We all know vaguely what happens when you have a caesarean section – you’re given anaesthetic, a cut is made in your abdomen and then, minutes later, your baby is pulled out and passed to you. It’s a magical medical moment.
But it turns out there’s actually a hell of a lot going on from the obstetrician’s perspective. More than you could possibly know.
A fascinating Tiktok video explaining the anatomy of a C-section has been viewed more than 11 million times after showing just how complicated the surgery can be.
Using various sheets of coloured fabric and paper, Tina (@mamma_nurse) explained how there are various layers that surgeons have to cut through, before moving muscle out of the way and then manoeuvring past organs – and that’s before you’ve even reached the area where the baby is.
Most information given on C-sections by healthcare providers is lacking in details. Probably for good reason.
But if you’re the type of person who likes to be super informed ahead of birth – or you’re just really curious as to what the surgery involves – we asked Meg Wilson, an obstetrics and gynaecology consultant at London Gynaecology and the Whittington Hospital, to walk us through the process.
(Just a head’s up, there are some quite graphic images below.)
What happens during a C-section
First up, you’ll be given some pain relief – either a regional or general anaesthetic – and a catheter is fitted. Your abdomen will be cleaned and a drape will be put up so you won’t be able to see the surgery unfold.
An obstetrician will make a 10 to 15cm cut along the skin at the bottom of your abdomen, just at the top of your pubic hairline.
The first layer they cut through is the skin, and that cut also goes through a layer of fat. “Then you come down on to the rectus sheath – a white fibrous layer – that is covering the muscles of the abdomen,” says Wilson.
They’ll make a cut in that as well and all these cuts will be done in the same direction: horizontally.
Next up, they come to the rectus muscles “which people know as their six pack muscles,” says the obstetrician.
These two muscles run as a strip down the abdomen and where they join together is something called the linea alba. It’s a weak area which surgeons can basically “poke through” to open it up, says the obstetrician.
“That takes you into your abdomen, by making that little hole, and then you’re into what we call the peritoneal cavity which is the proper wet inside of your tummy.”
Surgeons will make the hole a bit bigger by basically moving the two muscles apart.
“You’re pulling them out to the side to make a hole there,” says Wilson. “I think it’s really important that people know you’re not actually cutting muscles, you’re just shifting them apart.”
When in the peritoneal cavity, surgeons will get a nice view of the surface of your bladder and then the main event: the womb itself.
Now comes the really interesting bit. They have to actually move organs to get to where they need to be – so yes, they shift your bladder out of the way.
“You lift up a little bit of something called the peritoneum,” she explains, which is “like a sheet that runs over the womb and the bladder.” Surgeons will make a small hole in that “sheet” and this allows them to see where the bladder is attached to the womb.
“It allows you to push the bladder out of the way and push it downwards a little bit,” Wilson says, noting it only gets moved about 1-2cm.
In the operating room, they have a specially designed surgical instrument that goes in to protect the bladder and hold it down and out of the way.
The surgeon cuts into the womb (again, a horizontal cut in the same direction as the skin cut). The womb is a muscle so they expect to have some bleeding at this point as muscles have a strong blood supply.
In cases where a parent has placenta previa – where the placenta completely or partially covers the opening of the uterus – it might be a bit more complicated, she adds, and they might have to cut higher up in the womb or even through the placenta, which could result in more blood loss.
“Then you’re going to hit the membranes around the baby – the amniotic sac – and you see that bulging out when you reach it,” Wilson continues. “You keep going and make a little hole in that with the scalpel and usually lots of amniotic fluid all comes spilling out in a big gush.”
At this point it’s all about getting the baby out. In a straightforward pregnancy the baby will be in a head down position, so they’ll get a nice view of that.
The retrieval process involves a bit of teamwork. “You put your hand in and slip your hand around the baby’s head – like a cupping action – and your assistant will put lots of pressure on the top of the woman’s tummy, pushing right at the top of womb where the baby’s feet are, and you’ve got your hands acting as a little slide for the baby to come out,” she says.
The head pops out, then comes the neck, and then there’ll be a bit more gentle pulling to deliver the shoulders one at a time, and then the body “slips out relatively easily after”.
At this stage the curtain is often lowered and the parent(s) can see their baby and hold them. They tend to let the umbilical cord pulsate for at least a minute to give the baby beneficial nutrients and then they’ll clamp the cord, cut it and hand the baby to the midwife who will wrap them up and dry them off.
“Then it’s a case of removing the placenta, which is still stuck on to the lining of the inside of the womb,” says Wilson. “We pull a little bit on the cord and the placenta will be detaching.”
After the placenta has been removed, surgeons will then clean out the inside of the womb which Wilson says is “a very simple action” of rubbing a swab around the insides of the cavity “to make sure there’s no little bits of membrane or last little threads of placenta that are still there”.
The mum will still be bleeding at this point so time is of the essence to get the womb stitched up again. Once that’s done, surgeons will take a moment to do a check and assess that there’s no additional bleeding anywhere.
At this stage, she says, they clean away any spilt fluid and blood that may have collected in the sides of the pelvis using a swab. They also check the womb is contracted and that the ovaries and fallopian tubes look normal.
“It’s just an opportunity to do a health check because you’ve got the tummy open and it’s a relatively straightforward thing to do,” she adds.
The instrument protecting the bladder is then taken out and “then you allow everything to fall back into place,” adds Wilson. “The bladder will go back to where it was originally placed and those two rectus muscles that you held open to get into the cavity of the tummy will fall back into place as well.
“You don’t routinely close the rectus muscles ... they will come back together naturally and reform their meeting point.”
The next layer that’s surgically closed is the rectus sheath, which is the layer just beneath the fat. “We sometimes put a stitch in the fat layer but for most women we then just close the skin with another running stitch,” she adds.
“By routine we remove all the drapes and clean any collected blood that’s in the vagina,” she adds, “and make sure there’s no clots of blood or anything.”
At this point they might put in a painkiller suppository and a dressing is placed over the c-section wound. The whole process is complete in less than an hour.