Recovery after a Caesarean
by Liz Brown, MSc MCSP Sports & Pelvic Physiotherapist
So you’re planning a Caesarean delivery or have been told it might be an option? Are you worried about recovery? Should you do pelvic floor exercises? When can you return to exercise? What is the difference between recovery for a vaginal vs Caesarean delivery?
The conflicting advice can be confusing!
In this article, we will run through the recovery times for Caesarean delivery, and how that can affect your timeline of expected return to exercise.
Let’s start with what actually happens before an abdominal delivery. It may be that you have had rounds of IVF or perhaps reduced exercise before pregnancy. It could be you were unwell in pregnancy which meant you couldn’t keep fit, or perhaps the pressure of bump meant your pelvic floor was already struggling a little.
It is worth taking these factors into account when setting your expectations of recovery before your baby is born. Whichever delivery type you have, your body (& pelvic floor) has carried a baby for 9 months, so it will need some attention and rehabilitation to return to usual function.
DO I NEED TO BOTHER WITH MY PELVIC FLOOR WITH A C-SECTION?
Yes! Pelvic floor rehabilitation is needed for all deliveries, and it is a good idea to have your pelvic floor checked by a pelvic physiotherapist before you return to certain activities like pilates or running.
If you do have a vaginal delivery, your pelvic floor can stretch to 3.5 times it’s usual length, to get out of the way for your uterus to contract, and push your baby out (wow!). It can take 4-6 months or more for these muscles to return to strength after this, depending on any intervention or trauma during delivery [11,12].
If you have a planned Caesarean delivery, then your body won’t go through a pushing phase of labour, which can make pelvic floor recovery a little easier than if you have an Emergency Caesarean and have done some pushing [2,12].
Sometimes a stressful labour can actually cause tension in the pelvic floor, which means rehabilitation will focus on relaxing, rather than just strengthening the area. Both an overly-tight or overly-weak pelvic floor can cause leaking [2]. Practising relaxing the pelvic floor muscles is as important as squeezing.
WHAT HAPPENS DURING SURGERY?
OK, to the nitty gritty.
If you’re having a planned Caesarean, you will have had a ‘pre-op’ appointment a few days before to sign consent forms and run through risks of surgery.
The day of the surgery, the hospital can’t usually give you an exact time for your operation, but someone will be able to guide you on where to sit and explain things to you before you go in.
Your partner should be able to be present throughout the process to reassure you. Usually, a spinal block is applied so you can’t feel anything from the waist down, which can be quite a strange sensation! A catheter (a tube connecting to your bladder via your urethra) will be fitted while you’re under anaesthesia and you will feel a tugging but no pain during the procedure for your baby to be born.
It is best not to have painted toenails and nails so that your oxygen levels can easily be measured via a clip on your finger. You’ll have compression socks on your legs to reduce risk of blood clots, a drip attached for fluids and your midwife will help you check the amount of vaginal bleeding you have as you recover in hospital. Usually, the catheter is removed about 12 hours after surgery.
Of course, if your Caesarean delivery is an emergency for you or baby, then your partner should still be allowed to be present. Everything will be slightly more rushed to ensure safety of you and baby, so it might be worth looking into risks of surgery before a consent form is thrust into your face at the height of an emergency. Everything is your choice at the end of the day.
Caesarean deliveries are graded to the level of emergency, and it is helpful to note this when setting recovery expectations.
Category 1. Immediate threat to the life of the woman or fetus (for example, suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia).
Category 2. Maternal or fetal compromise which is not immediately life-threatening.
Category 3. No maternal or fetal compromise but needs early birth.
Category 4. Birth timed to suit woman or healthcare provider. [NICE Guidelines 2004, amended 2021] [9]
WOUND HEALING
To access your baby, the highly skilled medical team need to cut through 7 layers as quickly as possible to reach the uterus, and of course all 7 layers need some time to heal.
Your wound will immediately need:
Light compression (think activewear maternity leggings, Juzo or Lola & Lykke compression belly bands)
To be kept clean and dry - your midwife or nurse should be able to guide you how to do this [9]
Painkillers are advised to be taken regularly for at least the first 3-4 days
THINGS YOU CAN DO RIGHT AWAY
Straight away, you can start:
Skin to skin contact with baby
Prioritise staying hydrated
Pelvic floor exercises (lifting and relaxing) after your first wee (yes, really!)
Gentle walking - start with 5 minutes daily at a slow pace
Relax your shoulders and take slow breaths while you’re feeding
Exhale as you lift your baby to activate deep core muscles. (Bonus points for lifting your pelvic floor muscles as you lift little one here - just make sure you relax your back passage after instead of ‘holding on’.)
HOW TO GET IN & OUT OF BED
Manoeuvring can be difficult or uncomfortable while you’re recovering from your surgery. When you’re getting in or out of bed, try:
rolling onto your side
dropping both legs over the side of the bed (gently)
pushing yourself up with your lower arm into a sitting position with an exhale
WHEN CAN I….?
Things that may take a little longer could be:
Scar remodelling takes 21 days to 2 years
Lifting washing baskets of clothes (around 12 weeks)
Driving (around 6 weeks)
Sex (around 6 weeks)
Higher impact activities e.g. running are not recommended before 6-9 months post abdominal delivery (3 months for vaginal delivery) [3].
HOW CAN I MAXIMISE HEALING?
Once your wound has completely healed (no stitches or infection and scab has totally gone), then you can start to use daily massage to ease any adhesions that may have built up after surgery. A scar physiotherapist or scar massage therapist can guide you if you’re not sure.
Massage is particularly important because:
It helps reconnect brain & body to optimise healing
Improves circulation (blood flow)
Improves appearance of your scar
Allows movement of fascia (webbed layers covering our whole body), which helps optimise muscle activation
Improves sensation (it is quite normal to have some numbness around the scar area)
Silicone sheets are a recommended way to maximise healing by improving collagen and reducing the risk of infection. Check with the brand you buy, but some sheets can be used as early as 1 week post-surgery and can give brilliant results on scar appearance. It is also recommended to have the scar reviewed every 4-8 weeks to check no further intervention is required [10].
WHEN TO GO BACK TO YOUR DOCTOR
During recovery, pain levels can be high, and it can sometimes be difficult to distinguish if your pain is ‘normal’, or if there’s something else going on. If you’re unsure at all, please have your wound checked for infection by your GP or midwife.
Other symptoms to watch out for [11,12]:
Severe pain
Leaking urine
Pain when weeing
Heavy vaginal bleeding
Your wound is red, painful and swollen
A discharge of pus or foul-smelling fluid from your wound
A cough or shortness of breath
Swelling or pain in your lower leg
WHEN TO SEE A WOMEN’S HEALTH PHYSIOTHERAPIST
Some women prefer to see their physiotherapist during pregnancy, to ensure they know if they need to practice strengthening or relaxing their pelvic floor, and so they can be guided on birth preparation.
After any delivery, it is recommended to wait 6 weeks before any internal pelvic floor examination. Scar treatment is not possible until the scar is completely healed, however your physiotherapist is able to guide you on self-releasing aches and pains and strength work.
If you have a particular goal e.g. returning to running, then your physiotherapist can guide you on this. It is recommended to see a registered Mummy MOT or POGP physio (Pelvic Obstetric Gynaecological Physiotherapists) in the UK.
You can book with Liz Brown at www.almaphysiotherapy.co.uk/book-online or email lizbrownphysio@gmail.com.
References:
Arici, E. et al. (2016). The effect of using an abdominal binder on postoperative gastrointestinal function, mobilization, pulmonary function, and pain in patients undergoing major abdominal surgery: A randomized controlled trial. International Journal of Nursing Studies, 62, pp.108–117. doi:10.1016/j.ijnurstu.2016.07.017.
Baud, D., et al (2020). Comparison of pelvic floor dysfunction 6 years after uncomplicated vaginal versus elective cesarean deliveries: a cross-sectional study. Scientific Reports, [online] 10(1), p.21509. doi:10.1038/s41598-020-78625-3.
Brockwell E. et al (2019) Returning to running postnatal – guidelines for medical, health and fitness professionals managing this population [online] https://absolute.physio/wp-content/uploads/2019/09/returning-to-running-postnatal-guidelines.pdf
Faubion, S.S., Shuster, L.T. and Bharucha, A.E. (2012). Recognition and Management of Nonrelaxing Pelvic Floor Dysfunction. Mayo Clinic Proceedings, [online] 87(2), pp.187–193. doi:10.1016/j.mayocp.2011.09.004.
Gauglitz, G. et al. Hypertrophic Scarring and Keloids: Pathomechanisms and Current and Emerging Treatment Strategies.Molecular Medicine (2011) Jan-Feb; 17(1-2)113-125
Monstrey, S. et al. Updated scar management practical guidelines: non-invasive and invasive measures. Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67: 1017-1025
Mustoe, T.A. et al. International Recommendations on Scar Management. Journal of Plastic Reconstructive and Aesthetic Surgery (2002) 110(2): 560-571
Meaume, S. et al. Management of scars: updated practical guideline and use of silicones. European Journal of Dermatology (2014) 24(4): 435-43
www.nice.org.uk. (n.d.). Recommendations | Caesarean birth | Guidance | NICE. [online] Available at: https://www.nice.org.uk/guidance/ng192/chapter/Recommendations#factors-affecting-the-likelihood-of-emergency-caesarean-birth-during-intrapartum-care.
Niessen, F. et al. Topical Silicone Sheet Application in the Treatment of Hypertrophic Scars and Keloids. Journal of Clinical and Aesthetic Dermatology (2016) 9(10): 28-35
NHS Choices (2019). Overview - Caesarean section. [online] NHS. Available at: https://www.nhs.uk/conditions/caesarean-section/.
www.tommys.org. (2021). Recovering at home after a c-section. [online] Available at: https://www.tommys.org/pregnancy-information/giving-birth/caesarean-section/recovering-home-after-c-section.
Shek, K. and Dietz, H. (2010). Intrapartum risk factors for levator trauma. BJOG: An International Journal of Obstetrics & Gynaecology, 117(12), pp.1485–1492. doi:10.1111/j.1471-0528.2010.02704.x.
Stær-Jensen, J., Siafarikas, F., Hilde, G., Benth, J.Š., Bø, K. and Engh, M.E. (2015). Postpartum Recovery of Levator Hiatus and Bladder Neck Mobility in Relation to Pregnancy. Obstetrics & Gynaecology, 125(3), pp.531–539. doi:10.1097/aog.0000000000000645.