Half of my pelvic physical therapy patients are those who’ve given birth by C-section. I’m always amazed at their resourcefulness and resilience considering how little guidance and support they receive for their recovery.

Before I specialized as a prenatal and postpartum pelvic physical therapist (PT), I worked as a neuro PT in a hospital. Doctors routinely sent me their patients who just had surgery or required rehabilitation for head injuries.

For virtually all major surgery, it’s standard protocol to follow up with some type of therapeutic rehabilitation, except for when it comes to a C-section.

This baffles me.

C-section is major surgery

Not only is a C-section major surgery, there are significant physical demands of caring for a newborn.

C-section mamas are commonly told not to lift more than their baby. But what about having to carry the baby in the car seat? Shoving the stroller in the trunk? Lifting an older child? Carrying groceries?

In addition to just having had major abdominal surgery, my C-section patients commonly struggle with a sense of failure for not having a vaginal birth. In my practice I see how those complex feelings lead to self-imposed pressure to “bounce back” and heal faster.

First, I want to acknowledge that there’s no failure in giving birth by C-section. We all make the best decisions that we believe will lead to healthy outcomes for ourselves and the baby. Give yourself a hug and a break!

Second, there’s a misconception that people who give birth by C-section won’t have issues with their pelvic floor, which is typically associated with vaginal deliveries.

I can’t tell you how many times C-section patients come to my clinic confused about why they’re experiencing pelvic floor dysfunction and pain.

So what exactly happens with a C-section?

Let me share what happens during a C-section so you can see how this surgery impacts pelvic health and function.

During a C-section, the skin and many layers of tissue below are cut horizontally. At the abdominal muscles, the surgeon parts them vertically down the middle. The bladder is moved out of the way to get to the uterus. Then an incision is made in the uterus to get the baby out. After, the uterus is stitched up, the bladder is put back in place and the outer layer of skin and tissue below it are closed with stiches.

Check out this video for a non-gory visual explanation.

Healing and scar tissue

During healing, the body creates collagen to form a scar. It’s a tough fibrous tissue made up of the same protein as the tissue it replaces. Scar tissue appears on the surface of the skin as well as the layers beneath.

Scarring is our body’s natural healing process, but scar tissue forms in a way that is different than normal tissue. It doesn’t allow for as much give or movement, which inhibits nerve and blood supply to the affected area.

How can my pelvic floor possibly be affected when the baby didn’t pass through there?

When it comes to the pelvic floor health, we tend to focus on vaginal delivery. We forget that carrying a baby for 9 months causes constant downward pressure on that very important group of muscles.

Also, it’s common for adhesions to impact surrounding organs like the intestines, bladder, rectum, and uterus. The lack of movement in these tissues above the pelvic floor eventually leads to restrictions in the pelvic floor.

C-sections, a seemingly “simple procedure,” can leave postpartum women with the following symptoms:

  • Pulling or tension through the abdomen (can be linked to the scar tissue).
  • Feeling of weakness in the core.
  • Back pain from compromised abdominal muscles..
  • Pain and sensitivity at the scar.
  • Pain with sex.
  • Bladder frequency, urgency, and/or leaking.
  • Pain with urination.

What happens to my core?

Regardless of how we deliver, during pregnancy our posture changes. Our bodies don’t just “bounce back.” It takes time and effort to recalibrate our center of gravity and retrain our core muscles to function optimally.

Imagine our core muscles form a barrel: diaphragm (top); pelvic floor (bottom); transverse abdominis (front and sides); and multifidus (back). During pregnancy, these muscle groups shift or take on greater loads to accommodate the growing baby.

The front of the barrel gets stretched out (and cut, for C-section mamas). The bottom holds extra pressure and weight for several months. The top is squished and not allowed to expand. New postures from a shift in center of gravity greatly affects the back muscles. It takes time for these structures to return to place.

As a result, your core muscles don’t fire or engage right away after giving birth. Standard postpartum care doesn’t teach birthing parents to rehabilitate these muscles. Too often, new parents end up living with symptoms listed above and chalk it up to having a baby.

My C-section patients commonly report feeling like their core is wobbly or numb. Some feel like there’s a “dead zone” between their upper and lower body.

These signs point to the likelihood that the core muscles aren’t able to support the load their given. That’s no surprise given the pregnancy, and abdominal surgery.

What steps can we take?

We can do a lot in those early postpartum weeks and months to support healing from pregnancy and a C-section. Here are my five recommendations.

1. Prioritize scar care

Touching the skin around the incision helps desensitize the area, and prepares it for clothes to brush up against it. Once the wound is completely closed and a scar has formed, start mobilizing the tissue and skin by rolling over the scar (see video for more details).

Be sure to check with your provider about whether your incision is fully closed and that you’re ready to work directly with the scar tissue.

2. Gently “wake up” your core

The immediate postpartum phase is not a time for intense exercise, but you can gently activate your deep core muscles (see barrel analogy above). Re-engaging your deep core muscles helps support day-to-day tasks. It’s also a foundational step in returning to your favorite activities safely.

Specifically, don’t ignore your pelvic floor. As we discussed, those who delivered via C-section also experience pelvic floor issues.

With the importance of “waking up” your postpartum core, I created a 6-week online program called From the Inside Out by Mommy Berries for new moms through a series of safe and effective exercises. This program should be used in conjunction with seeing a pelvic health PT who can provide individualized assessment and treatment.

3. Check for diastasis recti (abdominal separation)

Before returning to physical activity or engaging in new exercises, check if you have diastasis recti abdominis (DRA). This is also known as “abdominal separation” and refers to the split in your “6-pack” muscles after pregnancy.

Certain exercises, particularly crunches and boat poses in yoga exacerbate this separation. You can eventually add back these exercises, but you shouldn’t start with them during the postpartum period. Click here for more details.

You can ask your postpartum caregiver to check if you have DRA. Better yet, you can do an initial check yourself at home. This short video takes you through the steps.

4. Keep an eye on posture

Make sure your rib cage is stacked over your pelvis. Avoid thrusting your ribs forward or tucking in your tailbone when sitting or standing. The goal is to limit undue downward pressure on your pelvic floor.

Proper alignment gives your core muscles a fighting chance to support your body the way they should.

5. Work with a pelvic health professional (in-person or online)

Pelvic PTs are very familiar with injuries and issues from childbirth. Our caseload is filled with postpartum patients. Even if your pregnancy and delivery were relatively smooth, I recommend at least one visit to a pelvic PT to assess your core’s alignment and function, as this is unique to each postpartum mom.

For those who do not have access to a pelvic health PT in your community, there are therapists who offer one-on-one sessions online, like Sara Reardon, DPT.

Postpartum rehabilitation isn’t yet standard care in Canada or the US, which means a provider is hard to find or costs for services are prohibitive. My online program  helps bridge this gap by providing the education and introductory information that I believe all postpartum women should have.

From the Inside OutTM Program

The 6-week program includes:

  • Weekly bite sized videos explaining your body’s postpartum transitions.
  • Gentle exercises re-connecting you with your pelvic floor and core muscles that support you during everyday movements. (Safe to start days after giving birth.)
  • Tips to promote optimal posture and habits that protect your pelvic floor.
  • Self-care tips to ensure your cup is full.
  • Weekly emails with important information about C-section scar care, symptoms that you should never ignore, how to use your core during every day mom tasks, and how to safely progress back to your favorite exercises.
  • Access to our closed Facebook community full of supportive like-minded moms.
  • Access to me through our Facebook community, where I answer your questions and help you succeed.