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  • Writer's pictureMicaela Zettel, PT, MScPT, MCISc AHCP SEM, BScHK(hons),

C-section Rehab: What I recommend and want you to know


Mom holding baby with a physio

If you’ve had a cesarean section (c-section), you know it’s a major abdominal surgery. Before we dive into what I recommend for rehab of a c-section, we need to all appreciate what happens during this surgery. 


There are 7 different layers cut through to get your baby out safely. It’s a common myth that the abdominal muscles get cut in this surgery, but they do not. Once your OB gets to the muscular layer of the abdominal wall, they separate the linea alba (the midline of the abdomen, which is connective tissue), move the bladder and intestines out of the way, and then, voilà, they are at the uterus. The OB makes an incision in the uterus to get to the baby. Once the baby is out, they stitch the layers back together going from deep to superficial. Even though the abdominal muscles are not directly cut through, they are still affected during this surgery. 


Abdominal wall anatomy showing the linea alba

C-section surgery also comes with risks, like any surgery. This definitely does not take away from the life saving benefits…..but it’s important to understand the impact the surgery can have on your body. Surgery comes with a lot of bleeding and swelling; there’s a risk of nerve damage/injury and/or vascular injury from the incision (1);  and it’s a big stressor to your nervous system. And… not to mention that you grew a baby that has just left your body - a truly bizarre feeling.. All of this to point out that there’s A LOT happening with this surgery. 


Going into or coming through c-section surgery, it can be quite helpful to understand and appreciate how you/your body has been impacted. So many females that I work with feel like they had the “easy way” of having their baby, but in reality, it’s not easy at all, it’s just very different and still a really big event for the body (& mind). C-sections can be very necessary and life saving for both the birthing person and baby, which can be traumatic. Everyone’s experience is different, but there are potential massive physical and psychological loads with this surgery. I think it is important to understand this heading into your postpartum rehab journey. It really is a journey, and there are no quick fixes, no DIY (in my opinion) and no avoiding taking care of yourself. Everyone’s situation is different, but you do need to take care of yourself postpartum. 


Ok, enough about that, I know you hear me.


Recovery from major abdominal surgery is not DIY.

While I’m thrilled there is more conversation and information than ever before around postpartum rehab, I also still strongly believe that you need individualized care. We need to “make it make sense”. One comparison I think of is if you have an ACL (knee injury) surgical repair -  you don’t do that on your own. Why? Because surgeons know there are better outcomes when structured rehab is done, over an entire year!!! The expectation is set that you will need physio after surgery. But after a c-section, there are no recommendations at all. So I’m telling you, you will have better outcomes if you can get individualized care (physio) from a skilled practitioner (2). Please go into your rehab with the expectation that you will need support and guidance after. You don’t have to wait until you are having a problem!! Soap box done….maybe. 


There is no one way to rehab after a c-section, but here’s a general breakdown of things to consider. My goal here is to give you some guidelines and considerations for what your rehab needs to include, but also know that my BEST recommendation for you is to get individualized care, and also electro-acupuncture on your scar…read on to learn more :). 


The first focus in rehab is early healing, where the focus is HEALING. 

This is day zero up to around 6 weeks…..as always, everyone is different. 


*Side note: If you are wayyyy past the early healing phase, the part of this phase that would still apply is learning the piston breath…if you haven’t already.


Here’s why:

  • Your incision needs to heal 

  • You need to start moving again

  • And you have a little one to take care of (+ maybe older kiddos?!?!) 


It’s a lot. So during this part of your rehab, here is what I recommend (keep in mind, none of this is carved in stone, everyone is different):

  • Connect with your breath and pelvic floor

  • You can start this when you feel ready, even the first day after surgery, but definitely within a couple days after surgery to start to reconnect your diaphragm, pelvic floor and abdominals. 

  • This breathing is fantastic for early days to help you with transitions like getting in and out of bed, lifting your baby, getting out of a chair and so on → you will want to focus on a gentle inhale into the lower ribs, lengthen the pelvic floor (if you know how) and then start a gentle exhale through pursed lips (like blowing out a straw) and then move), known as Blow before you go. → Also use this strategy for any lifting that you need to do

  • If you’re not sure how to connect with your pelvic floor, that’s ok, you can focus on the breathing part of the piston breath and that will still be really helpful → but I recommend you go and work with someone who can teach you how to connect, when you feel ready. 

  • Start with the inhale/lengthen/open the pelvic floor, as described in the video, get comfy with this before adding in the squeeze/lift on the exhale

  • An awareness of your posture is also incredibly helpful because this can impact how well you connect with your core, breath and body (how you move affects your core and vice versa). Everyone will be different but generally speaking

    • Avoid squeezing your glutes while standing 

    • Try to stack your ribs over your pelvis and breathe gently into the lower ribs (back and side of your ribs) and abdomen (avoid holding that tummy in! It will not help you in the long run). 

    • This can be done in standing, sitting and while holding your baby

  • Walking → this is great exercise, and helps reduce post-op complications (3). I recommend starting out with shorter walks and go a couple of times a day if you can. Maybe you start around the block (~5-10 minutes) and gradually build from there until you feel up to longer walks. 

    • How will you know when to increase:

      • You have the energy to walk longer

      • No/very minimal back, hip, pelvic, abdominal pain and other symptoms like pelvic heaviness/pressure

  • Stay hydrated and keep those bowels moving regularly!! Eat lots of fiber :)

  • If you’re itching for something more after a few weeks and feeling good, start with bodyweight exercises making sure to incorporate your piston breath (“Blow before you go”, on the exertion. For example: squat: Inhale down and exhale to come up).


From here you can progress based on how you feel. You do not need to wait until 6 weeks to be cleared (this is no longer considered best care). Six weeks is an arbitrary number based on approximate length of tissue healing. This does not mean you are ready then or that you have to wait until then. BUT keep in mind that if your incision isn’t healing well, you may need to go a bit more slowly. Again, this is where individual guidance is needed (you can check with your midwife or MD/OB as well if it’s not healing). 


Because everyone is so different, here are couple things you want to avoid in the early healing phase: 

  • Avoid irritating/aggravating your scar/incision (you don’t want it to be painful, or opening/bleeding and so on). It needs to heal, the more aggravated the longer it will take.

  • Avoid activities/exercises that are causing pain (to your scar/incision, or any body part, including the pelvis), also ideally avoid getting symptoms like pelvic pain/heaviness in the pelvis and/or incontinence** (yes, you can still get these symptoms with a c-section even though your baby didn’t come out that way - it’s part of a system). 

** If you get these symptoms or run into these issues, you don’t need to panic. You want to avoid repeatedly doing the things that cause these symptoms. For example: if everytime you lift the car seat with the baby, you have abdominal pain/incision pain/pelvic pain/etc., then it’s likely too much of a load for you at this moment OR you need some help to learn a better way to lift/connect with your core → Try “blow before you go” here and see if that changes your symptoms. If not, get some guidance. 


In this part of your rehab, healing is the key and symptoms can help guide you with your activity/exercise. I’ve listed some of the more common symptoms to help guide you, but it’s not an exhaustive list. If you’re unsure, please consult a health care provider.

 

After that early healing and once your scar is healed and you are out of the “fog” and doing regular daily activity (I can’t give you a timeline, everyone is different, but generally speaking it tends to be somewhere between 4-8 weeks)…..here are things to consider and work on:

  1. Strength → full body and core → you need progressive strengthening exercises that start where you’re at and progress as you are able. This is highly individual and depends on many factors. 

  2. Scar → improve scar mobility and decrease sensitivity → often missed/not done or not done enough. 


Let’s dive in…..


Strength

female trap bar deadlifting

During pregnancy, muscles get weak because your body changes significantly. Abdominal muscles are lengthened and the pelvic floor is carrying a heavier load. Lengthened abdominal muscles that happen in pregnancy are weaker (4). Then, when you have surgery, this surgery creates more weakness (swelling, bleeding, changes to the connective tissue from the incision, irritation/injury to the nerves in the abdominal wall from the incision). In some cases, you’ve also laboured and then had surgery. It’s imperative to your rehab that you learn how to connect with your core (piston breath), integrate this into your strength training AND have exercises that target the full abdominal wall (all core muscles need training) and body. 


Side note: You also would benefit from having your abdominal wall assessed for diastasis rectus abdominus (DRA). 


First connect and activate, then load the muscles. Focus on building endurance (think higher reps and sets, as you are able, ex: holding planks for longer and higher reps), then build in more dynamic movements and heavier loads. There is no bad exercise, but there is bad timing for an exercise and there is bad technique. Importantly, it’s not just about the “core” and doing core exercises; you need full body strengthening because your core (& pelvic floor) supports movement and to regain your function you need to include your core in these full body movements (think squats, deadlifts, upper body, running, etc.). There’s so much variability in how people move and how people learn to move - you’ll hear it again - if you have the means, go and get an individualized plan. 

Regaining and building your strength will take time, so give yourself that time. It can take up to two years or more for you to feel “yourself” again. You will change and progress along the way, but it takes time, so be kind to yourself and establish a plan that is realistic for you to have success with. You do need to do the work here but you will feel so good!! It’ll be worth it. 


Now the SCAR….

After 3 months or so, once your scar is fully healed and there are no open spots or aggravated areas, I recommend starting a gentle scar massage. Then around 6 months starting with electro-acupuncture. 


There’s no rush here. You can safely start scar massage away from the scar earlier, but honestly, don’t stress if you can’t get it done. There’s a lot going on in that early phase of healing. At some point though, you need to touch and move your scar. 


When I assess scars I’m looking at two main things: 

1) Does it move? (how much tension and thickness is there? Can I lift and roll the scar? Or is it stuck down?);  

2) Is it painful and/or sensitive? Scar tissue can become sensitized, which means the nerves are irritated and they are signaling to the brain that something is “irritating or painful” when it shouldn’t be. You can think of this like miscommunication and the story needs to be set straight, the nerves need to settle down so they can tell the brain the right thing. 


Sensitivity and/or poor scar mobility can affect recruitment of the abdominal muscles, can be involved in low back pain, pelvic pain and hip pain (to name just a few). Symptoms you may experience if your scar is sensitized or has poor mobility: itchiness, pain, tenderness, gets irritated with different textures, doesn’t move, has a “shelf”, and so on.*


*If you’re reading this and your c-section was years ago, and you didn’t treat your scar, you can still do it now. The body is very adaptable and can change when given the right things. 


Electro-acupuncture is the single best modality to treat scar tension and sensitivity (that’s my opinion based on years of using it in clinical practice). It has some research

C-section scar treatment with electro-acupuncture

evidence to back it up as an effective treatment of scars with positive outcomes (5) (but no research claims saying it’s the best - that’s my claim 🙂). One caveat here, you need to be comfortable getting acupuncture done, otherwise it won’t be the best modality for you. 




Testimonial → here’s someone’s own experience:

“My c-section scar was quite ropey and tight causing a noticeable “c-section shelf”. Micaela recommended I try electro-acupuncture around my scar to release some of the deeper restrictions and tension that manual therapy and the dolphin neurostim were unable to release. I noticed improvements after the first few treatments! Acupuncture has significantly lightened my scar appearance and improved the ropey sections while also minimizing the appearance of my shelf.”


I’ll leave it at that. First heal, connect with your core and get moving. Then load your body. AND treat your scar! 


Any questions, please ask away and I’ll do my best to answer.  


References:

(1)Okiemy G, Ele N, Odzebe AS, Chocolat R, Massengo R. Nerfs Ilioinguinal et Iliohypogastrique. Bases anatomiques de prévention des névralgies résiduelles après appendicectomies, cure de hernies inguinales, césariennes [The ilioinguinal and iliohypogastric nerves. The anatomic bases in preventing postoperative neuropathies after appendectomy, inguinal herniorraphy, caesareans]. Mali Med. 2008;23(4):1-4. French. PMID: 19617174.

(2) Stone, Jennifer DPT, OCS, PHC1; Skibiski, Katie DPT, PHC1; Hwang, Sarah MD2; Barnes, Courtney MPH, MD, FACOG1. Physical Therapy in Addition to Standard of Care Improves Patient Satisfaction and Recovery Post-cesarean Section. Journal of Women's Health Physical Therapy 45(1):p 10-19, January/March 2021. | DOI: 10.1097/JWH.0000000000000187 

(3) Engel O, Haikin Herzberger E, Yagur Y, Hershko Klement A, Fishman A, Constantini N, Biron Shental T. Walking to a better future? Postoperative ambulation after cesarean delivery and complications: A prospective study. Int J Gynaecol Obstet. 2022 May;157(2):391-396. doi: 10.1002/ijgo.13815. Epub 2021 Jul 17. PMID: 34214190.

(4) Deering RE, Cruz M, Senefeld JW, Pashibin T, Eickmeyer S, Hunter SK. Impaired Trunk Flexor Strength, Fatigability, and Steadiness in Postpartum Women. Med Sci Sports Exerc. 2018 Aug;50(8):1558-1569. doi: 10.1249/MSS.0000000000001609. PMID: 29554014; PMCID: PMC6045430.

(5) Tuckey C, Kohut S, Edgar DW. Efficacy of acupuncture in treating scars following tissue trauma. Scars Burn Heal. 2019 Mar 11;5:2059513119831911. doi: 10.1177/2059513119831911. PMID: 30886746; PMCID: PMC6415480.

*Piston breath → learned from Julie Wiebe, PT. This is not my own creation :). 

** Anatomy picture from Complete Anatomy App


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