I'll be honest. Talking about C-sections makes me angry. It's not because of the procedure itself; I'm very appreciative of it. It's because of the atrocious lack of post-surgery education and resources for women.
If you're lucky, your client might be told not to drive, lift anything, or exercise for six weeks after their C-section delivery. That's it? That's all the information they get after major abdominal and pelvic surgery?
No guidelines for recovery? No lists of what they can do, or what they should do? No post-surgical exercise protocol? No follow-ups or physiotherapy? Nothing but "go home, and good luck"?
C-section rates are on the rise, and it's likely many of your clients have had or will have one. I want you to be confident in your ability to facilitate their recovery and help them return to exercise safely and strongly.
What is a C-section?
C-section is short for Caesarean section. These deliveries can be planned or unplanned. During the C-section, the doctor makes an incision into the skin, through the fat cells and connective tissue, and into the abdominal cavity.
The abdominal muscles are then spread apart, and the bladder is moved down and out of the way in order to reach the uterus. An incision is made into the uterus, and the baby is guided out. The placenta is taken out shortly after.
The uterus is then stitched up, the bladder put back in place, and the connective tissue, abdominals, and skin stitched up, to varying degrees. There are a lot of layers of sutures, and thus, scar tissue will form.
Healed in six weeks?
Not so fast. As you can tell from this description, a C-section is not the gentlest of procedures on the body and organs, so adequate rest and recovery are essential. Your client will need to be patient with the process and not push through it. You cannot out-train the healing process. Encourage clients to heal well now, and save themselves issues down the road in the short and long term.
Think of a C-section as you would a surgery, such as an ACL repair in the knee. Rehabilitation for it is a nine- to 12-month process. There are steps and checks along the way with the surgeon and physiotherapist, and a set timeline of when it is safe to return to certain activities. In my opinion, this is how C-sections should be treated.
Although the doctor might clear your client for post C-section exercise six weeks after surgery, be certain that this means light, gentle exercise. Beneficial exercises include breathing, walking, core restoration, and bodyweight exercises. Risky exercises include running, jumping, heavy strength training, crunches, leg raises, and other traditional ab exercises. We'll chat about the specifics of the return to exercise in a bit.
The healing process is not done at six weeks. Not even close. From the outside, your client's scar might appear healed, but the deeper layers inside the body still need time. The scar alone might not be that deep, but the deeper layers are still recovering.
"I didn't have a vaginal birth, so my pelvic floor is fine"
Although a vaginal birth increases the post-birth risk of pelvic floor dysfunction, a client who had a C-section still went through a pregnancy, which itself heightens risk of pelvic floor dysfunction. We still must reprogram the core, which is intimately integrated with the pelvic floor.
Here are some reasons why we still need to focus on the health of the pelvic floor after a C-section:
- The downward pressure of the baby can stretch the pelvic floor muscles and their connective tissues, leaving them more lax than normal.
- The expanding uterus puts pressure on other pelvic organs, including the bladder and rectum, and can disrupt their normal function.
- C-section scars can play tricks with pelvic nerve function, leading to such side-effects as urethral burning, the feeling of needing to pee all the time, and pain in the clitoris and labia.
- The alignment changes that happen during and after pregnancy and postpartum—standing with your bum tucked under, for example—can affect the tone of your pelvic floor muscles, leaving them tight and short.
Recovery in the early weeks after C-section
In the early days and weeks after a C-section, you should encourage your client to focus on resting and relaxing with the new baby as much as possible. These are the main things your client should be doing in the first 6 weeks postpartum:
1) Ask for help. Clients likely will want to do everything themselves and need to be reined in. Communicate to your clients how important it is to allow help and take up offers from friends and family. If possible, your client should have people bring the baby to her at feeding time to avoid twisting, bending, and crunching. Her job as a mama is to love, feed, and cuddle her baby and to get sleep herself.
2) Roll over. Hopefully, your client has been doing this throughout pregnancy and is in the rolling routine. Every time your client goes to lie down or to move from her back to a seated position, she lies on her side first. This avoids big crunching and sit-up type movements that put a ton of pressure on the abdominals and scar region.
An example of this exercise is getting in and out of bed. Getting into bed, she sits down, carefully lies on her side, and then slowly rolls onto her back, keeping the head relaxed and down throughout the roll. Getting out of bed, she rolls to her side, keeping the head relaxed and down, then slowly lowers the legs off the bed, and uses upper body strength to push up to a seated position. If possible, have her get someone to help with this whole process.
3) Restorative breathing. Core restoration can start within the first few days postpartum. Encouraging the client to pay attention to their breath, we want to start reprogramming the core to function from the diaphragm down through the trunk to the pelvic floor muscles. Have your clients practice core breathing from a supine position in the early days and, when comfortable, in a seated position.
In the initial days and weeks post-surgery, have clients use a gentle amount of contraction. On the inhale breath, they'll want to feel the ribcage, belly, and pelvic floor gently expand and relax. On the exhale breath, they should purse their lips (like blowing through a straw) and gently exhale to encourage activation through the pelvic floor and deep abdominal muscles. Have the client practice their core breathing before doing any exertion, say getting out of bed or picking up the baby. Start the exhale breath, get deep tension and support through the pelvic floor, and then begin the movement or lift.
4) Walking. In the first few days, your clients will want to stay off their feet as much as possible. As they begin to heal, slowly increase the amount of walking they do around the house. Monitor their energy levels that day and the next, and if they're feeling good, let them slowly increase their movement. Start with short, leisurely outdoor walks, and gradually increase their length. Use this as a time to breathe, relax, and move.
5) See a pelvic floor physical therapist. Within six weeks of delivery, if not sooner, your clients should see a therapist who specializes in the pelvic floor, even if they have no discomfort and the doctor has given them clearance for exercise after a C-section. The therapist can ensure everything is healing well and that there's no prolapse and start some extremely important scar mobilization work. Scar mobilization is not often talked about, but it can change the course of healing and deeply impact how the core functions long term.
There really is no magical date for when you should begin adding more activity, as everyone heals at their own pace. Some of my clients have begun adding in exercises within the first few weeks postpartum. Beneficial core restoration exercises include glute bridges, clamshells, and heel slides.
You can incorporate core breathing into each of these exercises. You'll want the client to exhale on the toughest part of the exercise, just before moving. For example, in the glute bridge, the client will start exhaling before lifting the pelvis and then inhale to return down.
Return to strength training after a C-section birth
In the return to more traditional strength training (after your client's six-week clearance and check-in with the pelvic floor physical therapist), you'll want to allow your client's body plenty of time to adapt to the increased movement and a good deal of recovery time between exercise sessions. If clients have any bleeding or pain (scar, pelvic, back) at all during or after exercise, decrease the intensity.
Try starting with two workout sessions per week with 15 to 20 minutes of work (not including your restoration activities). If all goes well, gradually increase the workout duration by five minutes every two weeks. You can slowly build up to an amount that works for the clients' lifestyle and needs.
When returning to strength training, you'll want to be conservative in loading of exercises. In terms of resistance, prioritize bodyweight, resistance bands, suspension trainers, and light weights. Examples of beneficial exercises include:
- Side plank
- Split squats
- Band pull-aparts
- TRX inverted row
Again, integrate breathing into each of these exercises. Clients should exhale during the toughest part of the exercise, just before the movement. For example, in the squat, clients should inhale as they squat down and then exhale to stand back up.
Also keep the body in neutral alignment. This means that the spine is kept in a long, straight line. We want a small arch in the lower back and a tall upper back, growing up into the crown of the head, just as in our other postnatal clients.
On the exercises to avoid list, you'll find:
- Crunches, sit-ups, leg raises, and front planks
- Running, jumping, step-ups
- Heavy overhead presses
- Heavily weighted exercises
- Anything that places direct downward pressure on the pelvic floor, such as a barbell back squat
Returning to exercise after C-section recovery is very similar to the return to postnatal exercise after a vaginal birth. Pay extra attention to how the body feels during exercise and its recovery after exercise sessions. Above all, program in ways that make your client feel safe, stable, and energized during and after exercise.