Physiotherapy following

Caesarean section

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� Cesarean delivery defines the birth of fetus via laparotomy and
then hysterotomy

� Two general types of cesarean delivery:

Primary: refers to a first time hysterotomy
Secondary: uterus with one or more prior hysterotomy incisions

� Caesarean births (when compared to unassisted vaginal

deliveries)
Were more likely to suffer exhaustion & bowel problems
Reported less perineal pain and urinary incontinence
Were more likely to be readmitted

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 Indications for Cesarean delivery
Maternal:
� Prior caesarean delivery
� Abnormal placentation Maternal –Fetal:
� Maternal request
� Cephalopelvic disproportion
� Prior classical hysterotomy
� Unknown uterine scar type � Failed operative vaginal delivery
� Uterine incision dehiscence � Placenta previa or placental
� Prior full-thickness myomectomy abruption
� Genital tract obstructive mass
� Invasive cervical cancer
� Prior trachelectomy
Fetal:
� Permanent cerclage � Non reassuring foetal status
� Prior pelvic reconstructive surgery � Malpresentation
� Pelvic deformity
� Macrosomia
� HSV or HIV infection
� Cardiac or pulmonary disease � Congenital anomaly
� Cerebral aneurysm or arteriovenous � Abnormal umbilical cord Doppler
malformation
study
� Pathology requiring concurrent
intraabdominal surgery � Thrombocytopenia 13-05-2020

� Perimortem caesarean delivery

� Prior neonatal birth trauma
 Procedure:

� Sedatives given at bedtime or night before surgery

� Oral intake is stopped at least 8 hours before the

procedure

� Midline vertical or suprapubic transverse incision is

chosen for laparotomy

� Depending on fetal presentation delivery of fetus.

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 Placenta delivery

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 Repair of hysterotomy and
laparotomy incision

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 Physiotherapy management

� Postpartum intervention for the woman who has had cesarean

delivery is similar to that of the woman who has had vaginal
delivery

� However C-section is a major abdominal surgery with all the

risks and complications of such surgeries & therefore the
woman may also require general postsurgical rehabilitation:

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Management guidelines:

� Potential structural and functional impairments:

Risk of pulmonary, gastrointestinal or vascular complications

Postsurgical pain and discomfort

Development of adhesions at incision site

Faulty posture

Pelvic floor dysfunction: Urinary or fecal incontinence, organ

prolapse, hypertonus, poor proprioceptive awareness and disuse
atrophy

Abdominal weakness, diastasis recti

General functional restrictions of post delivery

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 1. Improve pulmonary function and decrease
the risk of pulmonary complications;

� Breathing exercises
� Coughing and huffing techniques
� Spirometry

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 2. Decrease incisional pain

� Postoperative TENS

� Support incision with pillow when coughing or breast feeding

� Incisional support with pillow or hands with movement

education regarding incisional care & risk of injury

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 3. Prevent postsurgical vascular or
gastrointestinal complications:
� Active leg exercises:

- Ankle toe exercises

- Heel drags

- Isometrics of quadriceps, glutei

� Early ambulation: walking should be initiated as early as

possible; preferably after 24-48 hr. of delivery

� Teach abdominal massage to stimulate peristalsis

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 4. Enhance incisional circulation and
healing; prevent adhesion formation
� Gentle abdominal exercises with
incisional support

- Pelvic tilting

- Bridges and twists

- Partial abdominal curl ups

� Scar mobilization and friction

massage

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 5. Decrease post-surgical discomfort
from flatulence, itching or catheter

� Positioning instruction

� Massage

� Supportive exercises

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Correct posture
� Posture instructions

� Postures while child care

Prevent injury and reduce low back

pain
� Instruction in incisional splinting and positioning for
ADLs
� Body mechanics instruction

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1. Teach awareness and control of
posture after pregnancy

▪ Stretch, train, and strengthen the

postural muscles to meet postnatal
demands.

▪ Posture awareness training

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 Stretching Strengthening
•Upper neck extensors • Upper neck flexors,
lower neck and upper
thoracic extensors

• Scalenes •Scapular retractors and

depressors

• Scapular protractors •Shoulder external

rotators
•Shoulder internal rotators •Trunk flexors particularly
and levator scapulae lower abdominals( with
modification)

•Lower back extensors •Hip extensors

•Hip flexors, •Knee extensors

•Adductors and
19 hamstrings 13-05-2020

•Ankle plantar flexors •Ankle dorsiflexors

 8. Prevent pelvic floor dysfunction

� Pelvic floor exercises

� Education regarding risk factors and types of pelvic floor

dysfunction

Awareness of isolated pelvic floor muscle contraction and

relaxation:

- Kegel’s exercises

- Techniques: Contract-relax

Quick contractions
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 Develop abdominal strength

� Abdominal exercise progression, including corrective

exercises for diastasis recti

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� Stabilization exercise

- drawing in maneuver

- abdominal bracing

- posterior pelvic tilt

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 General postnatal exercise
protocol
� Aerobic exercises consideration:
F= 3-5 days
I = initiate with mild to moderate intensity to high intensity
T = interval to continuous type
T = 30-45 minutes
� Strengthening exercises focusing UE
� Abdominal and core muscle strengthening
� Psychological support
� Care of baby

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 References:

� Physiotherapy in Obstetrics and Gynecology by Jill mantle,

Jeanette Haslam 2nd edition

� D.C Dutta’s textbook of obstetrics by Hiralal Konar 7th edition

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