There are a lot of Australian women who give birth via Caesarean section, with recent statistics showing that it’s the case in approximately one third of births.
There are many different reasons for this, which we won’t go into in the scope of this blog, but the main thing to note is that some Caesareans are planned, or ‘elective’, and occur without having gone into labour, and some Caesareans are unplanned, or ‘emergency’ and occur after having gone into labour with the plan of having a vaginal birth.
The situation that led to your Caesarean birth can have a big impact on the way in which you recover. I know that I often see higher pain levels in women who have had an Emergency Caesarean, which is potentially due to either the more rushed nature of the surgical intervention, the fact that the woman may have been physically exhausted by that point after a long labour, the emotional state of the woman and whether she may feel distress at the fact that her birth didn’t go the way she had planned, or a combination of all three.
What occurs in the period immediately after a Caesarean birth can have a big impact on the recovery too. Some women, for a variety of reasons, end up with an infection at the wound site, or delayed healing of the stitches. And some women put more load through the new sutures than others, with caring for a toddler or needing to lift relatively heavy loads around the house, versus those who are able to rest more in those early weeks while the scar is very new and still healing.
So if you had a Caesarean section then ask yourself, how much information were you given about what to expect from your recovery and what you could proactively do to improve the way the scar healed?
After working in the obstetric field for over a decade and then having had a Caesarean section myself, I can tell you that in my experience the answer is not much. To be honest, this also is the case for recovery after a vaginal birth too, but you would expect when you’ve undergone major surgery that you would receive some extra guidance and check ups.
What happens during a Caesarean and how should it heal?
The surgical cut for a Caesarean section is not just one layer. In fact, the surgeon will go through the process of cutting the skin, then the fat layer, then the fascia (thick connective tissue), then they will part the abdominal muscles, then they will cut through the peritoneum (thinner, more delicate connective tissue layers), then the uterus, and then the amniotic sac around the baby.
After the baby is delivered, the surgeon repairs the uterus, then the other internal layers, and then the skin. These layers of sutures may not all be in line with each other, so where you see your external scar might actually be higher or lower than where the internal scars are.
These internal scars are often referred to as ‘adhesions’, and these can be much harder to diagnose and treat than the visible external scars.
The way that these internal and external layers of scar tissue heal can have a really big impact on the future comfort levels and quality of life of the mother.
Occupational Therapist Jessica Chandler explain scar tissue healing as follows:
“Scar tissue forms during your body’s natural healing process. When we cause injury to our skin and the deeper tissues in the body, it responds by producing strands of collagen to mend the damage. Unlike the rest of your body, where these collagen fibres are laid down in an orderly fashion and are soft and smooth, scar tissue forms as the strands are laid down any which way, causing knots and “whirls” – and lumpy scar tissue!”
She re-iterates, however, that there are many things that you can do in both the short term and the long term, that can improve the way in which this scar tissue is arranged in order to give it more flexibility and make it behave more like the rest of your skin.
What is normal when it comes to a Caesarean scar?
Jessica lists the following as things that are ‘normal’ to notice in your Caesarean scar:
- Tenderness and pain around the incision site while healing and for a few weeks afterwards
- Altered sensation or numbness that persists after the healing process has occurred, and is potentially ongoing
- A scar that appears red in the early healing phase and slowly fades to pink or white over time
- The scar staying flat and soft
- A pulling sensation around the scar area (but not PAIN) when you first return to stretches, physical activity or exercise
What is not normal when it comes to a Caesarean scar?
Jessica lists the following as things that are ‘abnormal’ to notice in your Caesarean scar, and should be further assessed and managed:
- Tenderness or pain on and around the incision site more than 6 weeks after healing
- Altered sensation like pins and needles, or pain with touch (like when drying the area with a towel)
- A scar that is still red or turns purple after the 12 week mark
- A scar that is raised, lumpy or pulls inwards
- Pain (especially sharp pain) or tight pulling during stretching, physical activity or exercise
- Palpable lumps of scar tissue over or around the external scar
What can you do in the first 4-6 weeks to optimize healing?
Here are some key things that you can aim to do in the very early post operative phase that could help with the healing process:
- Regular deep breathing, ensuring that you’re taking the air down to the bottom of your lungs and gently moving your abdomen, rather than only breathing up into the shoulders and top part of your lungs. Perhaps aim for 4 or 5 deep breaths every time you’re feeding the baby.
- Optimal posture, especially during repetitive or time-consuming tasks like feeding the baby, pushing a pram, or carrying the baby in your arms. Aim to straighten through your torso with sitting and standing postures as soon as is comfortable, and avoid spending long periods of time hunched forwards while the scar is healing.
- Gentle stretches within a comfortable pain limit, in particular aiming to get movement happening through the torso into rotation, extension and side flexion. The videos on the FitRight Membership site and in the ‘First Six Weeks’ video series sold on the website show examples of how you could do this.
- Avoiding activities that would put pressure on the healing layers of sutures. This would include lifting anything heavier than your newborn baby, getting coughs and colds treated as quickly as possible, and getting up and down from a lying position by rolling through sidelying. It’s the unfortunate reality that for Mums of toddlers, and/or those with limited support networks, lifting prams and small children may be unavoidable, but wherever possible it is advisable to limit heavy loads.
- Gentle return to walking on most days, as you feel able to. Most women should be able to tolerate gentle 5-10 minute walks in the first 1-2 weeks without any soreness in the Caesarean scar, and should be able to gradually work up towards 30-45 minutes of a more brisk-paced walk on most days by the 6 week mark.
- Very gentle massage over the scar. This can start to occur when the scar is fully healed (when you no longer have any dressings on), however you may prefer to wait until after your medical appointment at the 6 week mark. It is recommended to use a plain, unscented moisturizer that is water based, not oil based.
What can you do between approximately 4-8 weeks post Caesarean to optimize healing, when you’ve had the medical all clear that your scar is well healed?
- Continue to be aware of good posture and deep breathing
- Start to add in a gradual return to lifting the loads that you need to in daily life with good technique (keep the load close to you and use the strength in your legs to move up and down)
- Continue to do some low impact cardio exercise on most days, (either walking or another exercise of choice) ideally totalling 150 minutes per week.
- Continue to work through larger ranges of your stretches, and add in some gentle loaded exercises for your arms, legs and abdominal muscles (ideally taught to you by a physiotherapist), examples of which can be found on the Caesarean recovery workouts section of the FitRight Membership group.
- Increase the pressure of your scar massage. Jessica from Complete Scar Therapy advises to use firm circular movements using enough pressure to blanch to scar (turn it white), and to begin to also start gentle massage 2-3cm above and below the scar. Perhaps you could remember to do this for a few minutes each time you have a shower.
What can you do from 8 weeks onwards to optimize healing?
- Continue to regularly massage on and around the scar, especially any areas that feel tight or lumpy. Add in scar stretches such as those on the handout from Complete Scar Therapy, posted in the FitRight Membership group.
- Continue your return to your exercise of choice, ideally with the guidance of a Women’s Health Physiotherapist who has assessed your pelvic floor and abdominal muscles as well as your Caesarean scar. By this stage you should be able to move your torso comfortable in all directions and lie flat on your tummy without more than mild discomfort or a vague stretching sensation.
- Seek help and advice from a health professional experienced in scar management, such as the Occupational Therapists at Complete Scar Therapy, if you continue to feel any of the following after the 12 week mark:
- any pain, altered sensation or pulling sensations around the scar
- any signs of adhesions that have been ruled out to be from other causes, such as urinary urgency, painful sex, or pain before or during a bowel movement.
What can you do in pregnancy, if you know you’re going to have a Caesarean, to prepare for the recovery?
The main thing to do is to plan for minimal load to have to go through that area in the first 6-8 weeks after giving birth. So, if you’re the Mum of a toddler or toddlers and you know that having a Caesarean is a likely possibility, I would recommend spending the second half of your pregnancy ‘training’ the toddlers to do daily tasks in a way that doesn’t require them to be lifted.
- Can they climb in and out of the car seat and the high chair by themselves?
- Is there another way for them to get into their cot/bed that doesn’t involve you lifting them in?
- Are there games you play that involve them being lifted up that can be phased out during the later stages of your pregnancy?
The other thing to note is how you’re performing different transitional movements and whether they are putting unnecessary strain on the midline in pregnancy, which would also put unnecessary strain through the midline after birth.
- Getting up and down from the floor
- Getting in and out of bed
- Getting up and down from a chair
- Lifting your baby or another load
Make sure that for the first six weeks, getting in and out of bed is down through sidelying, lifting is limited (where possible) to no heavier than your newborn baby, and when you do any of these movements you’re breathing out at the same time and preventing ‘splinting’ and breath holding which are likely to cause more pressure in the abdomen.
And lastly, have you looked into the various options for abdominal support post birth?
- SRC Recovery Shorts
- Other support garments
Abdominal support and wound compression is very important! However, if you listen to Jess and I talk on the live Q&A you’ll understand that not all compression is created equal. The SRC shorts are significantly more expensive than other more simple forms of compression, but if they’re an option for you then they are worth the investment due to their specific amount of compression and the way they’re designed for the compression to be in exactly the right place for a healing Caesarean wound.
And lastly, have you looked into the various options for abdominal support post birth?
Most Caesarean scars heal well by themselves and don’t require any intervention. However, there are so many things you can proactively be doing in those early days and weeks to improve your chances of having the scar heal in a way that behaves like normal skin and doesn’t cause problems.
And if you do experience ongoing pain, tightness, or symptoms that might be associated with internal scarring, remember – it’s not normal for this to be the case after the first 2-3 months, and there are people who can help!