6 weeks have passed, SEE A PHYSICAL THERAPIST SPECIALIZING IN PELVIC HEALTH!  They will perform a full evaluation to assess pain, scar mobility and management, and pelvic floor muscle function.  Because the surgeons use blunt dissection to separate the abdominal muscles, the tissue has been damaged and thus requires specific strengthening and exercises to improve core strength and stability without increasing pain.  Participating in PT postpartum will help you return to activity and exercise safely and help you prevent future incidence of urinary incontinence, constipation, urinary urgency/frequency, pelvic organ prolapse, and low back/ hip/ pelvis/ knee pain.

Learning to activate the core after c-section.

This video is a great visual of c-sections: https://www.youtube.com/watch?v=VkxwN8xQz80

References:

Adshead D, Wrench I, Woolnough M. Enhanced recovery for elective Caesarean section. BJA Educ. 2020;20(10):354-357. doi:10.1016/j.bjae.2020.05.003

Chen I, Opiyo N, Tavender E, et al. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev. 2018;9(9):CD005528. Published 2018 Sep 28. doi:10.1002/14651858.CD005528.pub3

da Silva Charvalho P, Hansson Bittár M, Vladic Stjernholm Y. Indications for increase in caesarean delivery. Reprod Health. 2019;16(1):72. Published 2019 May 30. doi:10.1186/s12978-019-0723-8

Miseljic N, Ibrahimovic S. Health Implications of Increased Cesarean Section Rates. Mater Sociomed. 2020;32(2):123-126. doi:10.5455/msm.2020.32.123-126