The following text is the result of an analysis of the available scientific articles in various medical databases on the subject of cesarean section. We could start with the numbers of cesarean sections performed in Poland and around the world, but what will that change? A birth is a birth, whether it is a cut or a physiological method, because both methods affect the body of many women. Of course, information from some studies clearly shows greater impairment of pelvic floor muscle function after vaginal delivery compared to cesarean, but there are also some that have shown no significant difference between the two delivery methods (e.g., no differences in short-term pelvic floor muscle strength in primipara after delivery, regardless of whether they delivered by cesarean or physiologic). On the other hand, episiotomy or instrumental delivery was associated with lower pelvic floor muscle strength compared with women after cesarean section (1).

What plays the most important role?

The scars. Scars resulting from an incision in the abdominal wall or perineal area (episiotomy) or perineal tears can cause a number of complaints and affect the quality of life. Discomforts due to caesarean scars include pain in the caesarean area, pain in the pelvis and lower back, and increased pain during menstruation. Complications from a caesarean wound account for an estimated 2,826.6% of cases. Between 11 and 15% of women suffer from discomfort and pain in this area caused, for example, by scar hypertrophy, keloid formation, and adhesions. Wound healing after caesarean section is an orderly biological sequence involving interactions between cells, the extracellular matrix, and various biochemical processes. The resulting scar alters the viscoelastic properties of the skin and subcutaneous tissue, resulting in increased stiffness and/or decreased elasticity. These viscoelastic changes in the skin and subcutaneous tissues, as well as the fascia, may in turn contribute to altering the lubricity between tissue layers. This points to the need to assess the possible adhesions and adhesions that have occurred (2). According to Karel Lewit, the manual techniques for “loosening” soft tissue scars are aimed at: restoring the elasticity of the skin near the scar and allowing all the soft tissue layers around the scar to slide freely against each other” (3). As physical therapists, we have the manual skills and knowledge to effectively help patients with this type of condition (3). According to the authors of one of the more interesting articles, a caesarean scar can actually cause pain elsewhere in the body due to myofascial continuity. The fasciae in our body perform a number of functions – they transfer tension, coordinate the movements performed, maintain the stability of the body, and most importantly (even for us) have a perceptual function. This means that the correct mobility of myofascial tissues makes the body perceive, process and interpret various stimuli correctly (e.g. the depth sensation / proprioception, which is responsible for the perception of the body’s feeling in space, its movements, position, etc.). Any trauma in the form of tissue dissection, such as occurs during caesarean section, can disrupt the normal sliding of tissues with respect to each other and promote the occurrence of the above pain symptoms and improper neuromuscular control (4).

Grzegorz Jędrzejewski

References:

1. Driusso P, Beleza ACS, Mira DM, de Oliveira Sato T, de Carvalho Cavalli R, Ferreira CHJ, et al. Are there differences in short-term pelvic floor muscle function after cesarean section or vaginal delivery in primiparous women? A systematic review with meta-analysis. Int Urogynecol J. 2020 Aug;31(8):1497–506.
2. Gilbert I, Gaudreault N, Gaboury I. Intra- and inter-evaluator reliability of the MyotonPRO for the assessment of the viscoelastic properties of caesarean section scar and unscarred skin. Skin Research and Technology [Internet]. [cited 2020 Nov 19];n/a(n/a). Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/srt.12956
3. Wasserman J, Steele-Thornborrow J, Yuen J, Halkiotis M, Riggins E. Chronic Caesarian section scar pain Treated with fascial scar release techniques: A case series. Journal of Bodywork and Movement Therapies. 2016 Mar 1;20.
4. Fan C, Guidolin D, Ragazzo S, Fede C, Pirri C, Gaudreault N, et al. Effects of Cesarean Section and Vaginal Delivery on Abdominal Muscles and Fasciae. Medicina. 2020 Jun;56(6):260.