Having a caesarean section (C-section) is a major surgical procedure whereby the incision site is usually horizontal and located just above the pubic bone (below your underwear line). Occasionally it will be a vertical (and therefore a longer) incision if baby is in an awkward position such as breech or transverse, or the placenta is in an awkward position. Due to skin tension lines across the body (see diagram), a horizontal incision usually heals in a more 'tidy' fashion resulting in a neater scar, and is in a less noticeable location than a vertical incision, so is the preferred method.
A scar is formed whenever the deeper layers of the skin are damaged. The body heals breaks in the skin in four stages if conditions are optimal (i.e there's no infection, or disruption or delay to wound healing).
The stages of healing are: Haemostasis, Inflammatory, Proliferative and Remodelling.
Haemostasis occurs rapidly as soon as the incision is made and aims to stop blood loss. Your body constricts (narrows) local blood vessels to reduce bleeding, the blood starts to clot and fibrin starts to form a mesh, which in turn forms a thrombus (a blood clot).
Inflammatory phase causes swelling, heat and redness in fairer skin, it also occurs immediately after the incision and is your body's way of reducing bleeding alongside haemostasis, prevent infection by sending lots of white blood cells to the area and promoting healing to begin. Swelling can last a week or longer but usually you will see a noticeable improvement after the first week.
Proliferative phase is where your body heals the area with collagen and extracellular matrix in a mish mash pattern resulting in a thicker disorganised healing wound. A new network of blood vessels starts to form, and the edges of the wound start to close as new skin is formed (often pink and uneven in texture at this point). This process can last up to a few weeks. NHS guidance is that you can often return to normal activities 6-8 weeks after a c-section if there were no complications during your recovery (NHS, 2019).
Remodelling (or Maturation phase) The collagen that was laid down during the proliferative phase starts to be remodelled into a more organised structure along lines of stress and tension, which increases the strength of the tissue again (although usually only to about 80% of what it was pre-surgery). Any cells that are no longer needed are removed. Generally remodelling starts about 3 weeks after surgery and can continue for a year or more. During this time the appearance of a scar will change from a red/pinkish colour, to a lighter colour and will become less pronounced. Genetics and skin tone, and complications during the healing process can influence how noticeable your scar is. However there are some things you can do to help reduce its appearance. Keeping it out of the sunlight (or wearing a high SPF of at least 50), keeping the scar clean during healing, keeping the skin moisturised and mobile. Silicone products are widely recommended and easily available to aid in the reduction of scars (Decker et al., 2022).
Keloid scars are a complication during the healing process resulting in an enlarged, more pronounced and irregular scar due to too much collagen in the skin. They usually appear after a few weeks to years after you damage the skin and can continue to grow for a number of months or years afterwards. They can be itchy or painful during this time and even though they cannot be prevented, they can be treated. They are most commonly found on the shoulders, chest, lower legs, chin, neck or ears (NHS, 2023).
Scar Massage
After 6-8 weeks postpartum you may wish to explore scar massage which assists during the remodelling phase to reduce the appearance and improve the texture of scar tissue. It does this by helping the collagen during the remodelling phase, form more uniformly and evenly. Massage can also help increase blood flow which helps with the removal of any unwanted cells no longer needed, break down any unnecessary scar tissue, moisturise the skin, improve mobility and sensation of the skin, reduce any itching and help you become familiar and more comfortable with your scar (NHS, 2021). At Melyn I teach you how to do self- massage on your scar so you feel comfortable massaging your own scar regularly, as well as checking healing and performing massage in clinic. Please contact me for further information.
Scar massage is also a way of you becoming more comfortable with your tummy after pregnancy and birth, and it can be a method of emotional healing, especially if a C-section was not planned or not your first choice. Your tummy may look very different to how it looked before pregnancy and there are often unrealistic standards set as to how quickly you can 'bounce back'. Again, a lot of this comes down to genetics, your age, how stretchy and elastic your skin is, if you experienced stretch marks, carried a larger baby or had a multiple pregnancy, whether you went past your due date or carried your belly more infront. Muscle tone underneath your tummy and whether you have a diastasis recti also contribute to the appearance of your post-pregnancy belly. Some women have an 'overhang' of skin over their C-section scar which often reduces over time, but may still persist. By going through a process of acceptance of your post-pregnancy body and seeing your scar as a positive reminder of how your birth journey unfolded, can help reframe the way you see your scar. Learning self massage of your C-section scar can help with this process.
References:
Abdullzaher, EM. (N.D), Wound Healing [Online]. Available at: Wound Healing - Physiopedia (physio-pedia.com), [Accessed 24.10.23].
Decker, ID., Hoeksema, H., Verbelen, J., Vanlerberghe, E., Coninck, PD., Speeckaert, MM., Blondeel, P., Monstrey, S., and Claes, KEY (2022). The use of fluid silicone gels in the prevention and treatment of hypertrophic scars: A systematic review and meta-analysis. Burn Vol 48(3), pp. 491-509 [Online]. Available at: The use of fluid silicone gels in the prevention and treatment of hypertrophic scars: a systematic review and meta-analysis - ScienceDirect [Accessed 25.10.23].
NHS (2023). Keloid scars [Online]. Available at: Keloid scars - NHS (www.nhs.uk) (Accessed 27.11.23).
NHS (2019). Recovering from a C-Section [Online]. Available at: M-Recovering_from_an_Emergency_Caesarean_Section_leaflet_.pdf (enherts-tr.nhs.uk) [Accessed 25.10.23].
NHS (2021). Scars and Scar Massage [Online]. Available at: Scar-scar-massage.pdf (stgeorges.nhs.uk) [Accessed 25.10.23].
Underwood, JCE. (2000). General and Systemic Pathology, 3rd Ed. pp.84-85, 110-111. Churchill Livingstone, London.
Wallace, HA., Basehore, BM., Zito, PM. (2023). Wound Healing Phases [Online]. Available at: Wound Healing Phases - StatPearls - NCBI Bookshelf (nih.gov) [Accessed 24.10.23].