I think that the horizontal cut lower on the abdomen used to be done by request or at least it was not the normal procedure in a c-section delivery. What about now? How frequently is it done? Is it part of the pre-surgical conversation? Is it standard operating procedure?
I’ve had three C-sections. The first one was almost 15 years ago, and the last was just over four years ago.
It was part of the pre-surgical conversations for all three, but not as an options. More like “this is how we will cut you”. Period.
As far as I could tell from my dealings with my OBGYN and information I had from the hospitals, the bikini-cut was s.o.p. for all non-emergency c-sections. A vertical incision was never even mentioned to me.
I am not a doctor, and my information is anecdotal only.
My wife has had 2 C-sections and will probably have a third in a few months. The bikini cut was the only option that she was given and I can’t imagine why someone would want to do it differently. I have heard some people say it was the result of yuppie shallowness or some such nonsense. From listening to the doctors, it is simply a superior method that minimizes the trauma to the mother.
I actually watched my wife’s tow C-sections completely. They usually protect fathers from the sight of major abdominal surgery with a sheet but I told them I could take it and I wanted to see it. The actual C-section itself doesn’t take long at all. The whole procedure only takes about half an hour including prep and from incision to the baby being out only takes a very few minutes. I got to see the stuff my wife did not see. They make the incision just as big as they need, pull some organs out, and then pull the baby. It is very efficient and the relatively small size of the incision didn’t seem to hamper anything.
I have also seen a video of an old style C-section. Now that is a brutal surgery. The incision is very long and they remove many organs to get the baby. The length of the incision means that there is much greater recovery for the mother and a greater chance of infection or the incision opening.
I have also witnessed the C-section. Shag gave you the “straight dope”. I think that if you asked a competent doctor to do anything other than the bikini cut these days they would refuse on the grounds that they would be accused of malpractice.
I had a bikini cut for my first cesarean in 1991 which was a simple thing, baby was just too big and wasn’t coming out on his own.
I had a vertical inscision for my second cesarean in 2000, which was the result of having placenta previa (the placenta was lying over the cervix so the baby couldn’t get out, and if it ripped I and the baby would bleed to death) with the placenta on the anterior wall of the uterus. I think I got it right - the placenta was on the “belly side” of my uterus so they had to cut through it to get at the baby, which resulted in massive bleeding. They knew this in advance and spent many hours scanning the placenta and planning where they would cut but in the end it was a smash and grab job. I had a general so as to lower my blood pressure somewhat to slow blood loss and also because they didn’t want a panicking mother to deal with as well as everything else. Oddly enough, I was happy with that!
The outer inscision is long, from just under my belly button to below my pubes, but the inner inscision on the uterus was right around one side of the uterus, in an effort to cut as little placenta as possible. Recovery was a bizzarre feeling after the first couple of days of generalised pain, when the two separately cut places could be felt individually depending on what I was doing (uterus hurt when breast feeding and stomach cut hurt when walking or coughing.)
And I just want to say that aesthetically I wouldn’t wish a vertical cut on anyone.
My bikini cut is just above my hairline, a fine white pencil line with no thickness to it at all.
My vertical cut is a huge thick rubbery pencil width which kinks in the middle where two stitches went septic under my overhang of belly fat in the heat of the summer. Ig. I am now overweight again and I have a backside on my frontside, with the scar holding down my belly fat and it blubbing out on either side. Oh so sexy. Not.
The dr offered to tidy it up for me after two years when he saw the road map that is my stomach, but really I have had enough surgery and it’s not interfering with anything except my self esteem so for now I will leave it.
The “bikini-cut” incision, or Pfannenstiel incision, is indeed SOP in a c/s nowadays. It is on a line of little stress on the abdomen, and means that staples can be removed on post-op day 2, before discharge from the hospital (unless a person has a lot of truncal obesity). The procedure is pretty simple: cut the skin, cut the fascia, pull the rectus muscles apart, make an incision on the uterus (kind of in an arc), take the baby out, hand the baby off, scoop out the placenta, massage the uterus to try to get remnants and blood clots out, sew up the uterus, sew up the fascia, and staple/sew the skin. Skin to skin is often under 20 minutes, and can be as short as 12.
Vertical incisions are done for several reasons, including previous verticals, complications, and several other reasons. Wound care is a lot more intense, with stiches out at 5-7d and a lot longer time to heal.
In terms of surgery, it is still kind of bloody, with average blood loss of around 1 liter around here.
Here’s the story of one exception: I had a combination of the two procedures done. My first cut is a bikini cut, which cut through my skin and some layers of fat and muscle. A second incision was made vertically along the uterus itself. The baby was sort of wiggled out both cuts, with a LOT of tugging (I couldn’t feel pain, but I could feel a lot of pulling and tugging, and my body was rocked rather vigorously on the table, which was more than a little disconcerting!)
The reason for my two cuts was explained to me like this: the bikini cut is indeed preferred, because it cuts along the line of the abdominal muscle, instead of across the fibers. This makes healing quicker and more complete. However, my pregnancy was only 23 weeks along, so the bottom of the uterus wasn’t yet stretched out large enough to pull the baby out down there. It seems the uterus stretches up first, then out on top, closet to the lungs, and only reaches full stretch on the bottom in the last trimester. So the vertical cut was needed to get her out of the uterus itself.
From the outside, though, all you see is one scar, and it’s almost completely invisible 1 year later. It was strange feeling the other, internal incision healing, though, and I still occasionally feel a twinge internally, just to the right of my midline.
I will never be allowed a VBAC (Vaginal Birth After Caesarian) because of that vertical cut - the uterus being cut that way is prone to rupture or separation during contractions. Of course, this needs to be carefully explained should I ever have an emergency delivery, since it LOOKS like I have a VBAC friendly scar!
But as for the question in the OP, yes, bikini cuts are S.O.P. for caesarians nowadays. My emergency c-section at 23 weeks was anything but S.O.P.!
Pfannenstiel incision with lower segment CS (LSCS) is the S.O.P. for normal term deliveries in the West. This is the low transverse skin incision that then cuts into the lower segment of the uterus.
- LSCS lowers the risk of bleeding
- LSCS halves the risk of uterine rupture in future pregnancies to about 0.5%
- Pfannenstiel is cosmetically preferable
- Pfannenstiel heals more quickly
- Pfannenstiel reduces the risk of abdominal wall herniation through the scar.
Vertical uterine incisions, or “Classical CS” are used when delivery is done extremely early, as the lower uterine segment only forms in the last trimester of pregnancy.
They are also done for placenta praevia when the placenta lies over the cervix, meaning that an incision through the lower segment would cut through it. The larger incision allows the surgeon better access to stop the usually severe, if not torrential bleeding.
Vertical uterine incisions are also used for “smash and grab” where the baby has to be deliver ASAP and 12 minutes just isn’t quick enough, or when the baby lies horizontally across the uterus rather than vertically i.e. baby’s head is by mum’s right or left flank rather than by her ribcage or pubic bone.
Now, you can have a vertical uterine incision with a Pfannenstiel skin incision like WhyNot if the baby is small enough and the surgeon confident that they’ll have enough room to work, or, a vertical uterine incision with a vertical skin incision, like Hokkaido Brit if the CS needs to be quick, the surgeon needs a wider field and/or the baby is going to be big.
In the rural Indian hospital I worked in for a month they actually did vertical skin with lower segment uterine incisions. They had a very, very good reason for this. Vertical skin incisions avoid some of the major blood vessls and are technically easier and quicker to do, while the LSCS also reduces the risk of bleeding. In this hospital, remember, there was no such thing as an elective section, only real life-or-death emergency sections.
In a hospital with rudimentary anaesthesia and no blood bank, doing operations as quickly and safely as possible, so as to minimise the length of time the patient is under anaesthesia, and the amount of blood they will lose, takes a much higher priority over cosmesis and future abdominal herniation. If you have a live baby and a live mother at the end of the op, it was a success.
So, in other words you can have any combination of vertical and transverse incisions, but transverse and transvere is preferable for normal term delivieries in Western hospitals, with exceptions being made as the surgeon sees fit.
Wha?? Now I feel completely ignorant, but isn’t the uterus right there for them to grab the baby from? Don’t the internal organs remain behind (toward the woman’s back) the uterus? What organs are geting pulled out?
That is where my distinct lack of medical school training makes things more difficult. I was watching but questions and answers weren’t encouraged.
They pulled decent amounts of “something” out during the procedure. I don’t know if organs was the right word. Placenta was mentioned above but I was pretty sure I saw intestines or something as well.
Maybe one of the medical experts above can say what they pull out and put back in.
And I have, of course, violated Rule #1 - do some research yourself before you start asking others for help, dummy. I just looked in Wiki and there’s a very nice article about c/s and the nature of the cuts, s.o.p. and all manner of info. Although I much prefer the quasi personal nature of the interaction on this wondrous bbs and the various nutcases that populate it. Having been a follower of the Master and his column in the Reader, lo these many years, I’ll be hooked in here for eternity. Fact is, I even have a question and answer in the original Straight Dope book. Just sayin’. xo, C.
This is what happened to my sister-in-law last year. There were complications and blood pressure issues and they ahd to get the baby out right away. But, afterwards, when the doctor apologized for the scar, he did mentioned that since she’s really active (currently training for a marathon) the vertical incision would actually probably heal better than the horizontal incision would have since the abdominal muscles were just pushed apart and not actually severed.
Ok, I do have some knowledge (not a lot, but enough) of human anatomy.
Shagnasty I hope to God you didn’t see intestines, because they 100% should not be in the way!
The only thing between the abdominal wall and the lowers segment of a gravid uterus is the bladder, which is usually emptied by a cather to keep it as small as possible, and even so it is pushed down by a retractor rather than pulled through the incision.
You may have seen blood-soaked strips of gauze, various metal instruments, placenta, a baby and lots of blood, but you shouldn’t have seen small bowel and you couldn’t have seen large bowel. In heavily pregnant women the bowel lies above and behind the uterus, which pretty much fills the pelvis, it doesn’t lie in front of or below it.
He may be talking about the finishing of the hysterotomy, where the uterus is rotated out of the abdomen after the baby is delivered for stitching up and massaging out the blood and remnant products of conception. In that, there is this big giant organ sitting on the surgical field for a few minutes.
edwino I’ll give you that, I suppose I’m just so used to knowing what intestines look like (shiny, pale pink tubing) as opposed to what a uterus looks like (shiny, big, dark red organ) that I forget other people aren’t quite as intimately aware of the visual differences!