Medical Disclaimer *Please always follow your OB provider's instructions. This is meant to provide general guidelines and does not take the place of the directions given to you by your doctor*
The arrival of a precious little one (or little ones!) is an extraordinary experience. But let's be real, after a cesarean you and your body are going through a lot. I'm Dr. Sterling, a board-certified OB/GYN and a mom of three, and I’ve seen the full spectrum of experiences in the recovery from cesarean. In this article, I want to chat with you about what to expect while recovering from a cesarean birth, or as some call it, a belly birth. The first thing I want to make clear is– this recovery is much longer than 6 weeks. In my personal and professional experience, recovering from pregnancy and birth often takes at least a year. While I won't be bombarding you with every nitty-gritty detail of this 12+ month recovery process, my goal is to arm you with plenty of useful information to help make those first few weeks just a little easier. So, grab a comfy seat, and let's discuss some of what you can expect in the physical recovery from your cesarean birth.
What to Expect: Immediately After the Cesarean
After your surgery is complete, you (and most likely your baby) will be taken to the postoperative recovery room. Sometimes, your little one may be taken out of the operating room first, either to the NICU if they need more support or to the recovery room to be weighed and measured so they are ready for some skin-to-skin once you arrive. However, most of the time your baby will be yours to hold while you are wheeled out of the operating room and into the recovery room. There you'll spend several hours, and if both you and baby are in good shape, you'll have the wonderful opportunity for some skin-to-skin bonding time. Your caring nurse will keep a watchful eye on your uterus, sometimes performing uterine massage to help prevent excessive bleeding. They'll also monitor your vital signs closely to ensure you're ready to transition to your postpartum room.
You will likely remain in bed for most, if not all, of the first 24 hours after surgery. You may have a catheter inside your bladder draining your urine, so you don’t need to get up to go to the bathroom. This catheter is typically removed once you are able to get out of bed. Your nurse will help you move about, especially the first few times, as many people experience lightheadedness when changing positions in the first few days after birth.
The incision from your surgery is usually covered with bandages for the first 24 hours. Studies show that keeping an occlusive dressing on the surgical wound for 24 hours reduces the risk of infection. Your nurse or doctor will likely remove the dressing themselves.
What you see when the dressing is removed depends on what technique your OB used to close your skin. The two most common ways to close skin incisions after a cesarean are sutures just below the skin (so you don’t see the suture material) or staples. The staples can be metal or absorbable. If you have metal staples, they are typically removed on day 3 after surgery, though we sometimes keep them in for longer. Don’t worry, for most, removing the staples is far less painful than they expect. If the staples are absorbable, they do not need to be removed. Another common component of skin closure are small white strips (called “Steri-Strips”) which are frequently used to reduce tension on the healing skin. Different surgeons have different recommendations for how long they should remain, so make sure to ask your provider when they want you to remove them.
Caring for Your Incision
*Please always follow your OB provider's instructions. These are meant to be general guidelines and do not take the place of the specific directions given to you by your doctor*
Taking care of your incision in the early days is mainly about keeping the area clean and dry. After the first 24 hours you can shower and get the incision wet. It’s okay if soap touches the area but the incision doesn’t need to be cleaned directly with soap. Lather with some gentle soap on your abdomen and let it wash over the area. After showering, make sure the area is dry. If you have some belly that hangs over the incision you may find it helpful to use a hairdryer on a low, cool setting to dry the area. Unless instructed otherwise by your OB, your incision does not need to be covered or bandaged after the first 24 hours. Some use pads, gauze or a soft cloth to protect the area from being irritated by clothing.
Your Healing Abdominal Wall
The skin incision is the part of your surgery you can see, but the other layers of your abdominal wall need to heal as well. It's best to avoid putting any unnecessary tension or strain* on this area, as the primary strength layer, known as the fascia, needs time to heal. Coughing, sneezing, or even laughing might cause discomfort initially. Some find holding a pillow to their belly during these movements helps ease the discomfort, while others benefit from an abdominal binder. Abdominal binders are frequently provided by the hospital. Though they aren’t necessary for recovery, many find they help.
*see below for activity restrictions
After your surgery you will discover that you use your abdominal muscles quite frequently. Getting out of bed and changing positions might require a different technique, similar to late pregnancy, as you'll want to minimize the use of your abdominal muscles. Ask your nurse to teach you how to get out of bed so you get the hang of the technique before going home.
Remember, caring for your abdominal wall is a key part of your recovery, so listen to your body and take it slow while gradually rebuilding your strength. You can also ask your provider about a referral for physical and/or occupational therapy to help your postoperative recovery.
In addition to healing from surgery, your abdominal wall is also healing from pregnancy. During pregnancy your abdominal wall undergoes significant changes to accommodate your growing baby. Those changes took place over the course of many months and so they aren’t going to reverse quickly. Almost everyone will leave the hospital with a bump, although it is typically smaller than the one they arrived with. One reason for the postpartum bump is the separation of the abdominal muscles, known as the rectus abdominis. The separation of these muscles is called rectus diastasis. Over the course of 6 months this separation typically improves, even without intervention. However, there are exercises that can potentially help bring the muscles back together. If you have a significant rectus diastasis your provider may refer you to physical therapy. Keep in mind that you can always ask for this referral and, depending on your insurance and where you live, you may be able to self-refer for physical therapy.
Before you go home your doctor and/or nurse will give you discharge instructions that cover what activities you should avoid while recovering. I’ve included the most common activity restrictions so you can anticipate what your discharge instructions might be. You can also ask your doctor what post-cesarean activity restrictions you can expect prior to your surgery if you know in advance that you will be having a cesarean.
- No lifting >10-15 lbs (if your baby is >10 lbs you can lift baby) for 4-6 weeks.
- Light exercise such as walking as tolerated, avoid moderate or intense exercise until cleared by your physician.
- No driving while on opioid pain medications.
Expectations for Pain Management
Recovering from birth and surgery is painful. Most patients require strong pain medications that contain opioids (such as morphine) during the first few days. After 2 weeks it is unusual for people to have pain strong enough to require opioid pain medication. A percentage of the opioid dose you take will get into your breastmilk, so the general advice for both you and baby is to take the smallest dose at the lowest frequency required to control your pain. Not moving and staying in bed puts you at increased risk of serious complications so the general rule is to control your pain well enough that you are able to get up to the bathroom, get yourself a glass of water and pick up baby. During your hospital stay you will likely be given an NSAID pain medication, such as ibuprofen or ketorolac, either orally or through your IV. Your doctor will likely advise that you continue to take an NSAID for the first few days to weeks at home.
Contrary to popular belief, even those who give birth via cesarean will experience postpartum bleeding for approximately 6 weeks after birth. It's not uncommon to experience heavy bleeding and even pass clots during the first 24 hours. The good news? Your postpartum nurse will be your guiding light during your stay at the hospital, assisting you through this phase. The bleeding during these initial days shares a similar appearance to your regular menstrual flow, albeit with increased volume – this discharge is referred to as "lochia rubra." By day three or four, the discharge transitions to a more pinkish hue, known as "lochia serosa." As you approach the 10 to 14-day mark, the discharge takes on a yellowish or white color, aptly named "lochia alba." Over the next 6 to 8 weeks, you'll notice a gradual decrease in bleeding. If you find that your bleeding gets slightly heavier after increasing your activity level, there's no need for alarm – this is a normal response. However, soaking through more than two pads an hour for over an hour might indicate an issue, and you should promptly contact your OB provider. Late postpartum hemorrhages, heavy bleeding that occurs one to two weeks after giving birth, is experienced by approximately 1% of people recovering from birth.
By the end of pregnancy, your uterus is stretched to around 40 cm in length. Within four weeks it’s about a tenth of that size and by eight weeks it is back to pre-pregnancy size! This is accomplished in part by significant contractions of the uterine muscles. The most intense cramping, known as "afterpains," lasts for approximately three days. These afterpains can be as intense as labor contractions and are typically more pronounced during breastfeeding, triggered by the release of oxytocin from nipple stimulation. This hormone, responsible for uterine contractions, also plays a significant role in mother-baby bonding. Talk to your provider about using ibuprofen and heat pads to help ease the discomfort and pain of uterine cramping.
Hemorrhoids: The Other Type of Unwelcome Visitors
Hemorrhoids, those pesky swollen blood vessels around your anus and inside your rectum, often become more pronounced after childbirth. While time generally aids their resolution, you can alleviate discomfort through sitz baths and over-the-counter treatments. However, consistently avoiding constipation is key, as straining can exacerbate the issue. Adequate hydration, a diet rich in fiber, and a stool softener, like Colace, can contribute to smoother bathroom experiences. If you have hemorrhoids in pregnancy or in the hospital after giving birth, make sure you discuss this with your provider.
Understanding Pelvic Floor Changes
Pregnancy can have a significant impact on the pelvic floor. If you’ve ever seen a skeleton, you may have noticed that the pelvis is open at the bottom. The pelvic floor is what prevents your organs from falling to the floor. It consists of the muscle and connective tissue that forms a basket-like support for your vagina, uterus, bladder, and intestines. During pregnancy the pelvic floor muscles and connective tissues are stretched and sometimes injured. While your pelvic floor is healing you may experience urinary incontinence (peeing when you don’t want to), difficulty emptying your bladder, pain, and difficulty with bowel movements, and/or the sensation that something is falling out of your vagina. These sensations should slowly improve over the course of weeks to months. If you are still experiencing discomfort or incontinence at 6 weeks this needs to be addressed and discussed with your OB provider. Pelvic floor therapy is an invaluable resource for addressing these concerns and should ideally be accessible to all postpartum individuals.
A Note About Breastfeeding
While the breastfeeding expectations are beyond the scope of this article, I do want to mention that mature milk production (what comes after colostrum) can be delayed in those who give birth via cesarean. It’s a good idea to bring a hands-free pumping bra in your hospital bag as the pump is often used to help stimulate milk production. It’s not uncommon to need continued support for feeding (whether breast, bottle, or both) once you bring baby home. Ask your nurse and doctor about what support is available to you for feeding once you leave the hospital and who you should call if you have an issue or questions.
Red Flags of Recovery
Recovering from birth can be challenging even when everything is “normal.” While the vast majority of people who have a cesarean section recover without complications, this major surgery does place you at a higher risk for a postoperative or postpartum complication. If you experience any of these symptoms or are otherwise wondering “Is this normal?” contact your OB provider or head to the ER right away. In some instances, they may advise you to return to Labor & Delivery Triage for evaluation.
- Heavy bleeding: We often say to return to the hospital if you are bleeding enough to saturate 2 pads in an hour. Make sure you find out from your doctor how much bleeding is too much. Depending on your unique characteristics, your doctor may want you to be more cautious.
- Shortness of breath: This is not a normal symptom in the postpartum period and could signal a blood clot in your lungs or a problem with your heart.
- Fever (T >100.4 F or 38 C): There are numerous reasons you may have a fever in the postpartum period, some of them are no big deal and others are very serious. It is not up to you to determine the seriousness of your fever— that is the job of a trained medical professional. All fevers in the postpartum period warrant a phone call to your provider or a trip to the hospital.
- Headache not relieved by over-the-counter medications such as acetaminophen or ibuprofen: This could be the sign of high blood pressure and warrants medical evaluation. Preeclampsia is a pregnancy related condition that can progress quickly and can be life-threatening. While most cases of preeclampsia are diagnosed in pregnancy, it can also occur postpartum. The good news is that under appropriate medical care we can drastically reduce complications and risks from this condition.
- Change in vision, seeing stars or spots: Another potential symptom of preeclampsia or elevated blood pressure. These symptoms are not normal or expected and need immediate medical evaluation.
- New pain in the upper portion of your abdomen: This is yet another possible sign of a blood pressure issue and warrants immediate medical evaluation.
- Pain and swelling in your leg: This could be a sign of a blood clot. These frequently occur in just one leg making one leg more painful and larger than the other. Blood clots can be life-threatening, particularly if they travel to your lungs.
- Increased pain, swelling, redness, drainage or warmth of vaginal lacerations or hemorrhoids: This may be a sign of an evolving infection. Contact your health care provider right away.
*This list does not cover every possible postpartum complication, please always contact your health care provider should you be concerned about your symptoms.
Embracing the Journey Ahead
As you embark on your postpartum journey, remember that it's a process extending beyond the traditional six-week timeline. You deserve comprehensive support, encompassing physical recovery, emotional well-being, breastfeeding, and newborn care. Sterling Parents is a membership that offers the preparation and support that new mothers often lack in traditional healthcare systems. Your birth and recovery deserve the best care, guidance, and education. Here's to a smooth delivery and a robust start to your postpartum journey. You've got this! This site is intended for informational purposes only and does not provide medical advice. Please consult your physician or other health-care professional.
This site is intended for informational purposes only and does not provide medical advice. Please consult your physician or other health-care professional.