C-Section Recovery: Why Your Abs Don't Just "Bounce Back"

As the most common surgery in the United States, c-sections have become almost routine for OBs, with 1 in 3 people undergoing this type of birth each year. Despite how simple and routine a cesarean may be for a medical team, it's rarely routine for the birthing person or their family. Unfortunately, detailed education about what truly happens to your abdominal muscles during surgery — and in the recovery phase — is almost non-existent. Most pamphlets and articles provide an abbreviated and oversimplified version of the truth.

For example, according to the American College of Obstetricians and Gynecologists (ACOG), a cesarean section is completed through two separate surgical incisions: one cut that's made through the skin and your abdominal wall, and then a second cut — which may or may not match your skin incision — is made through the uterus. To get from the outside of the abdominals to the inside where your uterus is, the American Pregnancy Association reports the abdominal muscle layers are "pulled apart," but not cut.

While technically accurate, this description is a half-truth, likely meant to reassure patients who might be worried about recovery. Unfortunately, it fails to provide a comprehensive understanding for those preparing for cesarean birth and blocks a clear path for healing when navigating postpartum challenges.

During a cesarean section, the surgeon has to get past 4 layers of abdominal muscles, which is no easy feat. Let’s dive into the details of what happens to your abdominals during a cesarean section so that you can feel more informed and confident when making decisions about your body during and after birth.

Abdominal anatomy & your fascia

Before going into the specific details of what happens to your abdominal muscles during a cesarean section, it may help to review the anatomy.

The muscular abdominal wall is a layered group of muscles that consists of four main muscles: The rectus abdominis, the external obliques, the internal obliques, and the transversus abdominis. These abdominal muscles work together with your pelvic floor muscles, low back muscles, and diaphragm to:

• Bend, rotate, and move your spine
• Control reflexive actions such as breathing, coughing, sneezing, and vomiting
• Create stability and strength throughout your core

Each muscle is wrapped in layers of connective tissue, which all eventually come together at the middle of the abdominal wall to form the linea alba. The connective tissue that wraps around each layer of abdominal muscle is also known as fascia which plays an extremely important role in abdominal muscle function. In fact strong, healthy fascia is as important to the muscle’s function, as is healthy blood flow and intact nerve function. Fascia:

• Wraps around and encases each muscle to provide structure and support.
• Reduces friction between muscles and other structures in the body to allow for muscle flexibility and efficient movement.
• Communicates with the nervous system about the body’s position in space during movement (aka proprioception) in order to enhance muscle performance.
• Allows for efficient and strong transfer of forces between different muscles and the skeletal system.

Your fascia can become injured in a variety of ways including overuse of the tissues or direct injury. An example of a direct injury would be cutting or tearing of the fascia during a cesarean procedure.

When fascia is injured, it can become thickened, dry and stiff, which can lead to significant pain and muscle dysfunction. Research shows that fascial injury will not only impact the function of the surrounding healthy tissues, but it may even cause pathologic changes in the muscles which are akin to the muscle being directly injured.

What happens to your abdominals during a c-section

During a cesarean section, 7 different layers of tissue are carefully opened before the baby is born. These include:

• Skin
• Subcutaneous adipose tissue (aka Camper’s fascia)
• Abdominal wall fascia (Scarpa’s fascia and the rectus sheath)
• The abdominal muscles (rectus abdominis, external obliques, internal obliques, transversus abdominis)
• Peritoneum
• Uterus
• Amniotic sac

Each layer is either cut through with a sharp surgical tool (a scalpel or electrocautery tool) or “bluntly dissected”, meaning it is pulled apart with the surgeon's fingers or another blunt tool. For transverse incisions, the opening is made at least as wide as a full-term baby’s head, usually about 15 cm in width or 6 inches, extending out towards each hip bone.

Specifically how your abdominals are really affected by the cesarean procedure depends on the type of skin incision made. While the chosen incision is typically based on a variety of factors that have to do with circumstances surrounding the birthing person, the baby, the surgeon’s training and experience, and best available evidence at the time, here are some helpful details for what to expect during the most commonly used incisions.

Pfannenstiel:

The most common type of cesarean skin incisions is this transverse incision that is made really low on the abdominal wall, about 2-3 cm above the pubic bone. The skin and adipose tissues are opened to reveal the fascia of the abdominal wall.

To get through your fascia to the abdominal muscle layers, a small incision is made right into the middle of the tissue, and then either cut with scissors, or pulled apart by the surgeon. The fascia is then pulled open up towards your head, and down your pubic bone to reveal the rectus abdominis muscle.

With this surgical technique, to get through the abdominals, the full thickness of the linea alba is cut vertically (in the opposite direction of the initial incision), and then all 4 abdominal muscles are collectively pulled apart sort of like curtains, making enough space to birth the baby. Under the abdominals is the peritoneum, which is a thin layer of tissue that protects and insulates your organs. This is cut or pulled apart to finally get to the uterus.

Joel-Cohen:

The details of this incision type and closure are very similar to the Pfannenstiel, except when using the Joel-Cohen incision, the transverse incision is about 3 cm higher, and the fascia and abdominals are both separated using blunt dissection (instead of being cut like in the Pfannenstiel).

Maylard:

The Maylard incision also starts very similar to the Pfannenstiel incision, but once reaching the rectus abdominis muscles, all four of the abdominal muscle layers are cut open out to the sides, and then pulled up and down to expose the uterus. When closing the abdominal muscles, the cut edges of the abdominals are sutured to the rectus sheath before the fascia is closed with sutures.

Vertical:

While less common, the vertical incision is often used when the birth needs to be accomplished ASAP, as it is a slightly quicker method. When performing a vertical incision, the skin, adipose tissue, abdominal wall fascia, abdominal muscles, and peritoneum are all opened using the same vertical incision, and then the layers are pulled open to the sides, to expose the uterus.

After the baby is birthed, the closure of the abdominal wall is generally described as the same for all types of skin/abdominal wall incisions. The abdominal muscle layers may or may not be surgically reapproximated and most often the vertical incision that was made between the abdominal muscles is left to heal naturally, without being sewn back together. The transverse or vertical fascial incisions however, are sutured closed with slow dissolving stitches, and the skin is closed with surgical thread, glue, staples, or a combination of the three.

The impact of a c-section on your abdominal muscle function

So whether your abdominals were simply “pulled apart”, or surgically cut, they are undeniably impacted by the cesarean section procedure. And even after the surgery is over, your abdominal muscles continue to be impacted which is likely to contribute to lingering pain and dysfunction. For example, cesarean sections are associated with:

• Scar tissue adhesions are seen in up to 93% of people after abdominal surgery, adhesions can contribute to bowel obstruction, pelvic pain, and secondary infertility. Adhesions can also complicate surgical outcomes in future abdominal surgeries including subsequent cesarean sections.
• Pain during sex is more common after cesarean sections when compared to non-surgical births.
• Alterations in the abdominal muscles and fascia. Ultrasound imaging has shown a possible correlation between cesarean sections and thicker abdominal fascia, a wider postpartum distance between rectus abdominis muscles (also known as the inter rectus distance), and thinner abdominal muscles.
• Cesarean scar syndrome including symptoms of pelvic pain, pain during menstruation (dysmenorrhea), and menstrual changes.
• Increased rates of low back pain and chronic pain.

How to heal your abdominals after a c-section

With a better understanding of what truly happens to your abdominal muscles during a cesarean section, it’s easy to see why it is important to take the steps to care for them as you heal. But you don’t have to go at it alone. Seeing a pelvic physical therapist after your cesarean section is one of the most important, and easy steps you can take.

Not only is pelvic physical therapy effective at addressing many of the common concerns after a cesarean section (for example, scar discomfort or pain, abdominal adhesions, discomfort while baby feeding, and pelvic or low back pain), research has shown that participation in physical therapy after a cesarean can lead to decreased pain, and improved confidence in your body and its function, a whole lot sooner.

At Origin, we deeply understand the importance of seeing a physical therapist after you have had a baby. In fact, it is why we created a rehabilitation program specifically for your needs in the early postpartum period. Our postpartum care was designed for all individuals in their fourth trimester, and after a cesarean section, we encourage you to be seen by one of our physical therapists as soon as you are home from the hospital. While you may not be up for leaving the house, early postpartum care is designed to be done virtually. We are committed to helping you start your recovery with your best foot forward and want to teach you everything you need to know to safely heal and rehabilitate your abdominals.

Call today to learn more about physical therapy at Origin or skip right to online scheduling. In the meantime, we have more great resources to help you feel empowered and informed. Check out our Ultimate Guide to Cesarean Scar Healing and 10 C-Section Recovery Must Haves.