One third of women deliver by cesarean section, and the postpartum maternal care leaves something to be desired here in the US, particularly the education on a cesarean shelf. As a pelvic physical therapist, I often hear women say, “Well, I had a cesarean, so I don’t think pelvic PT would help me.” However, this could not be further from the truth! It is common for women who have had cesarean deliveries to assume that pelvic PT will not be helpful for them. The truth is that pelvic PT can be hugely beneficial in helping reduce pain and improving mobility, function, and quality of life, no matter the type of delivery. Our postpartum bodies are different from our pre-baby bodies, no matter the type of delivery you had and your pelvic floor is a big player in both vaginal and cesarean births.
Specifically, postpartum cesarean moms may need scar massage to minimize scar restriction and the tummy “shelf” that can persist, abdominal restrengthening, and pelvic floor rehab. Remember, even though you had a cesarean delivery and have a section scar, your pelvic floor is affected by the pregnancy itself.
How a c-section affects your pelvic health
Although a cesarean delivery does not require the baby to pass through the vaginal canal, the pelvic floor muscles, vaginal, and vulvar tissues can still sustain stress throughout the pregnancy that can cause issues with urinary, bowel, and sexual function. In addition to pelvic floor dysfunction, patients who have had a cesarean delivery can experience restriction of the tissue around their healing incision, leading to pain and limited function post pregnancy. Although many of these impairments are common, they are NOT normal, and pelvic PT can perform a thorough evaluation to assess the function of all these tissues.
Tissue restriction from a cesarean scar
Scar tissue restriction from an abdominal or cesarean scar can contribute to all of the below. Painful sex, incomplete bladder emptying, urinary leakage, constipation, scar pain, or a “shelf” after cesarean birth. All of which can be helped with pelvic floor physical therapy!
- Cesarean shelf
- Painful sex
- Back pain
- Painful ovulation and menstruation
- Straining during bowel movements
- Unable to empty bladder
- Section incision site feels numb, fuzzy, painful or sensitive
What is a cesarean shelf exactly?
In many cases, these scar tissue adhesions can be so significant that they cause a “shelf.” A shelf occurs when the various layers of healing tissue along the incision adhere to one another, and, therefore, the scar becomes indented. Over time, the tissue just above the scar can puff out like a shelf. This can be both painful and a source of insecurity for many women. While there are severe cases that ultimately may require a consultation with a plastic surgeon for scar tissue revision, most patients can be treated conservatively with pelvic PT.
Causes of cesarean shelf
- Giving birth via cesarean section
- Having an incision that is too tight
- Scar tissues, extra fat, and excess skin
- Having loose skin
- Diastasis recti
Things PFPT can do for a cesarean shelf
- Test for DR (which might contribute to the cesarean shelf)
- Scar massage
- Belly massage
- Core work / abdominal etc
- Diaphragmatic breathing
What you can do to help your cesarean shelf
MASSAGE YOUR SCAR. Immediately after childbirth, this area will feel very numb, but you start massaging gently 2-3 inches around your scar to promote healing, blood flow, and sensation back to the area. After the initial six-week healing period, you can start massaging directly over the scar. Move it up and down, side to side, and spend extra time on the areas that feel tightest and hardest to move around. Doing this a few times a week for 2-3 minutes will help the scar be softer, flatter, and less purple-y. This also helps your scar from getting too tight, leading to the shelf, pain with sex, discomfort wearing pants, and peeing and pooping bladder problems. Whether your surgery was six weeks ago, six months ago, or six years ago, it’s never too late to start!
If left untreated, the cesarean shelf can cause:
- Belly pooch
- Pain with sex
- Discomfort wearing pants
- Bladder problems
- Pooping difficulties
What to expect in a pelvic health assessment after a cesarean
One of the first places a pelvic PT will likely assess is the connective tissue of the abdomen. This is where cesarean mommas commonly experience pain, tightness, mobility restriction of the scar, difficulty activating the abdominal muscles, diastasis recti, and potentially numbness around the healing cesarean incision. The pain a patient may experience following a cesarean can vary from diffuse abdominal pain to local pain along the incision. In addition, it may present muscular pain or pull with activity, hypersensitivity to touch, and numbness along the scar. This variation in the type and location of the pain can often lead to discomfort wearing specific clothing, aversion to touching the scar, difficulty with daily activity (like lifting their child), and limitation with exercise. The pain and activity limitations are primarily due to scar tissue and myofascial restriction to the connective tissue surrounding the scar.
Assessing for diastasis recti
In addition to assessing the mobility of the connective tissues of the lower abdomen, the pelvic PT will most likely evaluate you for potential diastasis recti. They will assess your ability to properly activate your transverse abdominis and correctly manage the pressure in your abdomen with daily activities. This is important because improper pressure management can lead to unwanted stress on the healing abdominal tissues, increased risk of diastasis recti, and increased risk of pelvic floor dysfunction.
Pelvic floor assessment via internal exam
Lastly, the pelvic floor PT will most likely do an internal vaginal exam (only once you have given consent). The purpose of this exam is to determine how well your pelvic floor is able to contract (kegel) and relax, and to determine if there are any areas of tightness (trigger points) in these muscles. This is important because we need full contraction of these muscles to hold in urine and poop, support our internal organs with daily activity and exercise, and for sexual function. Equally important is the ability for these muscles to relax. This relaxation is necessary to empty our bowel and bladder, and for sexual function. And yes, these muscles can be weak, tight, or both even if you did not have a vaginal delivery.
What does treatment look like?
Some of the things that can be done in pelvic PT for treatment of the above listed impairments include, but are not limited to:
- Manual Therapy – Manual therapy and myofascial release to the scar itself and abdominal tissue surrounding the scar. These are techniques in which the therapist will perform hands on connective tissue release to reduce scar tissue adhesions and improve mobility. These techniques can also improve blood flow to the area to help promote healing.
- Desensitization – Desensitization to the scar and tissue directly surrounding the scar with items of varying textures (tissue, towel, q-tip, makeup brush, etc). This technique can reduce hypersensitivity that may cause pain from clothing or touching the scar.
- Dry Needling – Dry needling (once you are at least 30 days post delivery). This technique is used to improve blood flow to the area, promote healing, and reduce adhesions from scar tissue formation.
Had a c-section and wondering if you can have a vaginal birth for your next baby? Check this out!
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Are you currently pregnant or planning to conceive? If so, make sure to download my FREE resource — How to Prepare Your Pelvic Floor & Core for Childbirth + 8 Must-Dos for C-Section and Vaginal Deliveries.
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