When a c-section birth is done with care and precision it can make all the difference in the healing and recovery for the mother. Operating the right way will also enable a woman to continue to have more pregnancies in a safe and secure way.

In this episode, Dr. Yaakov Abdelhak, a high risk perinatologist MFM specialist, lays out his method for operating in a c-section and includes what can be discussed ahead of time from a woman to her provider. What an opportunity as he reveals his unique method for conducting C sections step by step in this episode of The True Birth Podcast. He explains the best ways to perform the surgery to minimize the risking scarring, post-operative pain and complications.

Planning C-Section

[3:45]

No one thinks they're going to have a C-section until the time comes to have a C-section. Because the heart rate in labor may stop progressing, you won't have time to develop a C-Section when the time comes. It is something that needs planning, like a birth plan. Doctors, on the other hand, dislike being taught how to operate. However, they will tell you things that are entirely feasible and reasonable.

Plan C

[4:43]

When a patient is on the operating table, the personnel in the room, such as the surgeon and nurses, must take a timeout to ensure that everyone is on the same page and help the patient clarify the surgical case.

[5:48]

Before Dr. Abdelhak makes an incision, he uses a marker and draws a line about two inches above the pubic bone. Some people have a natural line that is sometimes faded or darker in pregnancy because of more melanin deposits.

Why Dr. Abdelhak has a marker

[10:31]

If you put a patient back together just a half-centimeter off on the skin, which has the most nerve ending and they're going to feel it, it's important to pay attention and make sure you get them back exactly the way they came apart.

Performing C-Section

[11:51]

Once you open up the skin, the next step is to now get through the subcutaneous fat. Most of the time, you take the electric cautery, and you burn down to the fascia so that you can see the fascia. The fascia is the membranous connective tissue that holds everything together. It's the linings of the muscles that come together in the midline. It's a white, very thick sheet that's holding your abdominal sheet. Cut down to the level of the fascia only in the midline with the electric cautery. Then bluntly separate the rest on the right and left with your fingers because what you're doing is you're pushing the blood vessels laterally instead of cutting them.

[15:06]

When you open the fascia, you have to do it in the same direction as you're doing the skin. Underneath the fascia is a muscle, and now you have to get through the muscle. Doctors learned that it is terrible to cut the abdominal muscles because it's better to pull them to the side. After all, there's a natural kind of separation between the two.

[15:45]

Pull the muscles to the side, stretching before you pull both sides. You have to separate that overlying fascial sheet from the muscles to the side. Then you enter the perineum that is holding all your abdominal content. Now you have exposure to the uterus. At this point, you are making sure that you have enough exposure.

[17:12]

Making a small incision on the skin is very important to have a good recovery. If you have a repeat C-section, you have to go more prominent because you need more exposure. If somebody has a repeat C-section, they might think about opening a larger incision. You have to make no incision on the uterus. Before you go inside the uterus, look at the bottom to make sure the uterus is not tilted to the right or left. It's essential to know that if it's tilted, you can end up cutting some blood vessels.

The Bladder Flap

[19:05]

The bladder runs directly over the uterus, and the perineum joins the bladder to the uterus and becomes the uterus's skin. There is a stage in between where it exits the bladder and forms the uterine skin. You can see on the uterus a potential space. You lift that space, you make a minor incision, you lift it, and when you push the bladder up and away from the uterus, you have more exposure to the lower uterine segment.

Opening the Uterus

[20:36]

When you open up the uterus, you have to be careful not to cut the baby. It would help if you had a "butterfly touch" whenever you are cutting through the uterus. You can use the suction, then use your finger, and you rub it. It will cause the cut to open up more rather than performing another incision.

[24:03]

The thick borders are critical because the uterine wall collected at the lateral edges is protective from extending the incision. So when you pull the baby's head out, if you have a sharp edge there, it's straightforward for the pressure or your hand and the baby's head to cause that sharp edge to elongate. When it elongates, it goes where it wants, usually towards the side and the uterine vessels, and then you get a lot of bleeding. But if you are careful and have thick borders, it's much less common when you pull the baby's head out.

Getting the Baby Out

[26:52]

You're trying to push from the top and shoehorn the baby's head out because you want the baby to come out, not just straight down. When you move on the top, you put your hand in to help guide the head out. You're shoehorning the baby out. Keep as much space as possible for the head and not your hand.

[27:44]

Occasionally, Doctors will produce a vacuum to assist with vaginal deliveries. This suction can also be used for C-sections. The vacuum is very nice as it puts on the head, and you can quickly bring the head out without having your hand in there. You can guide the head, and you don't need to have a big incision.

[28:31]

Once you get the head out, make sure the cord is not around the neck or reduce it, and then you bring the baby out ultimately. Clamping the cord can be done then show the mother her baby. Then give the baby to the nurses so they will dry and clean up the baby.

Closing the Belly

[33:25]

Once you get everything cleaned out, you look at the uterus again and make sure it's dry. If you created a bladder flap, don't repair it as it sits naturally there and heals fine. You don't need to put an extra layer of sutures.

[34:10]

You have to close the perineum because if you don't, you have a much worse adhesion. Failure to close the perineum will lead to many complications and can become messy in the surgery room, so it is imperative to close it properly to prevent that from happening.

[34:53]

If you have a cut edge, it's going to heal whatever is around it. If you put things together with the way they came apart, they heal together. There are areas of the uterine wall, which are still a little raw because you close it, or there are scrapings on the serosa. But just from manipulating the skin, it's going to heal to whatever it's touching.

[37:02]

Do not simply contract the muscle. What you're doing is you're taking sutures, and you're bringing the muscle to the midline, and you're switching the right side to the left side every two or three centimeters. Many women have had C-sections. The muscle was never re-approximated to the midline. Then they have abdominal diastasis, where instead of having a flat belly, you have this pouch right in the middle that bulges out because your muscles are not working to hold everything in nature.

Using Needles

[41:19]

When you use a straight needle, you're holding the needle with your hand just like you're sewing. When you use a curved needle, you're using a needle holder.

Not every C-Section method is the same.

[41:45]

There's not a recipe to do C-sections. Understand that there are many optional steps and different ways to do this. If you understand the difference between a human being and a monkey, it's about 98% the same DNA. That 2% difference is a lot. Somebody else would only consider that 90%. But that 2% makes a huge difference as far as recovery and other factors in the body.

Scarring

[43:32]

Patients hate the scar from C-sections. They would look right at fascial skin incisions as unfavorable. However, there is a way to get rid of the scar, but it takes time. However, you finish up with a cosmetic scar concealed. That is why a Pfannenstiel incision is used in 98 to 99 percent of C-sections since it is considerably more preferable to a woman who does not want a scar.

Things to remember

[46:01]

Minimize the skin incision as small as you like. Then close the perineum. Then bring the muscle to the midline with a suture and get the right side to the left side to avoid being marginalized.

[47:33]

Make sure that you ask them to make a minimal incision on the skin. Ask your surgeon to close the perineum and bring the muscles to the midline. Those are crucial things.

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