C-Section

In full, Caesarean section, the birth of a child by means of a surgical opening of the uterus and withdrawal of the fetus. In the USA it is common to drop the diphthong “a” and spell it Cesarean. The procedure is known surgically as a hysterotomy or opening of the uterus.

Although it is commonly supposed that Julius Caesar was born in this manner, that seems most unlikely since his mother was alive in his later life and although hysterotomies were performed on dying persons, no one survived. More probable is the suggestion of confusion over the Latin word for “to cut,” or even a desire to report for posterity a miraculous birth which is common to many religions.

The “classical” C-section is by a vertical, longitudinal, incision, extending from above the umbilicus to the pubis, and a similar incision through the uterus which lies immediately beneath the skin – this permits extraction of the baby in literally a couple of minutes, and was appropriate for emergency deliveries of a distressed fetus, or in circumstances where anesthesia competence was doubtful, and the quicker the procedure finished the better. It had the cosmetic disadvantage of leaving a noticeable scar. It had the medical disadvantage that, following a C-section, a further pregnancy might result in rupture of the uterus when contracting in childbirth. This led to the saying, “once a C-section, always a C-section,” or the corollary, “Trial of Vaginal Birth after C-Section” which required cautious observation of the mother during her delivery and readiness to go immediately to an opening of the abdomen (laparotomy) should the uterus rupture. However, the classical operation can be performed with very little skill, and in Africa where “very little skill” is the maximum in many places, it is a life-saver.

For many years the “low section” has been the norm, performed through a suprapubic Pfannenstiel transverse incision, cutting into the non-contracting part of the lower uterus; this is rarely followed by rupture in later pregnancies, but is technically more difficult to perform, and is accompanied by the opportunity to cut major arteries.

“Too posh to push” has become a term for the elective C-section which at one time was only performed for specific difficulties or delays in childbirth, but is now performed for nearly half of the deliveries in some countries. It allows childbirth to be at a convenient time of day, almost an elective procedure, and precludes damage to the “birth canal,” otherwise known as vagina. Obviously there are substantial differences in opinion on the propriety of this procedure.

The low transverse incision follows the skin lines, and leaves a very acceptable scar. The vertical incision transgresses the skin lines and the scar is often very obvious. Part of the problem may come from the indifference of the surgeon to techniques of skin closure – her interest lies in the welfare of the baby and not in the mother’s cosmetic concerns, and this vertical incision almost says in itself that this was an emergency procedure performed by a less than fully trained obstetrical surgeon.

A mother is left with substantial “extra” folds of skin after the child is born and the size of the uterus reduces with involution. The question arises, should she have a “tummy-tuck” performed immediately after childbirth? The general opinion seems to be that she should delay this decision until some months have passed, during which much of the relatively elastic skin is reduced in volume, and the noticeable scar may also become less visible. She may also find that the pleasures and requirements of child care have become more important to her than the unsightly appearance of the extra skin.