Dooley Noted: 6/15/2017
Cesarian (C) Section is the surgical removal (typically of a child or mass) via abdominal incision.
No matter how old the scar, C-Section scars must be analyzed regarding a patient’s ability to build intra-abdominal pressure (IAP), particularly in the lower abdomen.
C-section can be carried out with two major methods. One is a vertical cut through the linea alba.
The more commonly used in modern C-section surgeries is the transverse cut, through abdominal aponeuroses (broad, flat tendons) above the pubic bone.
It makes much more sense from anatomic perspective to cut through the linea alba via the vertical cut, since this is our natural scar in life and where we were once all open during embryonic development. Our intestines actually develop mostly on the outside of us and then come back into the abdomen, where we are “zippered” up right before birth in this bloodless plane that we call the linea alba.
This is the area where all of the anterolateral and anterior abdominal musculature connects via wide-based tendons to connect to midline from each side. The fact that it’s a bloodless plane also promotes less tendencies for excessive bleeding during surgery. However, this is not the common cut.
The transverse cut is aesthetically pleasing and was shown in some research to decrease certain morbidity markers in the baby, when compared to the vertical cut.
The problem with the transverse cut is the slicing through important aponeueituc connections to the pubis and into the iliopsoas fascia that is extending into the anterior thigh.
The surgeons might argue that they are not cutting through musculature. But these aponeurotic connections are very important for the maintenance of pelvic position during IAP, as well as the transfer of stability through the iliopsoas fascia via TVA and IAO’s conjoint tendon connections.
Cut the tendons, and you cut the connections for force transfer.
The transverse cut is also not a bloodless plane like the linea alba. It is also not a natural scar, like the linea alba.
In my 10 years of experience observing those with C-section scars, 99% have been these transverse cuts. And in 100% of the C-section scars I have assessed, the lack of extensibility and proprioceptive input at parts of these scars lead to improper building of IAP.
Some common symptoms reported to me in regards to connections made with C-section scars in the building of IAP:
1. Bilateral limb pain, especially at the knees and anterior hips
2. Low back pain
3. Pelvic floor symptoms like incontinence or constipation/diarrhea, despite the fact they did not give vaginal birth
4. Feelings of numbness or absence of sensation in the area around the scar, coupled with the loss of connection with contractibility of the lower abdomen
5. Perception of bilateral anterior hip tightness, even though their hips are passively and/or actively mobile
Many women have never associated the presence of the C-section scar with their symptoms. After all, their symptoms tend to not always be close to the area of the C-section scar!
The importance of the scar becomes an anatomic study of the building and release of IAP. It’s important to discuss what this means, and why it affects so many parts that are distal from the site of the scar.
At maximum inhalation, with the proper building of IAP, the diaphragm descends, causing the pelvic floor to move down but upwardly buttress this downward pressure to prevent prolapse through its hiatuses. In turn, the exhalation muscles (TVA, IAO, EAO, psoas, QL, multifidus, and lumbar erectors) elongate and create a pressurized core for prevention of excessive lumbar movement around the center of mass.
As we properly build IAP, the thoracic cavity decreases sharply in pressure, creating a vacuum through which air is sucked into the lungs. So, you never actively have to raise the chest, if good IAP is built, leaving the accessory muscles of breathing to receive a stable platform for their primary actions.
If the anterior tendinous connections are cut, proprioception is altered. The IAP is lost and becomes uncoordinated upon its generation and release.
This results in tight hips, as the iliopsoas fascia loses its slack and it’s stable proximal platform.
It may result in improper cueing of the response of the pelvic floor, since this is dependent on eccentric loading of TVA and IAO at the pubic crest.
This IAP loss also can result in shoulder dysfunction, since serratus anterior may be recruited actively as a breathing muscle instead of freeing its scapular border for upper limb movement.
The uncoordinated IAP loss almost always equates to some level of low back stiffness and tightness, as the body falls into a lower cross, anteriorly tilted pelvis and overloaded low back with excessive lordosis or lack of extension load-sharing with the thoracic spine.
So, add this scarring – and all abdominal scarring – to your list of questions at the intake.
I’m happy to help you describe to your patient why that surgery through the anterior abdomen is linked to the hip pain, pelvic floor dysfunction, shoulder distractions, back pain, knee discomfort, etc., may be linked to an IAP loss due to the scarring.
As always, it’s your call.
– Dr. Kathy Dooley
Research article on transverse versus vertical cuts and morbidity rates:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228350/
For more on scars and how they affect neurological relationships:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3883554/
See a scar therapist trained in NKT Level 3 to help with these effects: