#PTonICE Daily Show – Monday, August 14th, 2023 – Invisible physical scars postpartum

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses three postpartum physical scars that are often invisible to rehab providers. She explores how these scars can impact exercise prescription for clients in the early postpartum period.

Take a listen to learn how to better serve this population of patients & athletes.

If you’re looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don’t forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!


00:00 INTRO

What’s up everybody, we are back with another episode of the PT on Ice Daily Show. Before we jump in, let’s chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you’re looking for an easy way to navigate payments, here’s what we recommend. Head over to jane.app slash payments, book a one on one demo with a member of Jane support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports like memberships with the option to automatically invoice and process your membership payments online. If you know you’re ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one month grace period while you settle in. Once you’re in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything, they offer unlimited support and are always happy to jump in. Thanks, everybody. Enjoy today’s show.



Welcome to the PT on ICE Daily Show. Dr. April Dominic here. I am your host representing the ICE Pelvic Division. Today we’ll focus on three postpartum physical scars that are often invisible to the rehab provider. We’ll talk about how these scars can affect exercise prescription when it comes to working with a client who is early postpartum. But before we dive into that, let’s chat about all things, updates and course offerings for the ICE Pelvic Division. If you’re looking for a virtual option to learn all things fitness, athlete, pregnancy Our next Level 1 online cohorts starts September 5th. Otherwise, you can catch us on the road. We’ve got tons of courses coming up for this fall. And our next one is September 23rd and 24th in Scottsdale, Arizona. This is going to be with the lovely Dr. Alexis Morgan and Dr. Rachel Moore. This course is chock full of literature outlining the ins and outs of pelvic floor basics, pelvic floor dysfunction, the assessment for the pregnant or postpartum fitness athlete that includes an external exam or an internal exam option. We also have a lot of super fun labs that are going to cover core and c-section management. We also have tons of labs on reintroducing or continuing to use the barbell, do rig work and endurance exercise. Please go hop on PTONICE.com. Get yourself in one of our courses. We would love to see you there virtually or in person.


Today I wanted to hop on and shed some light on physical scars that a postpartum body endures early on. These scars aren’t always visible or front of mind for the rehab provider. So think about it like this. You may have someone who is coming in very early postpartum due to some sort of orthopedic injury like for their hip, their shoulder, maybe their back, or they may be coming in for core and pelvic floor work. So it’s important for all of us to be aware of these scars as they heal and the role that they play early postpartum with movement and exercise prescription. So when someone is pregnant, there is usually some sort of baby bump or something that is a visible reminder to others of their condition that they are pregnant. Enter the postpartum period. For many postpartum folks, those visible reminders of pregnancy fade and the physical impact the labor and delivery on the body are invisible to others. When someone is postpartum, there’s no physical sign that they and their body have gone through this incredibly challenging feat. There’s no cast for like when we have for a broken bone. There’s no crutches for that ankle sprain. There’s no sling to support the wounds. Unless maybe they have their newborn with them, there’s really no obvious physical sign that someone is recovering postpartum. So three invisible scars that we’ll chat about today are the uterine scar, the perineal scar, and the lower abdominal scar from a cesarean section. Let’s circle back to wound care from school. Remember for our healing stages, our tissue healing goes through four major stages. Starting with the first couple, the hemostasis and inflammatory stages. This is going to be a period of local swelling. Next, the proliferative stage. And that’s going to be the stage focusing on covering and filling the wound. And then the remodeling stage is characterized by scar tissue formation, which this can last for a year or two, if not. So let’s unpack those three major postpartum scars. The first, the uterine scar. I feel like this is the most invisible. It’s as the name indicates, a wound on the uterus. And in terms of time to heal, the uterus typically involutes or returns back to its pre-pregnancy size that’s smaller by six weeks. And muscles that may be impacted by this scar, by this wound on the uterus, would be indirectly the pelvic floor and the abdominals. In terms of considerations to return to movement when we’re thinking about uterine healing, if someone does some physical activity and there is an increase in vaginal bleeding, then that is going to be a sign for regression that the uterus and body may not be ready for that specific intensity level of physical activity or the duration of physical activity.


Our second scar is the perineal scar. In terms of where it is, it is on the perineum. And the perineum is the tissue that’s between the vaginal opening and the anal opening. A perineal scar or injury may occur due to a large stretch on the tissue at the vaginal canal as the baby exits through that vaginal canal. In terms of time to heal, a majority of the stitches are dissolved by about two to four weeks. So there are two ways to tear the perineum. And that’s either naturally or via an episiotomy. And that’s going to be when the provider actually makes a cut in that perineal tissue. In terms of levels of severity of the perineal tear, there are four. The first degree is the licevier. It’s small, skin deep. The second degree is going to involve the muscles of the perineum. The third degree is going to be a tear of the external anal sphincter. And that is what we use to keep poo in or keep poop out, like allow for defecation. And then the fourth degree tear is going to be the most severe. And that’s going to be a tear that likely involves the internal anal sphincter, the external anal sphincter, and the rectal mucosa. One time I was talking to a group of OBs and one of them said, you know, we were talking about perineal tears. And one of them said, you know, the vagina is just simply remarkable. It gets to heal in real quick and nobody F’s with that vaginal tissue. So that is the one good thing about perineal tears is that the vagina takes care of business. So muscles that are impacted by the perineal tear, the pelvic floor. And then when we’re thinking about return to movement with someone with a perineal scar, movements that are wide-legged, like maybe a sumo squat or lateral lunge or really deep squat, there may be some discomfort at that perineum due to that stretch on the tissue in those wide positions.


And then we have our C-section scar. So where is it? I’ll talk about the most common cut that is done is called the bikini cut. And then it’s about four to five inches long and it’s stretched across the lower abdominals. In terms of time to heal, that’s going to depend on various factors. But some scars start to close at the skin level as early as two weeks. And then we know by six weeks, generally speaking, the scar is fully healed if there are no complications. And that’s about the same timeline that someone is likely returning back to their provider. Some complications with scarring may be hypertrophic scarring or keloid scarring. And the keloid scar is going to be when the body over heals and the scar tissue extends beyond the original boundaries of the wound. So we want to make sure that we are referring them back to their provider if that is the case, if we happen to see that scar on the client. We know that around six weeks, abdominal tissue has only regained about 50 percent of its tensile strength. And by six to seven months, it’s approximately in the 75 percent range of its tensile strength pre-incision. And muscles that are impacted by this scar, the C-section scar, are going to be our abdominal group. So the rectus abdominis, internal-external obliques, and the transverse abdominis.


In terms of considerations for return back to exercise specifically for a C-section scar, we’re thinking we got to watch for that core heavy work, any sort of rig or gymnastics-based movements, or any lifting that may involve some sort of contact at the lower abdomen. So those are the scars. Now let’s talk about two movement categories more in depth that may be affected by those scars. We have the return to exercise and then return to intimacy, which we’ll dive into. So in terms of movement early postpartum, when dosed appropriately, it can assist in so many areas of recovery. We’re talking reduction in postpartum depression risk or reduction in risk of blood clot, promoting tissue healing, promoting getting better sleep. That’s just to name a few of why movement is important early postpartum. But when it comes to exercise, variables such as sleep and fuel not only influence the risk of injury and recovery, but they also directly relate to the energy status needed to participate in exercise. So sleep, we should be getting nosy and ask about sleep status. Be realistic and recognize that you’re talking to a person with a newborn. So their sleep is going to look a little different given the newborn schedule. But we do want to make sure that the client in front of us is optimizing their sleep. Are they creating the best environment? Is it a cool environment? Can they make everything dark? Can they talk with our partner and be like, hey, I need this chunk of time for sleeping. Can you handle the baby while I do this? And then maybe they switch. In terms of fueling, are they able to nourish themselves with nutrient dense packed meals that are full of protein, packed with plants, reduced processed sugars that have sufficient calories, especially caloric intake is important, especially if someone is breastfeeding. They’ll need about 400 to 500 extra calories. Okay, let’s talk about return to exercise. Generally speaking, when we’re talking about return to exercise for someone who’s early postpartum, it’s a great idea to start somewhere close to where they left off at the end of pregnancy and then build tolerance from there. Early postpartum, that’s a time to determine the body’s capacity for tolerating exercise. As a provider, it’s helpful to have a conversation with our clients about ways we can manipulate exercise dosage to meet their current needs of their current physical status. These modifications are temporary. This is something that we want to communicate with them. We want to educate them on signs for regression with, hey, they did a certain workout or did certain exercise and then, hey, they experienced some leakage of urine or fecal matter. They had some pain or increased abdominal discomfort or vaginal heaviness. So we want them to communicate this to us so that we can then show them how we can alter a workout if needed through load, through adding rest intervals, maybe modifying the intensity or changing the volume and duration. That way they can still continue exercise without symptoms. So now let’s talk about scar types and different types of exercise such as core, impact, or lifting. So during the early days and weeks postpartum, walking, reconnection with the core, the pelvic floor, and breathing is a really great place to start. This is going to be when we are starting to add in a little bit more after the first early days or a couple weeks. So with core-centric movements, as we move towards adding more intensity or load, we want to ensure that that abdominal incision is healed to avoid dehiscence. We can begin to experiment with its tolerance, with the anterior abdominal core walls tolerance to stretch in all planes, specifically going into extension, flexion, side bending both ways, rotation, a combination of all those movements. We want to be mindful of tolerance to pressure on the scar, whether that’s pressure from simply just the workout clothes, or maybe they are baby wearing while they work out and they have some irritation there at the abdomen. Or maybe it’s increased pressure at the abdomen from a set of dumbbells when they’re doing a hip thruster, or when they slam down onto the floor with a burpee, or the rig or barbell making contact with the abdomen during gymnastics movements or lifts. With return to impact exercise, such as walking, running, or jumping, we want to be mindful that someone with a vaginal delivery and significant perineal tearing could experience an increase in their pelvic floor symptoms. Remember symptoms reported may be heaviness, vaginal bleeding from the uterine scar, or irritation of their perineum. And someone with a C-section could also experience these as well, but we’re thinking that it may be more common with someone with a vaginal delivery or more likely to happen. So with return to impact, we’re going to find their guidepost in terms of how much impact their body can tolerate, whether it’s starting with a walk around the block, then adding a few more blocks each day, or if it is explosive calf raises, single unders, or step ups. And then for return to lifting, maybe we start with a PVC pipe, or a light kettlebell, or a barbell only movement. This is going to allow the client to re-familiarize themselves with the movement pattern, say of a clean or any sort of overhead press, and then they will be simultaneously building tolerance and in ranges of motion and load at their perineum and abdomen, where some of their scars may be. So return to any exercise will be person dependent, but knowing their history, mode of delivery, current symptoms, and scar status can help you guide them. And bonus, maybe this is a time that they slow down and dial in on foundational pieces of complex lifts or impact training.


Besides return to exercise, we also have a different return to movement, and that is return to intimacy, specifically penetrative intercourse. Once cleared by their providers, return to penetrative intercourse, the postpartum person may run into difficulty tolerating that vaginal penetration. This could be from a finger, a toy, or a partner student, Natalia. So it’s estimated that 43% of women report pain with intercourse in that first six months early postpartum. And this is something major that we should be thinking about when someone is maybe sharing with us things that are going on with penetrative intercourse for them. A C-section or perineal tear can contribute to painful intercourse. There’s a greater risk associated with pain with intercourse with an episiotomy versus a natural perineal tear. Just as we would practice scar desensitization in any other part of the body, we’re going to do the same here at the vagina. And a pelvic PT is going to be really great in assisting and making recommendations for internal massage, stretching, or using a dilator set. So let’s recap. Today we talked about three main scars that a postpartum person may have. A uterine scar, a perineal scar, or an abdominal scar from a C-section. Remember to respect these healing timelines. They will be unique to each person. The next time you have a client who’s early postpartum on your schedule, encourage them to start small. Go slow for returning to exercise and intimacy. Educate them on progressive overload and how that may not be a straight line for them. Maybe a series of peaks and valleys that are impacted by external factors such as sleep, fuel their body’s current physical capacity. Communicate with them. Get curious about their invisible physical scars as they may not feel comfortable telling you and offering you that information that, Oh, they have pain at their vagina at the bottom of a deep squat or their abdominal incision site is really bothering them when they’re doing a hollow hold or hanging from the bar. So they will no doubt be thankful if their provider considers these scars, asks about them, and because they’re not often discussed. So thanks for tuning in, everyone. I hope you gain some awareness of these physical invisible scars that a postpartum person may be dealing with. Next episode, I’ll be discussing the emotional invisible scars in the postpartum period. Cheers y’all.

20:28 OUTRO

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. And be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ICE content on a weekly basis while earning CU’s from home, check out our virtual ICE online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.