Postnatal Recovery Advice After Caesarean Section

Information for patients

NHS Lanarkshire Maternity Department

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Pelvic Health Physiotherapy service

The NHS Lanarkshire Pelvic Health Physiotherapy service gives education and information to help you manage any pregnancy related musculoskeletal or pelvic floor problems.

It is very important to us that we give you the best evidence based information to help you make informed decisions about your care and promote healthy lifestyle choices.

We suggest you dip in and out of this booklet during your postnatal journey to avoid feeling overwhelmed with the information.

Immediate management

In the first 24 hours after caesarean section birth:

Start your pelvic floor muscle execises once your catheter has been removed.
Drink 1.5 – 2 litres of fluid per day.
Remember to empty your bladder every 3-4 hours (the sensation of wanting to pee may not return straightaway).
Try to move around regularly.
Avoid straining or holding your breath on movement.

You should also look at this physiotherapy video for information.

About your caesarean section

Most patients will have had a spinal anaesthetic for their caesarean section which will numb your body and legs from the chest down.

You will have a urinary catheter in place for 6-12 hours following the operation. This means you will not need to go to the toilet to empty your bladder until after the catheter is removed

You will have a wound across your lower tummy just above your bikini line and a dressing which will protect your wound for a few days

You should eat and drink within the first hour of your recovery and it is important to continue to drink regularly. You should aim for 1.5 – 2 litres of fluid per day

It is normal to feel some discomfort over your wound and lower tummy area. Most patients are given paracetamol and an anti-inflammatory painkiller to help to ease the pain and allow you to care for yourself and your baby. Everyone feels pain differently, if you need stronger painkillers it is important that you discuss this with your midwife

Circulation

Research has shown that after surgery, the sooner you move about and the earlier you are eating and drinking, the quicker your recovery will be.

It is normal to have swollen ankles and feet after delivery. Raise your legs above your heart to encourage the fluid to drain away from your feet.
Circle your ankles up and down 20 times every hour whilst resting to help to reduce the swelling.
If you notice any redness, swelling or pain around the back of your calf – please contact your midwife.

Getting moving

You should generally be able to get out of bed around 6-8 hours after your operation

Ask for help the first time you get out of bed, so that a member of staff can check that your legs have fully recovered after your anaesthetic.

Bend your knees up, one at a time. Roll onto your side, keeping your head on the pillow. Let both legs come off the bed and push up through your arms

You will be encouraged to sit in your chair instead of the bed, to allow you to move around more easily and care for your baby.

Keeping mobile helps to promote good circulation around your body, you should try to get up and walk around your room regularly. However, if you have been advised by your midwife or doctor not to get up, please follow their instructions about when you should do so.

If you need to cough or clear your throat, place a towel over your wound, place both hands over the towel and apply firm pressure to help ease any discomfort as you cough.

Bladder Care

You should pass urine in the first 4 hours after your catheter has been taken out. If you are having difficulty passing urine or not feeling the urge to empty your bladder, please speak to the midwife in charge of your care.
If you are having any leakage of urine or not getting to the toilet in time, please speak to the midwife in charge of your care.
Aim to drink 1.5 – 2 litres of fluid every day, especially if you are breastfeeding.
Avoiding caffeinated drinks e.g coffee, tea, Cola, Irn-bru can help to reduce any bladder irritation.
It is important not to pass urine too often throughout the day. You should empty your bladder every 3-4 hours.

If you are having difficulty emptying your bladder when you are discharged home, please contact Maternity Triage on 01698 366210.

Bowel Care

It is common to feel nervous about opening your bowels after delivery but do not worry, your wound and stitches will not be affected.

Do not ignore the urge to empty your bowels.
Try to avoid constipation by eating a healthy diet with high fibre foods such as: porridge, wholemeal bread, vegetables, beans, seeds and nuts. You will find more advice and a link to the British Dietetics Association on page 20.
Ensure you have a good fluid intake of 1.5 – 2 litres per day.
Avoid straining to empty your bowels by sitting in the position in the picture below, relax your tummy muscles, take deep breaths into your low tummy and take time to empty your bowels.

Acknowledgement to Crohn’s UK for image

Keep back straight
Spread feet wide
Lean forward
Put elbows on knee
Keep knees higher than hips

Advice for home

When you get home after your hospital stay, your full attention will be on caring for your baby. It is important not to forget about the important advice in this booklet during your day to day activities.

Try not to lift heavy items around the house for the first few weeks.
Complete household tasks steadily so you do not tire yourself out
When you are feeding your baby make sure your back is well supported and you are sitting or lying in a comfortable position.
Try to change the side that you feed and carry your baby on, especially as they get bigger.
Pushing the pram and going for walks is a good way to get moving after your caesarean section. The distance you cover and the time you are walking for will depend on your sleep pattern, energy levels and pain.
Going for a 10minute walk twice daily is a good aim, then adding on 5minutes each week until you are feeling comfortable for 45minutes-1hour at 6weeks.

Pelvic Floor Muscle Exercises

What are the pelvic floor muscles?

The pelvic floor muscles are a large group of muscles that support your bladder, womb and bowel. They provide strength and structure to your vaginal walls. Your pelvic floor muscles also help to control passing urine and opening your bowels.

Why do I need to strengthen my pelvic floor muscles?

Pregnancy puts a lot of pressure on your pelvic floor muscles and it is normal for the pelvic floor muscles to stretch during pregnancy. Even if you have not had a vaginal delivery, your muscles can be weaker and you may feel more pressure vaginally, so it is very important to strengthen your pelvic floor muscles soon after you have had your baby.

By doing your pelvic floor exercises you can avoid having symptoms such as leaking urine when laughing, coughing, sneezing and symptoms of vaginal heaviness.

When can I start my Pelvic floor exercises after delivery?

These exercises should be started as soon as your catheter has been removed and your pain is under control.

How do I strengthen my pelvic floor muscles:

Start these exercises lying on your back or side. Then progress to doing them in sitting or standing.

Step 1: Tighten the muscles around your back passage as though you are holding in wind (without squeezing your buttocks).
Step 2: At the same time as your back passage squeeze, zip forwards to lift the muscles around the opening to your vagina, think about stopping yourself from passing urine.
Step 3: Lift and squeeze your pelvic floor muscles quickly 10 times.
Step 4: Lift and squeeze your pelvic floor muscles for up to 10 seconds 10 times. Relax for 4 seconds between squeeze.
Step 5: Try and complete these exercises when you are feeding your baby or three to four times every day.

Note: Do not hold your breath when completing these exercises

Reminder: Your pelvic floor muscle exercises are for life and can help to prevent you having bladder, bowel or prolapse symptoms in the future.

You can download the blue NHS pelvic floor app called ‘Squeezy App for Women’ to help remind and guide you through the progression of these exercises.

‘The Knack’

Before you cough, sneeze or lift your baby you should try to tighten your pelvic floor muscles. This can help to support your bladder and reduce the risk of bladder leakage.

Abdominal Muscles

What is Diastasis Recti?

During your pregnancy your abdominal (tummy) muscles stretch as your baby grows. This causes the stretch of the abdominal muscles and the fibrous structure that runs down the middle of the tummy, and is called Diastasis Recti.

This happens to every woman when they reach 35 weeks of pregnancy, but it can appear from 25 weeks.
This can be seen earlier in women carrying twins or those who have had a previous diastasis.
It is estimated that approximately 3 in 10 women have an ongoing diastasis. The recovery can take between 9 weeks to 2 years after delivery, this is normal.
To help the abdominal (tummy) muscles recover, we recommend you complete regular low level, core exercises.

We would advise that you start with Postnatal Pilates around 4 weeks after delivery.

Diagraam of the abdominal muscles after a caesarean section

Exercise 1: Basic abdominal contraction

Sitting or standing:

Breath into your stomach by relaxing your tummy muscles
Breath out and draw your lower tummy muscles backwards to your spine.
When completing this exercise make sure you keep your shoulders, rib cage and jaw relaxed.
Repeat 5 times.

Exercise 2: Pelvic Tilts

This exercise can be done lying down with your knees bent, lying on your side, sitting down or on your hands and knees.

Complete the basic abdominal contraction described above.
Breathe in and push your tail bone towards the floor and arch your back.
Breathe out and roll off your tail bone to flatten your back against the floor. Hold this position for a few normal relaxed breaths.
Repeat this 5-10 times.

Lower Back Pain and Shoulder Pain:

Due to repetitive movements with your baby (e.g changing nappies, feeding and bending over) the upper body, shoulders and lower back can get stiff and painful. We would advise that you try some of these exercises once a day to avoid having any stiffness in these areas.

These exercises combined with your pelvic floor muscle exercises help you to have strong core muscles around your pelvis. This will make it easier to move forward with your postnatal journey and begin your return to exercise.

Scar Tissue Massage (6 weeks after delivery)

Why is scar tissue massage important?

Scar tissue forms by laying down new collagen fibre tissue to support the wound. However, this tissue can become very tight and immobile. Therefore, it is important to break down any excess collagen fibres to encourage soft and mobile tissue.

How do I massage my scar tissue and wound?

Step 1:

Your wound should be completely closed.
There is no need to use expensive scar oil; any non fragranced moisturising cream or oil is fine.
Your scar may be sensitive to begin with. Start by massaging around the scar instead of over it. Once you get used to the feeling you can massage closer to the scar itself.
Increase the pressure gradually, and spend a couple of minutes massaging the scar in different directions.

Step 2:

Begin to massage deeper into the tissue.
With one hand pull the scar tissue across you tummy and with the other hand pull the scar tissue in the opposite direction to create a stretch over the wound. Pinch the tissue around the scar and roll the pinched skin up/down/side to side.

Returning to Sex (6 weeks after delivery)

When is it safe to have sex again?

Many woman worry about having sex after childbirth, particularly if you have had stitches. Once bleeding has stopped and your stitches have healed, you can have sex again when it feels right for you and your partner. There are some things that might help:

Use a vaginal lubricant
Find a position that is comfortable for you. This will make penetration more comfortable.
Perineal massage – once your stitches have healed some gentle massage over your scar can make sex more comfortable.

It is normal not to feel ready to have sex for a few months after delivery. If you have tried to have sex a few times and continue to have pain, you should contact your GP or NHS Pelvic Health Physiotherapist for advice.

How long should I wait before going back to exercise?

It is suggested that you always build up slowly over time and listen to your body by being aware of any symptoms that develop during or after exercise. The ‘Return to Exercise Guideline’ on page 16 is a good programme to follow to allow you to return to exercise safely.

Myth	Fact
“My core will always be weaker after childbirth.”	If you do the right exercises your core can be just as strong as it was before pregnancy.
“I can return to all exercise after my 6 week check from the GP.”	It is important to progress your exercise slowly like described on page 16 in the return to exercise guideline.
“Incontinence after childbirth is normal.”	Incontinence is very common after childbirth but never normal. It is advised that you follow all the fluid diet and pelvic floor advice in this booklet to reduce the risk of having pelvic floor dysfunction.

Am I ready to return to impact based exercise? (12 weeks after delivery)

You do not need to work exactly to the timeframe shown on page 16, but it is advised that you do complete the exercises in this order to prepare your body for impact based activity such as running, jumping and resistance training.

Exercises	Leakage	No leakage
Lunges (x 10 for each leg)
Single leg balance (30 sec R+L)
Forward bounds (x 10)
Jog on spot (1 min)

Do I need Pelvic Floor Physiotherapy? (12 weeks after delivery)

If you have tried all the advice in this booklet and you are still having issues with your pelvic floor, then answer these questions to see if you need Pelvic Floor Physiotherapy input.

	Yes	No
1a: Do you usually have leakage from your bladder when coughing, sneezing or laughing?
1b: Do you usually have leakage from your back passage/bowel when coughing, sneezing or laughing?
2: Do you have a sudden need to pass urine with little or no time to get to the toilet?
3: Do you have pain during sex?
4: Do you have a heaviness or dragging feeling in your vagina?
5: Do you have worries about your abdominal (tummy) muscles?
6: Do you have constant back or pelvic pain that affects your day to day life?

If you answer yes to any of the above questions 3-6 months after your delivery, please contact our NHS Pelvic Health Physiotherapy service. If it has been over 6 months since you have delivered your baby, please speak with your GP for a referral to the right service.

Glossary

Abdominal Muscles/Core: The tummy muscles.
Antenatal: The period of time that you are pregnant.
Bladder: A muscular sac that holds urine.
Catheter: A flexible tube inserted into the bladder to remove urine.
Circulation: The movement of blood around your body.
Constipation: A condition in which there is a difficulty in emptying your bowels due to hardened stool.
Linea Alba: A fibrous tissue that runs down the middle of your abdominal muscles.
Mucosa: The inner lining of your vagina or bowel.
Musculoskeletal: The muscles and skeleton.
Perineal Massage: Massage of the skin between the vagina and the back passage.
Postnatal: The period of time after you deliver your baby
Prolapse: When your bladder, womb or bowel move from their normal position and bulge down into the vagina.
Straining: To make a great effort, push or hold your breath on a movement
Urine: The fluid stored in your bladder and is emptied when you go to the toilet.
Uterus/Womb: The organ in which your baby grows before you give birth.
Vaginal Lubrication: A vaginal discharge to allow smooth movement.