Two key extrinsic factors appear to help promote wound care and healing: the use of antibiotic measures to prevent infection, and use of an appropriate dressing. NICE recommends antibiotic prophylaxis and its guidelines should be followed.1 However, since many post-operative surgical infections occur after discharge, it is also important to advise the woman on how to recognise signs of infection for herself. This may be particularly important where the woman is obese, as this has been associated with a higher risk of infection, especially in abdominal surgery. As with all surgical wounds, it is important to keep the site of the C-section clean. The purpose of a dressing is to do this, and absorb any small amounts of oozing until the wound edges have begun to heal. This is usually within 24-48 hours.
Stress has been found to delay wound healing. The stress of having a C-section, whether planned or unplanned, is naturally significant, and the midwife will need to be aware of this when discussing with the woman. The midwife will be able to offer practical tips on dealing with stress, such as accepting offers of help around the house or with the baby. The woman may find that pain limits her mobility, and that this in itself is stressful as it becomes difficult to get the baby out of the cot. Although regular pain relief should ease the pain, partners and friends or family can also help in caring for the baby.
Once the wound has healed and sutures have been removed, the wound will initially appear red and may feel lumpy as the scar tissue is reorganised during the maturation phase. This will reduce over time, but the process can be helped. Silicone gel dressings over the scar have been shown to help improve the scar appearance. These dressings can at first cause irritation when used for long periods of time, so it is important to advise the woman to increase the wear time incrementally until the dressing can be tolerated for eight hours or more. Another strategy is the use of massage during scar formation, which may disrupt the fibrotic tissue and increase the pliability of the scar. Massage can also help with itching and help the woman feel that she has some control over the eventual outcome of the scar. When massaging the scar, it is advisable to use a moisturising cream or oil to prevent friction from breaking down the scar. In the longer term, the woman will want to resume normal life. NICE suggests that activities such as driving, carrying and lifting heavy items, can begin once she has fully recovered from the C-section.1 There is no guidance as to how long this could be, but a rough guide is approximately six weeks.
If all proceeds smoothly, healing will be through primary closure, with the edges of the wound held together by sutures. The cosmetic outcome in this situation may be influenced by surgical technique, with tight sutures giving a poor cosmetic result and a more visible scar.
C-section scars can be hidden under clothing. This does not mean that the psychological effects of the scar will be less than that of one that it is more difficult to hide. The scar may be seen as a constant reminder of the surgery, even though the event probably had a happy outcome (the baby). Even a planned C-section may bring back unwanted memories of the pain involved. If the woman feels the scar is unsightly, she may be embarrassed. She may feel unhappy about undressing in front of others or reluctant for their partners to see them undressed. The woman may need to be reassured that the appearance of the scar will get better over time. The scar formation may take years. Therefore, it is important that the midwife goes through the process of how scar formation with the woman. Referring to other scars to help ‘normalise’ this process may help, but it is important not to trivialise the importance of the scar to the woman. Preparation for this can begin, where possible, before surgery and should certainly start before discharge. In extreme cases, referral to a psychologist may be appropriate.