Bringing a new life into the world is an incredible and transformative experience, but it's not without its challenges. Cesarean sections, or C-sections, have become increasingly common in recent years, with approximately one in three babies delivered this way, making it the most common surgical procedure performed in the United States. While C-sections can be a lifesaving intervention for both the birthing parent and baby, they also require careful management and healing to ensure a smooth recovery.
One important aspect of recovering from a C-section is working with a pelvic health physical therapist. Specialized in the unique stages of recovery, and challenges facing someone after a C-section, a pelvic PT can help guide you through the stages of wound healing, ensuring that you progress safely, and help you to avoid complications. Once you've been cleared by your healthcare provider for exercise, a pelvic health physical therapist can also help you regain strength and function to feel confident in the postpartum period.
To help you feel informed during your recovery, we’ve compiled a comprehensive guide on the stages of healing post-cesarean delivery, information on incisions and scarring, and the ways pelvic floor physical therapy and Origin can help with C-section recovery.
The C-section details you may be wondering about
A C-section — the surgically assisted birth of baby through the abdomen — is quite a complicated process. Care is taken to minimize tissue damage, protect blood supply to your tissues, and prevent infection. The exact approach that a surgeon will use for a particular C-section depends on a variety of factors including:
- How emergent the cesarean delivery is
- Location of your placenta
- Positioning and location of the baby in your uterus
- Health and state of your uterus at the time of your delivery
- The presence of scar tissue from past C-sections, abdominal surgery, or abdominal disease.
The C-section starts with a skin incision which is generally performed using a low transverse cut/”bikini cut” (a horizontal cut performed above the pubic bone, from left to right), or a vertical cut at your abdominal midline, and then the layers of adipose tissue, fascia, and muscle are cut in the same manner to provide access to the uterus. Depending on some of the factors noted above, the cut into the uterus does not always match what you can see on your skin, and is commonly one of the following:
- Classic: A vertical incision is made through the upper portion of the uterus which includes the myometrium (muscle layer of the uterus). This is not commonly performed, but will be done if the lower part of the uterus isn’t formed properly, is hard to access, if the baby is in a transverse, back-down position, or if a hysterectomy is planned to be performed during the same procedure.
- Low Vertical Incision: A vertical incision through the lower part of the uterus, that does not include the myometrium. This approach will be used in certain instances when the placenta is in a location that would prevent a low transverse incision, for preterm babies, and in extreme emergencies.
- Low Transverse Incision: A transverse or horizontal incision made in the lower part of the uterus. This approach tends to be the most favored outcome-wise, with less bleeding, improved healing, and fewer adhesion formations when compared with other surgical incision types.
The doctor then delivers the baby through the opening in the abdomen, cuts the umbilical cord, and removes the placenta from the uterus.
After delivery, the uterine incision can be closed with dissolvable stitches and the abdominal incision with surgical thread, glue, staples, or a combination of the three. Most get absorbed by the body and don’t need to be removed later on.
What are the stages of C-section incision healing?
As soon as the C-section is complete, your body gets straight to work to heal your incision. All damaged or injured tissue, including your C-section incision, progresses through the same continuous and symbiotic 4-stage process. Scarring is a natural part of this tissue healing process.
Although everyone’s specific wound healing process can differ slightly, here is what you can generally expect as your C-section wound heals:
The first few hours: Hemostasis
Hemostasis begins in the first few hours after the incision is made. This process happens while you’re still in the operating room, and can last for a few days. In hemostasis, your blood starts clotting to prevent bleeding. The blood clots will dry out and eventually form a scab. This is an important first phase, as it sets the foundation for the rest of wound healing to occur, and initiates the inflammatory phase.
Through day 6: Inflammation
At the same time as the blood begins clotting, the body begins to mount an inflammatory response in the tissues. The inflammatory phase of wound healing begins within the first 6-8 hours after surgery and can last up to 6 days.
During this stage, the body works to keep the healing wound clean and makes the building blocks for tissue repair. New blood vessels are formed, cells begin to multiply and fibroblasts are formed, which will soon contribute to the development of new connective tissue. Inflammation may cause your incision to be pink and warm to the touch. If you notice redness, or if it feels hot to the touch, these signs may indicate an infection in your incision, so it is best to check in with your healthcare provider ASAP.
As the anesthesia from surgery wears off, and the inflammatory process ramps up, it is common to feel pain and stiffness that can make it difficult, or even scary to move around to care for yourself or your baby. Don’t be afraid to speak up for pain medication options (prescription or over-the-counter), and other pain management strategies. Your healthcare provider will provide you with options that are safe for you.
Days 4 through 21: Proliferation
As inflammation subsides, the next stage can begin. Beginning around the 4-6th day after your surgery, you are likely recovering at home as proliferation begins. This stage is marked by the repair of broken blood vessels and growth of new connective tissue known as granulation tissue which protects and fills the wound bed.
two-weekWhile not always the case, you may get to see your provider for a follow-up during this period. Advocate for yourself and get an appointment with your healthcare provider around the two-week mark, so you can discuss any pain or concerns you may have about your recovery. This is also a good time to ask for a referral to a pelvic health physical therapist for further guidance and support during your recovery.
Week 3 through 1+ years: Remodeling
In the final stage of tissue healing, the new connective tissue that grew during proliferation matures into a scar, and then remodels over time to become stronger. The repaired tissue will never be as strong as before the surgery, but with proper recovery, the remodeled scar tissue will be approximately 80% as strong as before. Wound contraction also occurs during the remodeling phase of healing, so as time passes normally healing scars should become thinner, flatter, and less apparent.
Your six-week postpartum visit will happen during the remodeling stage. At this visit, your provider can inspect your scar and if you are ready, give you the go-ahead to return to usual daily activity (including regular exercise routines) based on your healing progress.
While your scar tissue is remodeling, scar massage and exercises that support the restoration and strengthening of your abdominal muscles and pelvic floor can help to support maturation and strengthening of the healing connective tissues, while also reducing chronic scar pain or itch, movement dysfunction, and adverse scar conditions such as adhesions.
What to expect from my C-section scar
Scarring is a totally normal and expected part of the C-section healing process. Most of the time, scars will get flatter and less noticeable with time.
Sometimes, though, a C-section scar can become raised and more visually prominent. There are two types of raised scars that can happen after a C-section:
- Keloid scarring: Keloid scars are raised scars that can grow in size over time, often outside of the boundary of the original scar. People with darker skin tones are more likely than those with lighter skin tones to develop keloids. People with a family history of keloids are also more likely to get them.
- Hypertrophic scarring: Hypertrophic scars are another form of raised scars. They may get smaller over time. Hypertrophic scars are easier to treat than keloid scars.
If your C-section scar heals in a way that looks abnormal to you, talk to your healthcare provider. The most common treatments for raised scars include topical medications, compression therapy, gel sheets made with or without silicone, and surgery as a final option.
Beyond genetics, abnormal scar healing is more likely to occur because of disruptions in the normal healing process — an infection, or reinjury for example — so during the six-ish weeks of initial C-section healing, it’s important to keep the following tips in mind:
- Avoid lifting anything heavier than the baby.
- Go on short walks to build strength and stamina, increasing the distance as time goes on.
- Avoid high-intensity tasks like deep cleaning, jogging, exercising, and anything that causes heavy breathing or muscle strain. This includes sit-ups.
- Avoid driving a car for at least the first two weeks, when you take narcotics, or when you feel too weak or unsafe to drive.
- If you’re breastfeeding/chestfeeding, use positions that avoid direct contact with the incision site.
- Listen to your body and rest when you need to.
How to take care of your healing C-section incision
Your doctor will provide exact instructions for taking care of the incision post-surgery, but these are some of the common recovery recommendations:
If the incision is protected with a bandage:
- Change it once a day or if it gets wet or dirty.
- Wear a bandage until your doctor tells you you can stop.
- Gently wash the incision with mild soap and water.
- You can remove the bandage when you shower if the incision was closed with stitches, staples, or glue.
- Avoid soaking in a tub or going swimming until your doctor gives you the okay.
If strips were used to close the incision:
- Do not wash off the strips or glue. You can pat the area dry with a clean towel after showering.
- Remove them only if your doctor says to after 10 days. They will likely fall off after about a week.
When to reach out to your healthcare provider
According to the American College of Obstetricians and Gynecologists, it’s important to reach out to your healthcare provider right away if you experience any of the following while healing from a C-section:
- Leg pain
- Draining or leakage from the incision
- Heavy bleeding
- Worsening pain
- Shortness of breath
Pelvic floor physical therapy and C-section recovery
Proper care for your healing incision is important, but your body needs to heal more than just your scar after a C-section. According to Dr. Ashley Rawlins, PT, DPT, a physical therapist and the clinical learning and development lead at Origin, “the primary role of physical therapy is to help optimize wound healing, while supporting whole-body healing for the postpartum person.”
Working with a pelvic floor physical therapist—a specialist who’s very knowledgeable about the pelvic area and skilled at guiding safe and effective exercises in the postpartum period—can look many ways after a C-section. However, the therapy will focus on rehabilitating the abdominal muscles and recovering the body from the surgery as well as the pregnancy.
“Pregnancy itself puts the birthing person at an increased risk for developing low back or pelvic pain, postural dysfunction, pelvic floor muscle dysfunction, diastasis recti, and general deconditioning related to early postpartum rest and recovery,” Ashley explains. You can start physical therapy as soon as you get home from the hospital, even before you are cleared for activity. Uniquely trained in your special needs during the early postpartum, a pelvic physical therapist can guide you safely and gently as you heal from your C-section.
In the first six weeks
Supporting the healing process: Incorporating gentle pelvic floor physical therapy in the early stages of C-section recovery can help you through the healing process. It may even offer a healing advantage.
In the first six weeks of C-section recovery, a pelvic floor physical therapist can help you with:
- First aid care for the incision
- Bowel and bladder support
- Gentle reconnection with the abdominals and pelvic floor
- Training for postural awareness
- Training for body mechanics
- Some lactation and breastfeeding/chestfeeding support
After the first six weeks
Reconnecting with deep core muscles: While your abdominals are not always cut during a C-section (depending on the incision type, they can be “pushed to the side”) the fascia connecting them is most certainly cut and injured in the process, which can impact abdominal muscle healing and function.
“The most important thing that someone can do when recovering from a cesarean is to reconnect with and properly engage their deep core muscles: abdominals, low back stabilizers, and pelvic floor muscles,” Ashley explains. “If you don’t consciously work on the connection between your brain and these muscles, then these muscles probably won’t actually be participating in any rehab, and any movement or exercise you do after will not likely be helping you.”
One way to re-engage the deep core muscles is to practice diaphragmatic breathing. During exhale, we naturally use our abdominals to help move air out of our lungs, so this can be an intuitive way to begin using these injured muscles, gently and without pain.
Guiding you in scar tissue massage: The deep abdominal scar tissue that forms after a C-section can sometimes cause numbness, tingling, chronic pain, and restrict abdominal movement, which in turn can lead to abdominal weakness and back pain. Complications from C-section scarring, while treatable, can even impact future fertility.
Many common discomforts related to C-section scars can be relieved and sometimes prevented with scar tissue massage. You can do scar tissue massage on your own or with a pelvic floor physical therapist. You can begin six weeks after a C-section as long as the incision is fully healed.
All throughout your C-section recovery
Offering educational support: “A pelvic PT will take the time to educate you about your symptoms, discuss treatment options, even educate you on symptoms to look out for,” Ashley says. “It can really help to understand your symptoms—and know that recovery is possible.”
While the population studied was pregnant people rather than in the postpartum period, a 2022 research report demonstrated that education about pelvic floor dysfunction can actually help reduce the distress that can come with symptoms of pelvic floor dysfunction.
Holding space for whatever you need: “The postpartum experience can be isolating in a lot of ways,” Ashley says. “It’s not uncommon to feel like an unrecognizable version of yourself: exhausted, tired, confused, disappointed/traumatized in your birth experience—which is particularly common in situations of an unplanned cesarean—and suddenly dealing with pelvic symptoms you never imagined would impact you.”
post-C-sectionPelvic floor physical therapists have an extensive understanding of your post C-section body, and can support you in your physical and emotional recovery. Comprehensive physical therapy support may even play a part in improving postpartum mental health. One study that evaluated a physical therapist-led program involving specialized exercises as well as parenting education found a 50% reduction in postpartum depression among participants “at risk” for depression.
Psychotherapy and support groups can also be incredibly impactful in the postpartum period. As many as 1 in 5 postpartum people experience significant depression and anxiety symptoms. If you don’t already have a therapist, your physical therapist can refer you to some—or you can search the Postpartum Support International directory. Learn more about the signs of perinatal mood and anxiety disorders and support groups in your area from Postpartum Support International.
C-section recovery at Origin
Whether you’ve delivered via C-section or vaginally, or you’re pregnant right now, Origin’s team of compassionate physical therapists are here to support you physically, mentally, and emotionally.
Using a combination of scar tissue massage, cupping, heat, exercise, and dry needling (when available), our physical therapists are skilled and equipped to promote healing, re-engage the core, improve mobility, and reduce discomfort after C-section—during and beyond the six main weeks of recovery.
Origin is in-network with most insurance providers. And if we don’t take your insurance, we can offer referrals to someone who does.
Learn more about our postpartum recovery program and round out your postpartum care team with Origin’s physical therapists today.