Originally published in Massage & Bodywork magazine, September/October 2010. Copyright 2010. Associated Bodywork and Massage Professionals. All rights reserved.
If your client has given birth by Cesarean section (C-section), she has scars that need to heal. The surface scar, unless there are physical complications such as infection, will heal automatically. Deeper scarring, both physical and emotional, may take more work and conscious effort from both you and your client. To recover from a C-section, and to prepare for subsequent pregnancy and birth, your client needs to heal on all levels--from deep-tissue healing to releasing emotions related to the surgery. Your job as a bodyworker is to facilitate and nurture her through this process.Adhesion Formation and Other Post-Surgery Issues
C-sections can save the lives of mothers and babies. During surgery, however, the body registers pain, loss, and outrage at being violated. It tries to protect itself from further injury by setting up involuntary muscle contractions and tension in the injured area. In my massage therapy practice, I have noticed that an area of ticklishness, for instance, in an otherwise non-ticklish person, almost always indicates an unconscious chronic muscle tension. Keeping this internal sentry standing guard can be the cause of a secondary pain, which may even outlast the original cause.
Chronic pain may also indicate the formation of adhesions after surgery. Adhesions are bands of scar tissue that can distort anatomy and glue together organs and tissues that are normally separate. An important clue that adhesions have formed may be the appearance of an external scar. Tissues glued together cause an uneven look, as the top layer of skin is pulled down toward deeper tissue layers.
Adhesion formation is extremely common for post-surgical patients. The Women's Surgery Group and other researchers estimate that adhesions can form in 55-100 percent of patients who have had gynecological surgery involving the uterus, fallopian tubes, or ovaries (including C-section).1
For the C-section client, other issues may arise in addition to chronic abdominal pain, including pain during intercourse (dyspareunia), bowel obstruction, and infertility (caused by the fallopian tubes being kinked, distorted, or blocked by adhesions). Subsequent surgeries, including repeat C-sections, are more complicated due to adhesions and can take longer and be more difficult to perform. Release Adhesions With Massage
While surgery for "lysis of adhesions" (adhesion removal) is commonly performed, resulting in 303,000 U.S. hospitalizations in one year alone at a cost of $1.3 billion,2
adhesions can re-form as much as 80 percent of the time, and additional adhesions can form as a direct result of the surgery meant to release them.
Certain massage techniques, however, such as Bindegewebsmassage, neuromuscular therapy, Rolfing, specific postpartum massage therapies, and deep tissue sculpting, can limit the formation of adhesions and scar tissue in new injuries and can reduce scar tissue, or make it more pliable, at old injury sites.
As soon after surgery as the client's surgeon approves it, delicate massage and thermal therapy using the body heat from your hands can increase circulation and therefore reduce ischemia to the injured tissues. This type of massage can also discourage the formation of thick hypertrophic scars and adhesions, drain injured tissues of the build-up of excess fluid caused by the surgery, and help reestablish lymphatic flow. With her doctor's permission, the client can begin the process even earlier by using her own (clean) hands to gently touch her incision and provide thermal stimulation.
The client can apply circular massage strokes to the abdomen in a clockwise direction to help reestablish the flow of the intestines and stimulate organ function. After about two weeks, gentle vibration of the skin over the incision, progressing to deeper pressure as healing occurs, can stimulate nerves and help relieve any numbness. Tissue stretching can begin after about six weeks to encourage movement and to loosen existing adhesions. Abdominal trigger points, or irritable spots which make the muscles prone to spasm, should be located by a bodyworker and extinguished with appropriate techniques.The Massage Protocol
When working with post-Cesarean clients, massage therapists and bodyworkers should remember to work only within their expertise. Concern for the safety of your client should be foremost in your mind.
When arranging an appointment with a new client, determine at the very first phone call if she is postpartum, and find out how many weeks. A note of caution--if her baby has died, she may not think of herself as postpartum, even if she is post-Cesarean, so be sure to ask about recent pregnancies and/or births.
I will work with a woman as soon as 24 hours after delivery, if she had a vaginal birth with no complications. If there were any complications, or if the birth was by Cesarean, I will work with her only if she brings a release from her OB-GYN authorizing massage therapy, or after she has been released from the surgeon's care after her six-week postpartum visit. I have a standardized release form that I send to her doctor, advising him or her of the work that I plan to do and asking for a list of any limitations or precautions they want me to follow.
What if you walk into the room to begin a massage session with a client, and you find out that she is not only postpartum, but also less than six weeks post-Cesarean? Consider carefully whether or not to continue the session. If you decide, for whatever reason, to work with her, be as safe as possible. Many of the concerns and precautions applicable to pregnancy massage will still apply for up to 8-12 weeks into the postpartum period.The Emotional Scars
During and after the surgery, physical damage reports flood the nervous system. As a surgical nurse, I've noticed that even while totally anesthetized, a patient's heart rate and/or blood pressure can go up in response to certain aspects of the surgery. Unconscious psychological controls can be activated, potentially producing anxiety, jumpiness, a lowered pain threshold, even a subconscious feeling of betrayal and anger at the person(s) who caused the experience.
Emotions may not be rational, but are valid. They can't be explained or justified; they just are. As a massage therapist, I've noticed that a medically necessary, planned C-section which resulted in a beautiful, healthy child, may still bring about emotional turmoil, and that turmoil may be present whether or not the woman links it to her surgical experience.
Long after visible scars are healed, she may still feel emotionally overwhelmed by details and obligations. She may distance herself from other people, from herself, or from her experience. She may not be aware of, or allow herself to feel, her emotions, instead storing them in her body. As she remains busy dealing with her ongoing life and caring for her new baby, this client may never make time for the emotional healing she may not even be aware she needs.
Until she finds a place where she can feel safe enough to release both the stored emotions and the muscle contractions with which her body is protecting itself, she may continue to physically and emotionally guard the areas where pain has lodged itself. A non-judgmental bodyworker offers a safe place for her to experience positive touch, to develop awareness of her charged areas, and to reconnect with her body and emotions. More Than Just A Rub
It's clear that, just as surgery involves more than the physical body, massage is more than just rubbing oil onto someone's skin. Touching connects to the brain's emotional centers. Massage therapy can be empowering, reaching not just the body but also affecting the client's self-image. As she gradually becomes aware of feelings stored in her body, maybe in the form of ticklishness, TMJ or jaw pain, lower back achiness, a rigid neck, or tight shoulders, the client can begin to use this awareness in her healing process. Once she acknowledges her feelings, she can take the energy she's been using to block them, and use it instead to guide their release.
Like her new baby, a post C-section mother needs to be cradled. Her surgeon and other caregivers usually don't have the training or the time to work with her the way you, a bodyworker, can. Although it is not your job, nor within your scope of practice to provide psychological counseling, you can support her and give her safe space for when she wants to cry or express emotion, and help her feel at home again in her post-surgery body. Releasing deeply ingrained emotional patterns and extreme negative self-images may require the help of a psychological counselor, to which you can refer. For a woman who wants to attempt a subsequent vaginal birth, this release can be a vital part of recovery. In some cases, psychological counseling from a postpartum specialist may be appropriate.
From my experience, labors following a previous C-section can slow or stop at the point where the Cesarean was performed, as old thoughts and emotional patterns surface. The more deeply hidden the issues are, the more difficult they may be to resolve. If a woman hasn't dealt with them before her next labor, she'll likely have to deal with them again in the middle of it.
From adhesions causing chronic pain and infertility to repressed emotions and self-image issues, the deeper scars that can follow a C-section need to be healed. Complete healing is possible if this client allows herself to seek and accept appropriate care. I encourage you to work with her and support her in her search for it. Melody Cook, RNFA, BS, LMT, CNOR, is an operating room nurse and an RN first assistant at surgery. Since 1989, Cook has been a Texas-registered massage therapist, specializing and certified in prenatal/postpartum massage therapy, and is also a certified infant massage instructor. She developed a "Supporting Birth Through Massage" class to teach birth partners massage and bodywork techniques for use during labor, which she teaches privately and to labor and delivery nurses, midwives, and doulas. For more information, visit her website at www.ccx.net/massage.Notes1. Women's Surgery Group, "Adhesions." Available at www.womenssurgerygroup.com/conditions/adhesions/overview.asp (accessed July 2010).
2. N.F. Ray et al., "Abdominal Adhesiolysis: Inpatient Care and Expenditures in the United States in 1994,"
Journal of the American College of Surgeons 186, no. 1 (1998): 1-9.