In all my years, I have not met one woman who has not planned out her dream birth! Copious amounts of birth classes, fertility nutrition, prenatal yoga, acupuncture, chiropractic care, finding the perfect doula, creating a birth plan and now even pelvic therapy are part of the planning process. Most women dream of having a healthy vaginal birth or unmedicated home birth! But 1 in 3 babies are born via cesarean section due to an emergency situation, or to protect Mother and Baby due to other health concerns. In the USA a cesarean section is the most common inpatient procedure. So many C sections are done each year. The number of c-sections outpace total hip replacement and total knee replacements combined (2014). Only 10-15% c-sections are actually emergent and 25% are “low risk”.
C-sections are a major abdominal and gynecological surgery, involving more body systems than a total hip or knee replacement. But there is no specific rehabilitation program or medical plan to start healing for a new postpartum and post surgical mother. As a PT, we know there is a specific plan of care from postoperative day one for a total joint replacement. On day 1, a PT comes to your hospital room, assists you in getting up, out of bed and to a chair/toilet. The therapist may even walk you down the hall with a walker or cane, coaching your every move. The therapist wants to make sure you are safe and strong enough to walk on your own before you go home. This care does NOT happen for any postpartum mother, not even a woman who could be considered post surgical due to a c-section! This bunches my panties and makes my blood boil!
The scar is the tip of the iceberg
Before I stand on my soap box anymore, Let's break down the basics of a C-section. What is it and how do they do it? The small 6-8 inch scar on the lower tummy is the tip of the iceberg. Once the scar is healed, many women forget more healing is occurring under the surface. Many OBGYNs play into this mindset at the six to eight week appointment sharing, “You're good to go and able to return to whatever activities you would like!” You would never hear an orthopedic surgeon say this to a client at 6 weeks after a joint replacement. You are prescribed continued physical therapy, a walking program and other activities. At 6 weeks post C-section, the abdominal fascia (connective tissue which supports the core muscles) only has regained 51-59% of original tensile strength!
So what does that mean as a new Mom? The core muscles have 50-60% of the strength that you had before in the core, making daily activities like lifting and carrying a baby more strenuous on other muscles. Not only do the muscles need to heal, the uterus itself had surgery as well. Women need to be appropriately educated on the changes their body has endured through this surgical and postpartum period. There are 9 layers which are sectioned to bring baby earth side:
the skin
the belly fat which keeps you insulated
the fascia of the rectus muscle is pulled off the rectus abdominis (your six pack muscles) because it is a very dense structure
the fascia that joins the obliques, deep abdominal muscles.
Once past the muscle layers of the abdomen:
the peritoneum is sectioned
the bladder is moved to one side to reach the uterus and
Finally the uterus and her three beautiful layers of muscle and tissue to then free baby!
Then once surgery is finalized, the uterus itself, being a very thick smooth muscle is stitched back together, then each layer of the abdomen is also sutured back together. The c-section scar is just the tip of the iceberg that we see! Can you see why c-sections deserve more credit and rehab compared to a musculoskeletal surgery for a total knee replacement?
Enhance your Recovery
The specific plan to start rehab with every total hip and total knee replacement patient occurs at every hospital around the country. In my personal opinion, a cesarean section, both a gynecological and abdominal surgery is a lot more advantageous of a surgical intervention than a total joint replacement. Not to mention the 9-10 months of carrying a small human, multisystem changes to the blood flow, kidney, digestive, breathing and muscle system, all mediated by the hormonal shifts that also occur during gestation and after giving birth to a new baby.
The first 6 weeks
The first six weeks are very important for healing after having a C-section. Until the first 6-8 week check up, women are instructed not to do “too much”. Have you ever known taking care of an infant to not be “too much”? Most instructions are to not to lift the baby, walk up and down the stairs, strain with a bowel movement, all for good reason to respect the healing tissue! But this can cause a lot of anxiety and fear, making some women feel they “can't do anything” during that time. But that's not true. With guidance and good education, there are many things that you can start to do after having a C-section. Like having a total knee replacement, there are slow and steady progressions to help you return to movement and confidence each day of your healing. For example, breathing, gentle belly massage and gentle movement of your arms and legs can enhance core healing, improve strength and reduce pain.
After the first 6 weeks
One thing many women start after their six or eight week postpartum visit is scar mobilization. Yet there is minimal instruction other than go ahead and rub your scar with some vitamin E, coconut oil or Bio skin. It's one thing to start mobilizing the scar, but it's another to know how to do it safely. Let's go over a bit of scar mobilization starting off easy and simple. When your scar has healed well and you feel comfortable, we first suggest an indirect technique to explore your scar and healing body.
Indirect Scar Massage
Massage the area around the scar. Place the pads of 2-3 fingers approximately 2 finger-widths above or below the scar.
Gently stretch the skin side to side, up and down, and in circles.
You may feel a slight burning or pulling with this technique, but it should not be severe.
Spend some extra time on areas that don't move as well.
Massage the area around the scar for 2-5 minutes a day depending on your comfort level.
Afraid to touch near your scar? It's valid to be nervous as this is new territory and you may need to reconnect with your body in different ways. You may find it helpful to start by rubbing or brushing over the scar. Using a towel, sheet, or cotton ball to rub around and over the scar can help with sensitivity and get you more connected with the area.
Support your healing
Along with good scar mobilization, seeing a pelvic therapist is another great way to check in to make sure your body is healing well! Remember your organs were moved around, shifted as you held the baby for 10 months previously, and now require healing along with the muscles and ligaments of the pelvis. C-section scar tightness can also cause tightness around the nerves of our lower belly which can affect our bladder, bowel and sexual function. (More on this in Part 2- C Section Healing). Have questions or want guidance on how to massage your scar, Our team at Breathe Life PT, provides skilled care with one-on-one support to help you create an active, comfortable and confident post partum life!
In the South Jersey area and want one on one care with our team? Schedule an appointment for your complimentary 15 min phone call to see how pelvic therapy can help you!
Dr. Amanda Heritage, PT, DPT is the owner of Breathe Life Physical Therapy & Wellness, LLC located in Collingswood, NJ. She has been practicing physical therapy for 10 years with a strong focus on pelvic health. She enjoys encouraging women and men about pelvic therapy as a treatment option for those suffering with pelvic pain, incontinence or constipation.