By Dr Mama-Aso Peprah and Carmen Levey
23 January 2024
Time to read: 8 minutes
A Caesarean section, often a life-saving procedure, is performed to safely deliver the baby and placenta from the uterus. While advancements in technology have made Caesareans safer, it remains a major operation requiring respect and adequate recovery time, like other major surgeries. Complications, both minor and major, including poor healing, are not uncommon.
Understanding the Recovery Process:
During a Caesarean section, a 10cm-20cm horizontal or vertical incision is made through the skin, adipose tissue, rectus sheath, rectus muscle (pulled apart, not cut), peritoneum, uterus, and amniotic fluid to facilitate the baby’s delivery. These layers are then stitched or placed back together to ensure proper healing.
Healing Phases:
There are four phases in the healing process after a Caesarean section. Here is what to expect: these phases are complex and may overlap, potentially taking longer than the documented time.
- Haemostasis phase:
- Time Period: Immediately as the operation happens.
- What’s Happening:
- Blood vessels bleed as they are cut during the operation.
- The body activates mechanisms to allow blood to clot, and vessels constrict to minimize blood loss.
- What to Expect:
- You may see blood staining on your dressings.
2. Inflammation phase:
- Time Period: 24-48 hours post op
- What’s Happening:
- The immune system becomes active.
- Macrophages, lymphocytes, and neutrophils (immune cells) move to the site of the Caesarean, initiating the cleanup process.
- Debris, dead tissue, and bacteria that should not be present are targeted for removal
- What to expect
- Erythema (redness), heat, and edema (swelling) occur.
- Pain is experienced.
- Decreased function may be observed during this phase.
3.Proliferation phase:
- Time period: 72 hours-3/4 weeks post-op
- Dissolvable stitches: Day 7-10
- Non-absorbable stitches removal times: 5-7days post –op
- What’s Happening:
- Granulation tissue formation
- Neovascularization (new blood supply) and nerve regrowth
- The wound is pulled closed and rebuilds itself.
- Regrowth of the epithelium (top layer), blood vessels, and fibroblasts, the foundation of healing.
- What to Expect:
- Visual cues: Initially, a red scar with intact and closed skin, presenting a beefy red, puffy, or mounded bubbly appearance that eventually dulls over time.
4. Tissue Remodeling/Maturation phase:
- Time Period:
- Tensile strength (the ability to withstand tension) by about 4-6 weeks.
- Thereafter, it takes 4 weeks to 2 years and may extend over years.
- What’s Happening:
- Tissue remodeling and maturation involve different types of collagen.
- Deep healing remodels and reorganizes once the skin is closed.
- Tensile strength increases, providing resistance to tearing.
- What to Expect:
- The appearance changes from deep pink to pearly pink, light purple, starting from the edges and gradually covering the entire scar.
- During this process, there may be stretching, itching, and even puckering of the wound.
Factors Affecting Healing:
- Blood flow, infection, oxygen supply.
- Age, hormones, stress, medical conditions, medications, obesity, alcohol, smoking, immune system, and nutrition.
Complications and Warning Signs:
- Regardless of the Caesarean type, up to 36% of mothers have post-operative complications.
- Common: infection, bleeding and bruising, wound edge separation, fluid discharge from the wound
- Less common: readmission to hospital, fever uterine infection, other medical complications.
Caesar scar management
Once the initial superficial layer of the scar has healed, and there are not scabs or dressings on it, you can begin scar management and massage. In general, you want to be doing it every day until the scar moves easily under your fingers. Once you’ve got it moving, then you can switch to massaging once a week. Scars continue to change for years. So you want to check in with it regularly to keep it moving.
Any scar can become hypertrophic: This means that the scar is red and raised. In this case silicone can be a useful treatment to improve the colour and flatten the scar. It is worth asking your Physio or GP to review your scar and see if silicone would beneficial.
Desensitization
If your scar is very sensitive, you may need to start with scar desensitization techniques. This will help you become accustomed to the feeling of pressure and materials touching your scar.
Start by gathering some different types of materials:
- Very soft fabrics: fuzzy cotton balls, silk scarf
- Mildly soft fabrics: towels, blankets
- Moderately soft fabrics: soft Velcro, paper towels
- Rougher fabrics: corduroy, jeans
- Starting with the softest material, gently rub your scar for three to five minutes a day.
- Once that material no longer irritates you, transition to fabric with a more abrasive texture. Many people find doing this for a few weeks helps reduce the sensitivity of their scar.
Scar mobility and massage
Phase 1 (week 4-6)
- Start by lying comfortably on your back, with your scar exposed and your hand clean. Using two fingers, gently tap the area above and below the scar and then over the scar itself- as if you are typing on a keyboard.
- Using two fingers, gently move the top layer of skin in small circles along the scar- this should be a light movement, that isn’t painful. Can you notice areas of the scar that are tighter or more sensitive than others? Spend some extra time working on those areas.
- Then you can move the fingers up and down in different directions along the scar.
- You can gradually add more pressure as the scar feels more comfortable.
- Repeat these 1-2x per day if you can.
- Follow with some deep breathing exercises.
Phase 2 (week 6-8)
- You can continue with the above exercises, but now adding more pressure with your fingers.
- Pull your scar horizontally from one side to the other.
- You can now start to gently pinch and lift the scar if comfortable, moving from one end to the other.
Phase 3 (8 weeks and beyond)
The initial phase of healing should now be complete, if there hasn’t been any complications with your scar.
You can now really get stuck into that scar and get it mobile.
- Start with the above exercises with as much pressure as you can tolerate.
- Add in your pinch and lift, and then add an up and down motion.
- Now, using 4 fingers from each hand, place then along the top side the scar. Taking a deep breathe in, on the exhale, push down and then pull the tummy up. Repeat along the length of the scar. This may feel uncomfortable, but as long as there is not acute pain, its ok.
- Start your deep breathing exercises followed by pelvic floor rehab!
See our helpful video here: https://www.instagram.com/p/C2cLBkzq19h/
The “mom pouch”, “shelf” or “overhang”.
A weak core and a scar that hasn’t been mobilised can lead to an overhang or mum tum… Women assume nothing can be done to improve this, but because scars are still remodelling up to 2 years down the line, there is still lots to be done. But it doesn’t happen overnight.
The overhang isn’t only caused by the scar, so a holistic approach to treatment with appropriate core strengthening will yield the best results.
Any scar can become hypertrophic: This means that the scar is red and raised. In this case silicone can be a useful treatment to improve the colour and flatten the scar. It is worth asking your Physio or GP to review your scar and see if silicone would beneficial.
References
- https://www.springphysio.co.uk/physio-blog/category/c-section
- https://myphysiosa.com.au/physiotherapy-post-natal-recovery-help-c-section-recovery-scar-massage-physio-sa/
- Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010 Mar;89(3):219-29. doi: 10.1177/0022034509359125. Epub 2010 Feb 5. PMID: 20139336; PMCID: PMC2903966.
- Kealy MA, Small RE, Liamputtong P. Recovery after caesarean birth: a qualitative study of women’s accounts in Victoria, Australia. BMC Pregnancy Childbirth. 2010 Aug 18;10:47. doi: 10.1186/1471-2393-10-47. PMID: 20718966; PMCID: PMC2939528.
- Almadani YH, Vorstenbosch J, Davison PG, Murphy AM. Wound Healing: A Comprehensive Review. Semin Plast Surg. 2021 Aug;35(3):141-144. doi: 10.1055/s-0041-1731791. Epub 2021 Jul 15. PMID: 34526860; PMCID: PMC8432991.
- Chhabra S, Chhabra N, Kaur A, Gupta N. Wound Healing Concepts in Clinical Practice of OMFS. J Maxillofac Oral Surg. 2017 Dec;16(4):403-423. doi: 10.1007/s12663-016-0880-z. Epub 2016 Mar 5. PMID: 29038623; PMCID: PMC5628060.
