When Ginny Stephan gave birth to her fourth child, she didn’t expect to experience so many problems afterward. Her first delivery was a cesarean birth and the next two were vaginal (vaginal birth after cesarean or VBAC). She didn’t note any lasting problems following her deliveries, until the fourth, at which time, she explained, “Everything went south.”
Subsequently, Stephan went to physical therapy for pelvic floor and core strengthening, and later sought out therapy to train her bladder. She couldn’t “run or jump at all without leakage,” she explained, and she struggled to strengthen her abdominal muscles.
In the years since Stephan’s experience, much has been discovered regarding the issues that may arise following a cesarean birth. Once your clients are ready to come back to training with you post-cesarean, having a great understanding of this procedure and how it affects the body can enable you to play an important role in their postpartum fitness plan.
Cesarean Basics
Because cesarean births are common—the latest stats from the Centers for Disease Control and Prevention estimate that 32.1% of all babies in the U.S. are delivered via cesarean birth—it’s easy to forget the fact that this is a serious procedure. Not only has the mother gone through nine months of pregnancy, but she also has to cope with giving birth, healing from surgery and taking care of a newborn all at once.
“Let me emphasize that a cesarean delivery is major abdominal surgery,” urges Joanne Donoghue, PhD, ACSM-RCEP, director of clinical research and professor of osteopathic manipulative medicine at the New York Institute of Technology College of Osteopathic Medicine in Long Island. “The abdominal wall has been stretched for nine months while working to support the body’s extra weight. Then it is cut, stretched so that organs can be shifted, and the uterus is then cut to deliver the baby. After that trauma, everything is stitched back together.”
It’s important to note that the muscles of the abdomen are not typically cut. “In most cases with a cesarean birth, no muscles are cut, which is great,” explains Reema Thakkar, PT, DPT, director of clinical education and professor at Touro College of Health Sciences in Bay Shore, N.Y. “The cesarean incision is [usually] made horizontally, just above the pubic bone, and the abdominal muscles are moved apart in order to reach the uterus.”
Add to this the natural consequences from relaxin, the hormone that is produced during pregnancy. While its specific purpose is to relax the joints of the pelvis, it creates laxity in all the joints of the body.
“During pregnancy, your body goes through a natural relaxing and stretching regimen to make room for the baby and uterus with the help of relaxin,” adds Thakkar. “While this is great for your new bundle of joy, it can often take a toll on your joints that are working overtime with the extra weight and the lack of stability from the ligaments and muscles all around.”
Regardless of the method of delivery, women during the postpartum period need to ease back into exercise; with cesarean birth, however, women have an added challenge in that their recovery period is often considerably longer than that of a woman who experienced a vaginal delivery.
A study published in Medicine & Science in Sports & Exercise highlighted the differences between women who had never been pregnant (the control group) and those who experience either a cesarean or vaginal delivery. The researchers found that all women in the study, regardless of the method of delivery, were weaker at all trunk angles at both eight and 26 weeks postpartum when compared to the control group. The muscles of the women who delivered babies also fatigued more quickly compared to the control group. However, women who delivered via cesarean birth had one distinct difference: They were 59% more fatigable at eight weeks compared to the vaginal delivery group.
How Health and Exercise Professionals Can Help
Prenatal fitness has undergone a transformation over the last few decades. Gone are the restrictive activity guidelines that severely limited women with uncomplicated pregnancies from participating in physical activity both during and after pregnancy. Whether or not your clients were able to exercise during pregnancy, a gradual progression should be followed during the postpartum period to allow time for the body to ease into its new normal.
As with any other condition, be sure to secure approval from your client’s healthcare provider before starting to work with her during the postpartum period to ensure your client does not have a medical reason to avoid exercise.
“Once cleared by her O.B., I would begin by making sure that she has no pain at the healing site,” advises Thakkar. “A good way to do this is to have her lie on her back with one knee bent and raise the other leg up about one inch to see if she feels pain at the site. Keep in mind that ‘tugging’ is not pain. She may feel a mild tug in that area, and that’s O.K. Any pain felt should be reported to her O.B. prior to beginning an exercise program.”
When it comes to core work, begin with core exercises that focus on isometric strengthening of the transverse abdominis (TVA), which is the deepest abdominal muscle, advises Leah Keller, founder of Every Mother. “This muscle engagement should always be paired with an exhalation to avoid increasing intra-abdominal pressure. It is very important to establish baseline strength, control and integrity of the abdominal wall with isometric strengthening prior to performing more challenging core stabilization exercises, such as full planks.”
Keller emphasizes the importance of performing TVA muscle activation properly. “The contraction of the TVA must always be in a concave direction—navel toward the spine—never in a bracing, barreling or flexing contraction that exerts outward pressure on the abdominal wall,” says Keller. Additionally, “the client should never feel like she is bracing the abs for a punch, bearing down on the pelvic floor, or tensing the muscle with such intensity that she cannot control the direction of movement. She should avoid any exertion that barrels or bulges the abdominal wall forward or the pelvic floor downward. Effective, therapeutic activation of the TVA must always be a controlled engagement toward the spine and combined with both an exhalation and a lifting squeeze of the pelvic floor—with the exception of those with pelvic floor hypertonicity.”
Note: Signs of pelvic floor hypertonicity include chronic constipation, tailbone pain and pain during intercourse. Women with any of these signs should be referred to a physical therapist for further evaluation, as pelvic floor strengthening may not be recommended for them. It is worth noting that research has shown that postpartum exercise may reverse diastasis recti—a gap down the middle of the rectus abdominis muscle—when performed properly.
The sidebar below offers a protocol you can give your clients to enable them to practice TVA/core contractions.
At approximately eight to 10 weeks postpartum, with clearance from their medical provider/O.B., you can begin to increase the difficulty of your client’s exercises. “A great place to start,” suggests Thakkar, “is by engaging the adductors while performing your [pelvic floor exercises]. Place a ball or pillow between your legs. When you [pull the pelvic floor muscles up] simultaneously squeeze the ball. Once you’ve mastered this, you can add a bridge.”
How to Practice TVA/Core Activation
Offer your postpartum clients the following protocol so they can practice TVA/core activation:
- Lie supine, knees bent, feet on the floor, with your hands on your abdomen.
- Inhale, allowing your abdomen to rise and “fill with air.”
- Exhale as you pull your abdominal muscles in toward your spine.
- While maintaining this abdominal position, take smaller inhalations, quickly exhaling and pulling the abdominal muscles toward the spine with each exhalation. Repeat for up to two minutes, performing this exercise for a total of about 10 minutes a day (accumulated over several “sessions” per day).
- Once the basic technique is mastered, urge your clients to practice it in other positions: sitting, standing and on all fours.
Thakkar also likes wall squats with the adductor ball squeeze. “These are great, because hip extension and gluteal strength are keys to helping with diastasis recti. This is due to a change in mechanics in the last trimester, which causes excessive abdominal pull. Pelvic tilts in standing help to reorient the spine and works with the transverse abdominis in diastasis recti.”
Use Caution
Many exercises are just too advanced and intense and should be avoided during the first 10 to 12 weeks following a cesarean birth. According to Donoghue, these include crunches, sit-ups, leg raises, planks, running, jumping, step-ups, overhead presses and heavily weighted exercises.
“Heavy lifting is an absolute contraindication until cleared by her physician,” urges Thakkar, “but consider lifting nothing heavier than the baby for three to four months.”
“Your client should be making steady, measurable progress in core strength and integrity,” advises Keller. “I typically gather abdominal circumference measurements every three weeks with postpartum clients. They [should] consistently show improvements in both abdominal circumference and waist circumference. They should also experience relief of back pain, steady improvements in pelvic floor function in that they have less or no urine leakage, improved core strength, improved tone and firmness in the abdominal muscles, and global improvements in posture, alignment and core function.”
Note: Measuring for diastsis recti can also be helpful in understanding where a client is in her post–cesarean birth recovery; however, this assessment should be performed by a medical professional.
Keller suggests asking pointed questions if progress stalls or regresses. “Did they stop doing daily [core/TVA exercises]? Are they trying to multitask while doing them? Are they jackknifing out of bed each morning? Did they recently suffer from a cold and go through a series of coughing fits? Did they introduce a new workout or exercise that is injuring the connective tissue they are working to heal?"
Donoghue agrees. “Returning too quickly to exercise without proper guidance can lead to poor biomechanics. This forces a new postpartum body to compensate with other muscle groups and can lead to orthopedic injuries in the future. Just strengthening is sometimes not enough. Having a professional work on proper body alignment and proper biomechanics is essential to prevent further injury.”
Giving birth is a phenomenal feat in and of itself and requires its own healing time. Giving birth via cesarean delivery adds a layer to healing due to the surgical trauma to the body. While you and your client may want to jump right in, it’s critical to go back to the basics and build a strong foundation, as this can help prevent a lifetime of problems later for your female clients.
Expand Your Knowledge
Effective Pre/Postnatal Client Assessment Strategies
In addition to the time and energy constraints in prenatal fitness routines, there can be additional challenges, such as concerns about exercise safety and, for the postpartum client, the need for programs that address conditions like diastasis recti and incontinence. Through this course, you’ll gain knowledge surrounding the challenges the prenatal and postpartum demographic face and develop the skills to conduct appropriate assessments. You’ll also learn how you can improve your screenings and consultations to help more moms adapt to the physiological changes that occur during pregnancy, rebuild strength, and meet the physical demands of motherhood after giving birth.
Oh Baby! Fitness® Pregnancy and Post-partum Exercise Instructor Training
Despite growing demand, there is a dearth of qualified health and fitness professionals who possess the specific knowledge and skill set to lead these crucial pre-and postnatal exercise programs. This training is for those who want to help new and expectant mothers regain strength and confidence, overcome postpartum depression, and forge a stronger bond with their child through the power of physical activity.
Coaching and Training Women
Learn from five industry experts speaking from their unique expertise about the physiological, biomechanical, and behavioral aspects of coaching and training women—a group that accounts for more than 50% of gymgoers, according to the 2020 IHRSA Global Report. Refine your coaching expertise, expand your reach and move your career forward.
by 
