Everything That You Need to Know About Caesarian Section Birth

Mar 19

Caesarian births (C-Section) is the most commonly performed inpatient surgery in North America (Sun & Mandy 2019). Unfortunately it is one of the ONLY inpatient surgeries that doesn’t involve any rehab follow up (the pelvic floor physio in me is WEEPING at this fact).

Most physiotherapists aren’t necessarily comfortable providing c-section rehab, it is an extremely niche field of study and I would suggest seeking our a pelvic floor physiotherapist for postpartum c-section care. Here is a link outlining how to find a pelvic floor physio near you.

Currently, 1 in 3 births in Canada are a c-section birth (Canadian Institute for Health Information). Women over 35 years old have a higher prevalence of c-section.

What Exactly is a C-Section Surgery?

What Are the Types of Incisions That Could Be Used?

What are Possible C-Section Complications?

Is There a Difference Between an Elective C-Section and an Emergency C-Section?

Most Common Reasons for a First Time C-Section Mama

When is C-Section Not Recommended?

Factors Influencing Rates of C-Section

Does C-Section Have Any Effects on My Baby?

C-Section Recovery Tips in Hospital

Helpful Items for C-Section Recovery

What is a Gentle C-Section?

What is a Maternal or Positive C-Section?

Practical Tips for Preparing for C-Section

Preparing for a C-Section with Your Pelvic Floor Physiotherapist

Familiarize Yourself with Post-Op Restrictions

Early Postpartum Red & Yellow Flags

What Role Does Virtual Pelvic Floor Therapy Have in C-Section Recovery?

How Do You Know If You Need Pelvic Floor Physio After a C-Section?

Pelvic Health Considerations to Talk to Your Pelvic Floor Physio About

Pelvic Floor Physio Treatment for C-Section Postpartum

When Can I Return to … After C-Section?

Return to High Impact and Running Postpartum After C-Section

Symptoms to Look Out For With Return to Exercise After a C-Section

What Can My Pelvic Floor Physio and I Do to Help Heal My C-Section Scar?

Tips for Managing Anxiety & Distress Surrounding C-Section

How Long Will My Pain Last Post-Op C-Section?

What are My Chances of Having a VBAC (Vaginal Birth After Caesarian)?

Uterine Rupture Risk with a VBAC

Questions to Ask Your Healthcare Provider For 2nd Pregnancy After C-Section

Association of Ontario Midwives Useful Resources

VBAC Resources

What Exactly Is a C-Section Surgery?

It is a major abdominal surgery and takes approximately 30-45 minutes (or as fast as 1 minute depending on the situation!)
The incision goes through skin, connective tissue, the uterine wall and fat tissue
The surgery goes between the right and left abdominal wall along the connective tissue of our midline called our Linea Alba
The surgeon moves the right and left abs out of the way to preserve them
C-section surgery may potentially affect the uracus ligament that suspends our bladder up inside of us
The surgeon must move the bladder out of the way downward to access the uterus
The surgeon creates an incision through the 3 thick layers of the uterine muscle wall
The surgeon ruptures the amniotic sac and reaches into the uterus for the baby’s head

What Are the Types of Incision That Could Be Used?

Classical (Vertical)

Used in cases with low placenta accreta or abdominal adhesions
Trial of labour after c-section (TOLAC) is not an option with this type of incision

Pfannenstiel

Most commonly used today
Advantages include less blood loss, easier to repair, less abdominal adhesions, option for future TOLAC
Disadvantage is that you can’t extend the incision

Modified Joel-Cohen

Less post-op pain, baby can get out faster, decreased blood loss and quicker post-op ambulation
Still being explored

A picture of a woman's abdomen depicting all the incision types of c-section surgery.

What Are Possible C-Section Complications?

With emergency c-section (after trial of labour or complications) , there is a risk of maternal morbidity, hemhorrage, fetal trauma (while surgeon is getting the baby’s head out) (Field & Haloob, 2016)
Thromboembolism is 4x higher than vaginal birth (women should be screened for thromboembolism up to 3 months postpartum) (Blondon et al., 2016)
Infection of incision (Gregory et al., 2012)
Placental abruption
Chronic scar pain
Scar adhesions

Bladder or bowel injury
Severe constipation (bowels in shock after surgery, slow movement of poop)
Re-laproptomy (needing to go back in and suture and fix tissues)
Nerve injuries (Okiemy et al., 2008; Hong et al., 2019)
Nerve related numbness and nerve related difficulty recruiting deep core
Loss of sensation over upper front thigh, labia majoras, pubic bone area, groin, outer upper hip from nerve damage
Leg weakness
Sciatica symptoms or shooting pain in outer lower leg
Possible nerve entrapment
Endometriosis lesions along c-section scar

Is There a Difference Between an Elective C-Section and an Emergency C-Section?

An elective c-section is planned and scheduled ahead of time with your OB-GYN and an emergency c-section could occur after prolonged labour (labour dystocia) or maternal or fetal complications (Malvasi et al., 2017).

There is a higher rate of complications following an emergency c-section and this can be attributed to several factors:
Prolonged time of baby’s head compressing nerve and tissues in mom’s lower pelvis causing nerve or tissue damage to heal from
More inflammation with emergency c-section that included long labour prior to surgery

Personally, I have noted that there is higher rates of birth trauma associated with an emergency c-section especially in cases where mom didn’t feel fully included in the decision-making process, consent was not obtained, initial skin-to-skin contact was delayed or mom was unconscious during and after surgery.

There are so many emotions (and hormones!) tied to birth and feelings of “things not going as planned”, “feeling like a failure”, and feeling disappointed/frustrated especially after preparing for birth certainly come up in my practice with my patients.

It is important to know that all births are equally incredible and processing some of these emotions and negative self-talk can be necessary for moms in the postpartum period. Here are a few mental health specialists who deal with postpartum mental health:

Red Brick Wellness - Terri Kwok
Elle Psychotherapy

Most Common Reasons for a First Time C-Section Mama

Labour dystocia: slow, prolonged labour
Breech presentation
Abnormal fetal heart rate
Suspected fetal macrosomia (baby > 9lb* this is extremely difficult to predict even with all of our tech) (Caughey et al., 2014)

When is a C-Section NOT Recommended?

There are no absolute contraindications to a c-section
There is a relative contraindication if mom has a bleeding disorder or issues with blood coagulation or there has been multiple abdominal surgeries
(Harde et al., 2013)
Ethical considerations if patient does not consent

Factors Influencing Rates of C-Section

1) Individual Factors (Tadevosyan et al., 2019)

Anatomical pelvis shape
Medical necessity
Maternal request
Maternal age
Obesity (1.78x more likely to have a c-section if obese)

2) Use of Tech and Medical Intervention (Davis, 1994; Reime et al., 2014)

Birth with a physician: there are higher rates of use of oxytocin and epidural
Reliance on continuous electronic fetal monitoring in hospital settings

3) Model of Care (Souter et al., 2019; Hodnett et al., 2012; Kozhimannil et al., 2016)

Use of midwives decreases prevalence of c-section birth by 30-40%
Use of doulas decrease prevalence of c-section birth by 28-56%

4) Institutional Policies

Asking your medical team “What are the policies surrounding adopting for a VBAC (vaginal birth after c-section) at your birthing site?”

Does C-Section Have Any Effects on My Baby?

A common concern is babies having an altered gut microbiome (good and bad bacteria in your guts) with c-section versus vaginal birth (Montoya Williams et al., 2018).

When a baby exits their moma vaginally, they will pick up their first bacteria to populate their microbiome from their mom’s vaginal canal where a c-section baby with have a microbiome similar to mom’s skin bacteria.

There has been some research that shows c-section babies will have higher rates of asthma and gut-related issues throughout their lifetime (limited research).

C-Section Recovery Tips in Hospital

Education prior to c-section surgery to reduce anxiety, fear of the unknown, improving patient advocacy. This should be done during birth prep with pelvic floor physio or doula!
Early post-op walking and gentle movement plan
Chewing gum (helps with gut motility)
Consulting with a lactation consultant
Providing written resources to bring home postpartum for mom’s healing and baby’s care-talking
Early eating for mom (promotes digestion)
Skin-to-skin time with baby for mom
Delayed cord clamping for baby

(Ituk et al., 2018; Macones et al., 2019; Wilson et al., 2018; Caughey et al., 2018)

Helpful Items for C-Section Recovery

Check out my Amazon storefront with all my helpful postpartum recovery tools here!

Gentle compression high waisted underwear
Squatty potty or step stool for feet while pooping
Pillow for splinting abdomen with moving, coughing, pooping postpartum
Breastfeeding pillow for breastfeeding ergonomic and to avoid straining incision
Silicone strips for scar healing (e.g. Scar Out)

What is a Gentle C-Section?

Using a clear sheet instead of a hospital sheet so mom can watch the surgery being performed
Dimming of non-essential lighting
Music playing (mom’s choice)
Immediate skin-to-skin
Immediate breastfeeding

This helps create a more relaxed and less ‘clinical’ experience and has shown to improve rates of positive birth experience, better breastfeeding results, and easier adaption for baby’s heart rate and body temperature (Armburst et al., 2016).

What is a Maternal or Positive C-Section?

Similar to a gentle caesarian but goes beyond with:
Mom scrubs into surgery with the rest of the surgical team
Definitely yet accepted as medical practice in North America, yet!
Mom reaches into abdomen and physically pulls baby onto their own chest

Practical Tips for Preparing for C-Section

You will need help, whether you like accepting help or not!

Prepare frozen meals or arrange meal deliveries in advance
Ask for meal delivery gift cards instead of gifts for your baby
Arrange to have someone home with mom for the first 2 weeks postpartum (partner, parent, friend, doula)
Set up your space all on one floor of the house
Have daily necessities accessible within one space or one room
Arrange care or activities for other children
Arrange transportation for other children activities/daycare/school (driving restrictions for new mom!)
Arrange dog walking (if needed)

Preparing for a C-Section with Your Pelvic Floor Physiotherapist

Birth prep and education
Learning how to advocate for yourself and discussing different birth and surgery options
Points for advocacy discussion including some topics like:
- Use of arm restraints?
- Involvement in decision making process and informed consent
- Discussion of any past trauma with medical care team
- Delayed cord clamping?
- Discussion of indications to pursue c-section versus VBAC or 1st time vaginal birth?
Discussion of risks and benefits with c-section surgery
Facilitating empowerment and reducing fear and anxiety
Education on signs and symptoms to look out for and course of action for early intervention
Education on post-op daily task strategies (i.e. how to move in bed, how to sit to stand, how to poop, etc)
Ergonomics for breast feeding, eating
Recommendations for postpartum tools to help with healing
Education on roles of practitioners within holistic patient care team (referring out to psychotherapy, doula, naturopathy, paediatric chiropractor, lactation consultant, etc)
Early rehab exercise ideas for core, breathing and pelvic floor activation and home exercise program
Referral resources for other professionals (mental health psychotherapy, lactation consultant, doula)

Familiarize Yourself with Post-Op C-Section Restrictions

Restrictions will be surgeon specific and case-dependent!

No lifting more than ____ (e.g. 20lbs, 30lbs, etc)
No driving for 3-6 weeks
No running or high impact activity for 6 weeks (this is standard for all postpartum women), some research says 12 weeks (Goom et al., 2019)
No baths or swimming for 6 weeks or until incision is healed
Light housework only for 6 weeks (i.e. no vacuuming)
Stairs (very little consensus here, but not repeatedly and not several times a day) x 6 weeks

Early Postpartum Red & Yellow Flags

Fever
Uncontrolled bleeding from incision or vaginal bleeding
Incision infection: redness, puss, oozing from incision, odour, fever
Nausea/vomiting
Dizziness/fainting
Chest pain
Shortness of breath
Blood clots larger than a toonie (passed vaginally)
Pain/swelling/redness in arms or legs
Headache with positional change (going from lying down to upright) (could be a slow cerebrospinal fluid leak from epidural, let it heal and lots of rest)
Anxiety
Depression (Edinburgh Depression Scale)

What Role Does Virtual Pelvic Floor Therapy Have in C-Section Recovery?

Allows for earlier access to a pelvic floor physiotherapist
Early intervention screening for infection, mental health, pain management, pelvic floor and core education and early rehab exercises
Convenience of appointment times
Decrease risk of illness transmission from going to in-person hospital/doctor office appointments
Decrease distress with having questions/concerns addressed quickly
Aligned with patient’s post-op restrictions (no carrying, no lifting, no driving)
Can progress through post-op rehab exercise with pelvic floor physio together in one-on-one virtual appointment ensuring good mechanics
Addressing somatization (the physical manifestation of the trauma, stress, negative emotions postpartum depending on birth experience) often including pelvic floor tension, tone, persistent pain, fatigue (Dekell et al., 2019)

Book virtual pelvic floor physio

How Do You Know If You Need Pelvic Floor Physio After a C-Section?

Have you ever said any of the following?

“I can’t even look at my scar”

“I haven’t touched my scar since birth”

“I can’t wear anything tight along my scar”

Do you experience any of the following symptoms?

Pelvic pain
Painful sex or penetration
Pelvic girdle pain
Low back pain
Abdominal wall pain
Hip pain
Pain along scar
Limited movement in trunk around scar
Bladder urgency
Pain with full bladder
Changes in bowel function since c-section
Core weakness
Low core endurance

Book pelvic floor physio (again!)

Pelvic Health Considerations to Talk to Your Pelvic Floor Physio About

There is a myth surrounding c-section births sparing us from experiencing pelvic floor dysfunction postpartum, however that is not always the case.

Especially in the instance of emergency c-sections, we see dissociation or ‘freeze’ response that can lead to super tight pelvic floor muscles postpartum that feel like they’re always ‘clenching’.

Constipation
Impact on pelvic nerves (sensation loss or pelvic floor muscle strength)
Dyspareunia (painful sex)
Low back pain
Pelvic girdle pain
Pain with peeing
Genital pain
Abdominal pain
Abdominal muscle weakness
Decreased core endurance
Scar adhesions causing movement restrictions or pain or possibly chronic pelvic pain (risk increases with each c-section)
Fascial gliding (layers moving upon each other - this can cause pain/discomfort with movement and changes in pelvic organ function
Prolapse symptoms
Stress urinary incontinence
Urgency incontinence
Fecal incontinence
Diastasis rectus abdominis (DRA) *remember c-section surgery does not cut through actual muscle
Changes in pelvic floor and core muscle coordination
Higher rates of anhedonia (lack of any emotion immediately after c-section) (Zanadro et al., 2018)

Pelvic Floor Physio Treatment for C-Section Postpartum

0-6 Weeks

Focus should be on resting, healing and recovery
Ensure proper nutrition and hydration
Pain management strategies
Get a handle on regular pooping schedule and manage constipation
Begin low impact exercise
- Pelvic floor rehab
- Core rehab
- Breathing exercises
- Walking
- Light stationary bike (if able)
- Swimming (once incision healed)
- Return to full body, functional movement strength training (>2-3 weeks postpartum)
Ergonomic intervention for transitioning between movements, breastfeeding, splinting for coughing/pooping
Manual therapy to low back and hips
Education around airway clearance (coughing management)
(Karakaya et al., 2012)

4-6 Weeks

Add in prone (lying on stomach movement) (e.g. Cobra pose)
Progress cardio intensity
- This will be individualized depending on patient
Progress core and pelvic floor exercise
- This will be individualized depending on patient
Add in functional movements (e.g. hip hinge, good morning, squat, lunge) with minimal weight
Neural mobility exercises
C-section scar care and desensitization work

6+ Weeks

This will look different for every woman depending on:
- 6+ week symptoms
- Woman’s individual goals

When Can I Return to...After C-Section?

Lifting

6 weeks or when cleared by surgeon

Swimming

6 weeks or when incision is fully healed

Pelvic Floor, Core, Breathing Rehab Exercises

Right away! Book a virtual follow up as soon as you are able with your pelvic floor physiotherapist and get started on breathing, core and pelvic floor rehab to help with your c-section healing!

Sports (Low Impact)

Dependent on each mom, should be symptoms-free and return gradually and progressively week after week starting with ~2 sessions per week and monitoring for symptoms in between

Sports (High Impact) and Running

Extremely dependent on each mom, the best method of return is to work with a pelvic floor physio or perinatal fitness coach for an individualized assessment and return to activity plan

Sex

6 weeks to allow for tissue healing and also rest (!!!), this will be very dependent on the birth experience, sleep and recovery quality, how you’re feeling mentally and physically and be aware of postpartum sex issues (vaginal dryness, dyspareunia, decreased sensation from nerve damage, decreased libido)

Return to High Impact and Running Postpartum After C-Section

Return to running or impact is appropriate for you if you can do all of the following symptom-free (Goom et al., 2019):

Walk for 30 continuous minutes
Stand on one leg for 10 seconds
10 single leg squats per side
Jog for 1 minute on the spot
10 forward bounds
10 single leg hops per side
10 running man reps per side
20 glute bridges
20 calf raises
20 side lying leg raises
Single leg sit to stand

Symptoms to Look Out For With Return to Exercise After a C-Section

Pressure or heaviness in the pelvic floor
Pelvic pain
Low back pain
Hip pain
Leaking pee or poop with exercise or after
Increased or new bleeding or spotting

What Can My Pelvic Floor Physio and I Do to Help Heal My C-Section Scar?

1) Scar Desensitization

Start with using different textures around incision (while healing) and over scar (once healed) - use cotton ball, q-tip, tissue, feather, fingers, fingernails

2) Graded Exposure

Start with short periods of light pressure and soft touch over clothes then progress to directly on skin and gradually increase day after day - consistency is key!
If they cannot touch their scar, start with visualization exercises first

3) Acupuncture

Can be helpful for nerve healing and adhesion healing

4) Scar Mobilization

Different massage techniques used over scar once incision is fully closed
Can be taught to do at home by your pelvic floor physiotherapist
Helps improve body awareness and connection with body and core postpartum

5) Electrical Stimulation (e.g. Dolphin)

Can help with pain management and nerve performance

Tips for Managing Anxiety & Distress Surrounding C-Section

Postpartum massage (Saatsaz et al., 2016)
Hand and foot reflexology prenatal and postpartum (Navaee et al., 2021)
Music in OR room and pre-post-op (Weingarten et al., 2021)
Pelvic floor physio birth preparation sessions done during pregnancy prior to birth
Early access to rehab services and virtual pelvic floor physiotherapy services
Holistic prenatal and postpartum support team including but not limited to pelvic floor physiotherapist, Webster certified chiropractor, doula, naturopath, perinatal psychotherapist, perinatal fitness coach

How Long Will My Pain Last Post-Op C-Section?

18% of women report pain at 3 months postpartum

11% of women report pain at 6 months

6% of women report pain at 12 months

Pain is reported primarily around the c-section scar either from scar tissue adhesions, nerve entrapment or nerve damage, followed by deep pelvic pain and abdominal pain

Women with a c-section are also at a higher risk for reporting low back pain or pelvic girdle pain postpartum (Mukkannavar et al., 2013)

Pain can impact breastfeeding or mom’s ability to care for her baby, however most moms don’t seek help even though they admit that they need it (Karlstrom et al., 2017; Lavand’homme, 2017).

C-sections are all extremely individualized based on a number of factors:

Onset of labour?
Parity (no prior births, one prior birth, multiple prior births?)
Gestational age (term? preterm?)
Fetal presentation (Head down? Breech or head up? Transverse or lying horizontally?)
Previous c-section or other relevant pelvic or abdominal surgery?
Number of babies?

What Are My Chances of Having a VBAC (Vaginal Birth After Caesarian)?

The rates change depending on your birth history:

1 previous c-section: 60-80% success rate

2 previous c-sections: 63-75% success rate

2 previous c-sections + induction: 28% success rate

1 previous c-section + 1 previous VBAC: 90% success rate

* There are factors associated with a VBAC as well: maternal age, medical complications with pregnancy, baby’s position for birth

(ACOG, 2017)

Uterine Rupture Risk with a VBAC

The risk of a uterine rupture is 0.5-1% of all births (Motomura et al., 2017), however there is no way to ‘predict’ a rupture with ultrasounds or testing. There can also be incomplete rupturing or an asymptomatic rupture. A vertical scar can increase risk of rupture.

VBAC Pros:

Shorter hospital stay
More functional movement earlier postpartum
No surgical risks or complications associated with c-section
Healing is generally quicker
No lifting or driving restrictions (important especially if kids at home already)

VBAC Cons:

Uterine rupture (if the surgeon can’t control bleeding, they may do a hysterectomy)
Emergency c-section
Rollercoaster of emotions (maybe)

Questions To Ask Your Healthcare Provider For 2nd Pregnancy After C-Section

What are your c-section rates?
What are your VBAC rates?
What steps do you and your team take to avoid unnecessary repeat c-section?
What are the short and long term risks of pursuing a VBAC (for both myself and my baby)?
What are the short and long term risks of pursuing a repeated c-section (for both myself and my baby)?
Are you supportive of a TOLAC (trial of labour after caesarian)?
What are your requirements for TOLAC?
What about the on-call physician? Are they supportive of a TOLAC?