C-Section Recovery and Return to Exercise

Why You Need to Know about Proper C-Section Care

Cesarean or C-sections are the most common inpatient surgery performed in Canada, the US, and the UK¹. They are more common than hip and knee replacements, fracture repairs, open heart surgeries, appendix removals, hysterectomies and more. In Canada alone, 1 in every 3 births are C-section, with numbers only continuing to rise¹.

Despite this, mothers are given minimal medical advice on what to do after surgery. Typically, we hear something along the lines of “take it easy for 6 weeks and avoid lifting anything more than your baby”. However, following other surgeries like hip and knee replacements, ACL reconstructions, and gallbladder removals, patients are given instructions on what they can and can’t do and are often sent for physiotherapy. Yet, despite being the most common surgery in Canada, little guidance is given for the post-operative protocol after a C-section.

To top it all off, most C-sections are emergency C-sections, which means they are unexpected or unplanned. In some cases, C-sections can be planned but even then, many mothers feel unprepared, overwhelmed and uncared for following their surgeries. Luckily, there are some health care professionals who can help you in recovery including pelvic floor physiotherapists (that’s me!). For all you mothers out there who didn’t plan to have a C-section, who feel unsure of what they can or can’t do postpartum, who want to feel educated about what happened to their bodies, or who feel a bit lost returning to exercise, this guide is for you.

What Exactly Happens During a Cesarean Section?

I find it interesting that most of my patients don’t really know what happens during a C-section. A C-section is a major abdominal surgery that involves cutting into the abdomen and the uterus to deliver a baby. Doctors cut through almost 7 layers of fat and tissue to get close to the uterus. The bladder is moved out of the way and the uterus is then cut to get the baby out. Afterwards, all of these cuts are stitched up including one final layer on the skin that we can see. There is so much more than meets the eye but this can help explain why even when the outer incision is healed up, we still feel deep discomfort as other incisions deeper down need time to heal.

This video is a great way to understand a bit more about what happens during surgery: https://www.youtube.com/watch?v=utCS5rzNkfU

Why Do I Feel Pelvic Symptoms If I Had a C-Section?

It is often thought that because a baby wasn’t delivered vaginally there is less trauma to the pelvic floor muscles, “sparing” the vagina. I mean yes, you don’t have to worry about tearing or an episiotomy but truthfully, C-section deliveries require the same, if not more treatment postpartum than vaginal deliveries.

Regardless of how you deliver, there is a growing baby inside the uterus for almost 10 months during pregnancy. This results in constant, downward pressure applied to the pelvic floor muscles and weakness over time. As I mentioned before, most C-sections aren’t always planned. Women who have emergency C-sections still undergo a lengthy labour, especially when pushing, so the pelvic floor muscles can still be affected.

Now, research does show that compared to vaginal deliveries, C-section births do have lower incidence of urinary and/or fecal incontinence, prolapse, and decreased pelvic floor muscle strength². However, C-sections are associated with an increased risk of infection, chronic pain, adhesions, pelvic floor muscle tension, constipation, abdominal pain, diastasis recti, lower back pain, pelvic pain, and pain with intercourse².

RED FLAGS: Things to Be Aware of Immediately After Surgery

As this is a major abdominal surgery, it’s important to know of any red flags following your surgery. If any of the following are present, please call your doctor or go to emergency immediately³.

• Signs of infection: redness, puss/oozing at the incision site, fever, vaginal odour

• Nausea and vomiting

• Dizziness/fainting

• Chest pain, shortness of breath

• Separation/opening of the incision

• Heavy vaginal bleeding, passing clots larger than a toonie

• Pain or swelling and redness in one or both legs

• Headache associated with positional changes (sitting upright or inclined)
  

Quick Tips: Early Recovery After C-section

It is important to remember that recovery will be different for everyone and that some mothers may take longer than others. Following any other surgery, we understand the importance of rest and allowing the body to heal. After a C-section, the same rules should apply. Here are some things you can do immediately after surgery to start your recovery.

1. Pain Management

Stay on top of your pain medication as being pain free will allow you to comfortably take care of your newborn and move more easily. You should notice pain around your incision decreases each day until you no longer require your medication.

2. Get Up and Moving

Although you may feel stiff and sore following a C-section, it is important to get up and move around. Walking improves circulation, reduces your risk of developing a blood clot, increases lung function, improves insulin resistance, and has been shown to reduce time in the hospital⁴.

3. Change Positions Properly

Moving from one position to another can be painful and challenging. It is important to use pillows for support when rolling or turning in bed to reduce pain and strain at your incision site.

• Roll onto your side first and then push yourself up when getting out of bed
• Avoid sitting straight up from a laying down position
• Use a bridge to maneuver in bed

4. Coughing & Clearing Your Throat

Coughing and sneezing can be painful following a C-section because of the increased abdominal pressure putting strain on the incision. To reduce pain and increase cough effectiveness, apply pressure to your incision using a pillow or folded towel while you cough or clear your throat.

5. Abdominal Wrapping

To reduce the risk of abdominal separation or diastasis recti, wrap your abdomen immediately following your C-section and up to 8 weeks postpartum. This can even be done when the incision is healing but should not be done if you have an infection or if you had delivery complications. The Ab Wrap, C-panties, or high waisted panties are great options.

6. Constipation, Hemorrhoids & Toileting

Going to the bathroom following a C-section can be challenging for many reasons. Your pelvic floor muscles are stretched causing bladder/bowel control to feel less as compared to before. Pain medication can also reduce motility through the gut increasing constipation. Bearing down can increase pressure in the body causing pain on or around the incision. When going to the bathroom, be sure to:

• Take your time!
• Try to relax and breathe
• Sit with your feet elevated on a step or stool, leaning forward slightly and resting on elbows
• Increase your water and fiber intake to help your stool soften and pass easily
• Use a pillow to splint your incision when pushing
• Try witch hazel sitz baths, Tucks pads or stool softeners to help with hemorrhoids and constipation

7. Breastfeeding positions

Breastfeeding may not be comfortable following your C-section. Many mothers prefer feeding in positions where baby is supported or there is minimal pressure on the incision including side lying breastfeeding, a football hold or an upright seated position with pillows for assistance. It may also be helpful to have your baby handed to you after you are positioned comfortably.

Exercise After Your C-Section

Once again, it is important to remember that return to exercise is different for every person. It really depends on how you are feeling. Do you feel ready? Are your symptoms managed?

Remember, recovering from a C-section is different than recovering from any other surgery like an ACL reconstruction or a gallbladder removal. You have a newborn to care for and possibly other children. You’re sleep deprived, stressed, and emotional. Your body is also going through hormonal changes, and you have new responsibilities such as breast or bottle feeding and an excess of laundry.

Before returning to exercise, it is important to set realistic expectations. Exercises in the first few weeks should focus on managing pain, improving your range of motion and restoring body awareness⁵. Once you are 6+ weeks postpartum and have been cleared to return to exercise by your primary care provider, you can engage in a postpartum exercise program. Always listen to your body, be patient, and return to exercise in a gradual manner. Use a Qualified Exercise Professional and pelvic floor physiotherapist to help you - they are the professionals! The Postnatal Academy is a great example of a postpartum program that helps you exercise safely and in a gradual manner.

General Return to Exercise Guidelines

As a general guideline, you can return to most activities around 6 weeks postpartum, once you have received clearance from your primary care provider⁵.

• Lifting: Gradually increase after 6 weeks or when cleared by your surgeon
• Swimming: You can begin when your incision is fully closed over
• Strengthening: Increase gradually at 6 weeks postpartum, beginning at 2x/wk, roughly 15-20min. Here are examples of exercises you can start with at 6 weeks postpartum.
  • You can begin pelvic floor strengthening exercises immediately postpartum!
• Sports (low impact): You can return when you are symptom free and are comfortable with basic strengthening exercises, generally around 2-3 months postpartum. Jenni recommends completing her 12-week Strength Program prior to returning to sports to decrease your risk of injury and pelvic floor dysfunction.
• Running/High Impact Sports: Again, this varies from person to person but the current guidelines suggest beginning after 3-4 months postpartum, and once you are comfortable with strength exercises such as those in The Postnatal Academy.

Signs That You are Doing Too Much

If you see any of the following, it is a sign that you are doing more than your body is able to handle. You should reduce your exercise levels and seek out a Qualified Exercise Professional and/or pelvic floor physiotherapist⁵

• Increased vaginal bleeding or spotting
• Pelvic pain, abdominal pain, lower back pain
• Urinary and/or fecal leakage
• Pelvic pressure/heaviness/feeling like “a tampon is coming out”
• Symptom increases lasting more 30-45min after exercise

Specific Goals & Exercises Week to Week

Weeks 0-2

• Cardio: begin walking at a low to moderate intensity for 5-15 minutes/day *roughly
• Breathing/deep breathing exercises
• Gentle movements to maintain flexibility
  • Stretches for your chest and neck
  • Reaching your arms overhead
  • Ankle pumps and circles when laying/sitting
• Gentle strengthening
  • Pelvic tilts
  • Heel slides while laying on your back with knees bent
  • Pelvic floor exercises/kegels (exhale and contract, 3 sets of 10-15, and then fully release)
  • Modified glute bridge (lifting bum off bed slightly)

Weeks 2-4

Begin increasing intensity or frequency of exercise, as comfortable.

• Cardio: continue walking at a low to moderate intensity but increase to 20-30min/day
  • If using machines, stick with something low impact like the elliptical or bike
  • When walking, increase the time or volume before intensity
• Stretching: Continue to stretch the chest, arms and back, extend the trunk
  • Cat/cow
  • Pelvic tilts on an exercise ball
• Strengthening: Avoid using any resistance and focus on functional, body weight exercises
  • Sit to stands
  • Chair squats
  • Glute bridges
  • Wall push ups
  • Side lying leg raise

Weeks 4-6

As you approach 6 weeks postpartum, you should feel flexible and like you have full range of motion in the upper body. Increase cardio and resistance exercise, as you feel comfortable.

• Cardio: Increase to walking 30min, 1-2x/day
  • Introduce swimming *if you are cleared to do so
• Strengthening
  • Side planks on knees
  • Bird dog
  • Squats
  • Mini or ¼ lunges

Weeks 6+

After 6 weeks postpartum, you can begin light strengthening workouts, 1-2 days/wk, increasing frequency and intensity as tolerated. You can also begin using weights and increased resistance. Here are some exercises that Jenni recommends incorporating at 6 weeks postpartum. This is also when mothers should see a pelvic physiotherapist for a follow up assessment of their incision, pelvic floor muscles and strength. Physiotherapists can also educate and help you return to pain free intercourse, learn how to massage your scar and reduce scar tissue build up, strengthen your muscles and help you with any other symptoms you may still be feeling.

Make sure to check out The Postnatal Academy to begin your safe and gradual postpartum exercise program after C-section.

References

1. BetraÃÅn, A. P., Ye, J., Moller, A. B., Zhang, J., GuÃàlmezoglu, A. M., & Torloni, M. R. (2016). The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PloS one, 11(2), e0148343. https:// doi.org/10.1371/journal.pone.0148343
2. https://www.med.umich.edu/1libr/Gyn/C-SectionPostOp.pdf
3. Batista, E.M., Conde, D.M., Do Amaral, W.N., & Martinez, E.Z. (2011) Comparison of pelvic floor muscle strength between women undergoing vaginal delivery, cesarean section, and nulliparae using a perineometer and digital palpation, Gynecological Endocrinology, 27:11, 910-914, DOI: 10.3109/09513590.2011.569603
4. Ituk, U., & Habib, A. S. (2018). Enhanced recovery after cesarean delivery. F1000Research, 7, F1000 Faculty Rev-513. https://doi.org/10.12688/f1000research.13895.1
5. BetraÃÅn, A. P., Ye, J., Moller, A. B., Zhang, J., GuÃàlmezoglu, A. M., & Torloni, M. R. (2016). The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PloS one, 11(2), e0148343. https://doi.org/10.1371/journal.pone.0148343

Note: This post is for educational purposes only and does not replace medical advice or treatment from your health care provider. Always follow the advice of your primary care provider when making decisions about your health and well-being.