What is it?
Caesarean Section (C-section) is a surgical technique used for foetal delivery during childbirth. An incision is made through the abdomen and uterus under a general anaesthetic or epidural which is a spinal anaesthetic that targets the pelvis and extremities. C-sections will be completed electively or in an emergency due to maternal or foetal complications throughout pregnancy or labour. This form of delivery occurs in one third of Australian women and requires a specific post-operative protocol and rehabilitation plan.
A C-section involves the incising the skin of the lower abdomen followed by two layers of fascia. There is then connective tissue of the abdominal muscles and the muscles themselves before arriving at the peritoneum of the abdomen. Below this is the uterus which has three layers itself! With over seven layer of tissue impacted and repaired during this delivery technique, the rehabilitation requirements are apparent. Oftentimes this can be misrepresented and post-partum guilt around rest or reliance on support can create a barrier to recovery.
The operative complications associated with a C-section include post-partum haemorrhage, wound complications, foetal lacerations, infection, pain, other anaesthetic complications and venous thromboembolism. When compared to a normal vaginal delivery however there is reduced risk of post-partum perineal trauma, prolapse and incontinence.
Why C-Section?
A vaginal delivery is the primary delivery pathway for women without the presence of foetal or maternal indications for a C-section. These include but are not limited to:
- Foetal distress or abnormal foetal tracking
- Previous C-section
- Unsuccessful assisted vaginal delivery
- Congenital anomoly
- Placenta abnormalities
- Cardiac/Pulmonary pathology
- Herpes or HIV
- Pelvic trauma
- Maternal request
Post-Surgery
Following a C-section in the absence of foetal distress and general anaesthetic, immediate skin to skin contact is facilitated. Whilst recovering, you will receive guidance from your midwife or hospital lactation consultant to encourage breastfeeding or expressing. Due to the surgery and increased recovery associated with a C-section, there is a minimum additional night stay at the hospital to monitor health outcomes. Depending on the health status of mother and child post-operatively, this can change.
Post-surgery you will be provided with medication for pain management to ensure that you are able to care for your baby. The medication prescribed will be continued under the guidelines of your treating team and weaned gradually over the first few weeks post-partum.
The wound will host either dissolvable or removable stitches. The latter of which can be removed at 5-7 days by your GP or Midwife. The dressing covering the wound may come off around 3-7 days post-delivery. Whilst the dressing is in situ, you are able to wash under the guidelines of the treating team without actively scrubbing the wound whilst it is healing. If there are any signs of redness, heat, swelling or persistent bleeding/weeping immediately present to your GP as the wound may be infected. It is to be expected that the wound and surrounding tissue may feel numb following surgery which will gradually improve over time.
Whilst the wound is healing certain movements that increase abdominal pressure or tension can result in pain or discomfort. To reduce pain over the scar site during coughing, sneezing or vomiting use a folded over towel or a pillow as a ‘Teddy’ to apply gentle pressure to the region and bend slightly forward with the trunk or draw the knees in to reduce the tension on the scar.
Deep breathing exercises or diaphragmatic breathing will enhance oxygenation post-surgery whilst also activating the piston movement with the pelvic floor and diaphragm. This video provides a guided example of deep breathing. When comfort levels increase usually a week post-partum, commencing gentle pelvic floor contractions each day will assist with circulation, activation and reducing swelling.
Effective toileting habits are also vital to reduce pressure at the scar site and strain on the perineum. Emptying the bladder should occur with an appropriate sense of urgency without preventative toilet breaks ‘just in case’. When voiding, your stream should be steady, not-strained and a light yellow colour. If you are experiencing changes to your stream, urgency, pain, dehydration, lack of sensation, incomplete emptying or urinary incontinence please contact your GP and Pelvic Health Physiotherapist. Bowel movements should be easy to pass and a smooth consistency without straining. Please read through this article for optimal bowel movement strategies and toilet posture.
Lifting and Driving
As a Physiotherapist, the biggest question for women post C-section is when can I start lifting and driving again? The general guideline is to not lift ‘heavy’ for 4-6 weeks post surgery but what is lifting heavy? Unfortunately there are no concrete guidelines. The risk of complications such as a hernia or abdominal complications restrict further studies. Most Physiotherapists will discuss return to sport at 12 weeks post-partum. Assessment of abdominal bracing, transversus abdominis activation, pelvic floor control, lower limb stability and plyometrics should be assessed prior to return to weight training or aerobic exercise. Commencement of activity is completely individualised and gradually progressed under the guidance of your Physiotherapist. To safely commence driving, the scar needs to withstand the pressure of a possible immediate stop.
C-Section Massage
The C-section scar is an inevitable outcome of this surgical intervention. Post-surgery the quality of the scar will be monitored by your treating team whilst in Hospital, and your GP when discharged. Your Physiotherapist may also review your scar to ensure it is healing well. A well healed scar will present as flexible, flat and light in colour. Interventions used aim to mitigate the formation of adhesions, scar tissue, pain and reduced mobility at the scar site. In addition to scar massage and mobilisation, techniques such as Kinesiotaping, Dry Needling and Laser Therapy can be used as an adjunct.
To commence scar mobilisation, the scar should be well healed without any signs of infection or opening. Early mobilisation can be implemented in the first few weeks in the vicinity of the scar without any discomfort or direct contact with the scar. Most therapy will commence 4-6 weeks post-partum with a ‘stroking’ technique either side of the scar. Massage techniques are progressed to include rolling, lifting and multi-directional mobilisation. Recommended dosage is around 30mins, 2-3 times per week for 8 weeks.
At home scar massage should be performed in a comfortable environment. Complete the massage with clean hands either lying down with a head support. A light lubrication such as natural oil or non-scented cream can assist with tissue glide. Your Physiotherapist will demonstrate techniques appropriate for you with education on pressure changes and tension points. If you have any concerns, please discuss with your GP and Physiotherapist.
References:
- Sung S, Mahdy H. Cesarean Section. [Updated 2023 Jul 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546707/
- The Women’s. The Royal Women’s Hospital Victoria. May 2024. https://www.thewomens.org.au/health-information/pregnancy-and-birth/labour-birth/caesarean-birth
- After Caesarean Birth. Monash Women’s Health. May 2024. https://monashwomens.org/patients/postnatal-care/after-caesarean-birth/
- Oliver Jones. 20th December 2022. Teach Me ObGyn. https://teachmeobgyn.com/labour/delivery/caesarean-section
- Physiotherapy following Caesarean Birth. Mackay Hospital and Health Service. May 2021. https://www.mackay.health.qld.gov.au/wp-content/uploads/2023/05/Physiotherapy-following-caesarean-birth-2021-review.pdf
- Lubczyńska A, Garncarczyk A, Wcisło-Dziadecka D. Effectiveness of various methods of manual scar therapy. Skin Res Technol. 2023; 29:e13272. https://doi.org/10.1111/srt.13272
- Daniszewska-Jarząb, Iga & Jarząb, Sławomir. (2021). Manual scar therapy on the example of a caesarean section scar. Aesthetic Cosmetology and Medicine. 10. 201-204. 10.52336/acm.2021.10.4.05.