By Shannon Pacella, DPT, PHRC Lexington
If you’re reading this, you probably know what a Cesarean birth (C-section) is,* but what you may not know is what to do once you have had one. Most women post C-section are not given much information regarding their healing incision, except to “keep it clean in order to prevent infection.”
*A Cesarean birth (C-section) is the delivery of a baby through an incision in the mother’s abdomen and uterus. The incision can be transverse/horizontal near the pubic hairline, or it may be vertical at midline.1
Whenever an incision has been made, a scar may form as part of the healing process. According to the American Academy of Dermatology, during the healing process, a temporary scab forms to close the edges of the incision together, and then the body creates scar tissue from collagen (a tough fibrous protein), which takes the place of the scab.
American Academy of Dermatology
It is important to note that scar tissue is not only what you can see on the surface, but it can extend into deeper layers below the skin, as seen in the picture above.
Scar tissue is composed of the same protein as the tissue it replaces, however, the fiber direction and pattern of the collagen is different. The collagen fibers in normal tissue go in all different varying directions (as seen below in box A), while the collagen fibers in scar tissue are formed in a linear single direction (as seen below in box B).
American Academy of Dermatology
This irregular pattern of collagen fibers that the scar is comprised of can create a wide variety of problems for new mothers including (but not limited to):
- Pain/sensitivity at and around the scar.
- Reduced mobility and elasticity; making bending forward and lifting uncomfortable.
- Feeling like that area is being pulled/tugged on, when standing up straight and reaching overhead, which can affect posture.
- Low back pain from compromised/weakened abdominal muscles.
- Myofascial trigger points in abdominal muscles that can refer pain to the urethra and clitoris.
- Superficial nerve irritation surrounding the area of the scar.
- Urinary urgency and frequency.
Now that you know what potential impairments may occur, we can discuss how to properly care for and treat this area, in order to reduce and even prevent these symptoms from happening. And the answer is…MASSAGE! Scar massage (also known as scar tissue mobilization) is different than the typical massage you may be familiar with, but it has many beneficial effects. A literature review of ten journal articles that looked at the role of massage in scar management concluded that 90% of the surgical scars treated with massage had improvement based on the Patient and Observer Scar Assessment Scale.2
You’re most likely wondering how massage can help with all the aforementioned impairments. Scar massage is all about reorganizing the collagen fibers in a similar pattern as the normal tissue, so the scar moves and stretches more like the skin surrounding it. The massage will also reduce adhesions in underlying connective tissues and myofascial layers. Adhesions are parts of the scar tissue that have attached onto other structures closeby, which if left untreated, can lead to reduced blood flow, nerve irritation, and pain.
This is where pelvic floor physical therapists can help! A pelvic floor PT will be able to assess your C-section scar and start treating the area with scar massage. This entails the physical therapist using their hands to manipulate/mobilize the scar and surrounding tissues in all different directions using skin rolling techniques, and pressing and rubbing motions.
This may be a bit uncomfortable and sensitive at first, so it is important to communicate how you are feeling with your physical therapist. It may be more comfortable to apply a warm compress to the area prior to the massage. If appropriate, the physical therapist can teach you how to perform the scar massage on your own as part of your home treatment plan.
Feeling nervous or uneasy about touching your C-section scar? You may find it helpful to start out with brushing/rubbing various items over the scar to get yourself more comfortable and connected to it, without directly touching the scar. This can also get the scar use to different textures and sensations. Some items to try may include: a damp face cloth, makeup brush, cotton ball, and q-tip.
Before starting C-section scar massage, wait until your ob/gyn confirms that your incision has closed, typically at the six-week post delivery follow-up. It is best to start the scar massage soon after the incision has closed, as the tissue will respond more quickly and reduce the amount of adhesions from occurring. Even if you have had a C-section scar for a long time, it can still be beneficial to perform the scar massage since your body is constantly remodeling and forming new tissue.
To find out more about how a pelvic floor physical therapist can help postpartum, check out these resources:
Why All Postpartum Women Need Pelvic Floor Physical Therapy
Pregnancy/Postpartum Physical Therapy
______________________________________________________________________________________________________________________________________
Are you unable to come see us in person? We offer virtual physical therapy appointments too!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836
References:
- Cesarean birth (C-section) frequently asked questions: labor, delivery, and postpartum care. The American College of Obstetricians and Gynecologists, 2015.
- Shin, TM and Bordeaux, JS. The role of massage in scar management: a literature review. Dermatol Surg, 2012. 38: 414–423.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
You are an angel for posting this! I have been dealing with nerve irritation for many years since my 3 abdominal surgeries. I am going to see a pt that specializes in this to help me. Thanks for all you do!!
I suffer with CPP and had a salpingo ovarian cyst surgery, I have a scar like a C-section. Wondering if this could be causing painful adhesions?
Author Shannon Pacella says:
Hi Vicki,
Any scar from a surgery has the potential to become painful from scar tissue restrictions/adhesions, just like how I described with C-section scars in the blog post. I would recommend getting an evaluation from a pelvic floor physical therapist, in order to assess the scar you have from the salpingo ovarian cyst surgery.
Kindly,
Shannon Pacella, PT, DPT
From one Physio to another – really good article. Nice to see a well written online resource with references. Thank you
Had 3 c-sections +now I’ve had a complete hysterectomy by c-section when they did that I had so much scar tissue that it was hard for Dr. To even remove 100% .that was the most painfulest procedure I’ve done in my life.
I had 2 c sections with the end of the right side of my scar has created a bump underneath the skin and every month before my cycle it itches them after my cycle it becomes sore. It’s very annoying and wondering if the massaging would help.
This was very helpful. I had a csection 11 years ago and wondering if this can still be of any help? Thanks
I have been having lower back pain and symptoms of a UTI for the past three months . I was referred to a pelvic floor PT. She told me that the source of my pain was coming from a 31 year old cesarean scar. I didn’t believe it until she started massaging the area and it triggered both back pain and the urinary tract symptoms.
Melinda,
It is quiet interesting how the body works! Postpartum care is essential for a full body recovery after childbirth- whether it is vaginally or through a c-section. Has your pelvic floor PT been able to help with your back pain and other symptoms?
Regards,
Emily
This was very helpful. I had a c-section 16 month ago and curious if this can still be of any help? Thanks
Hello, Yes it can be! If you are still experiencing pain or discomfort, we recommend you seeing a pelvic floor PT to help evaluate your current state of health. C-section scars can potential create this pain/discomfort down the line and affect other aspects of your body.
Can I still massage 14 years old my c section depress scar ?
Yes! Better late than never. You might try coconut oil or a little bit of lotion. This will help in making the scar tissue mobile, gauge how it feels (if it’s causing discomfort, stop). Repeat as necessary to help the scar.