C Section and vaginal deliveries and the impact on tissues of the body

May was the Post Natal module inside the mentorship program so what better way then to carry on with the theme and share with you a paper dedicated to C section deliveries.

 

Paper details – Effects of Cesarean Section and Vaginal Delivery on Abdominal Muscles and Fasciae – PMC (nih.gov) – Fan C, Guidolin D, Ragazzo S, Fede C, Pirri C, Gaudreault N, Porzionato A, Macchi V, De Caro R, Stecco C. Effects of Cesarean Section and Vaginal Delivery on Abdominal Muscles and Fasciae. Medicina 2020;56 (260)

 

The purpose of the study was to determine whether abdominal muscles and fascia differ in women depending on if they have had a C section (CS) delivery or vaginal delivery. They wanted to understand more about how fasciae responds to different delivery modes and how these alterations may relate to scar pain (SP), abdominal pain (AP), low back pain (LBP) and pelvic pain (PP).

 

Let’s dive into the nitty gritty of the study:

 

• • They recruited 13 nulliparous women, 13 women who delivered via CS and 10 via vaginal delivery (VA)

• • Women who had given birth had to be at least 2 years post delivery, only had 1 child, had not taken part in any rehabilitation program, not having any abdominal surgery or experienced any trauma in the postpartum period.

• • All participants underwent ultrasound imaging to evaluate the abdominal muscles and related fasciae in a supine position. Examiners measured:

     

    • • The linea alba – 2 cm above the navel button measuring the thickness of the LA and the inter-recti distance
    • • Rectus abdominis – at the level of the navel measuring the thickness of RA, anterior fascia of rectus sheath, posterior fascia of rectus sheath and loose connective tissue between sublayers of the posterior rectus sheath.
    • • Axillary line – At the level of the navel on the lateral surface of the torso. Measuring thickness of the external oblique, internal oblique, transverse abdominis, total abdominal muscles, fasciae between EO and IO, fasciae between OI and TA, posterior fascia of TA and abdominal perimuscular fasciae

** If some of those tissues are unfamiliar to you, don’t worry I actually had to google a few of them.

 

• • CS and VA women then completed a questionnaire about pain. They were asked:

     

    • • To rate pain according to a visual analog scale (1-10)

         

        • • on the scar
        • • in the areas of the the abdominal wall
        • • the lower back
        • • the pelvic floor

    • • How long the pain lasted after CS and VA (options were less than 1 month, 1-3 months and more than 6 months).

 

What did this study find?

In regard to muscle measures:

 

• • RA was significantly thinner on the left side in CS women and on both sides in VA women compared to nulliparous women

• • RA in VA women was significantly different between the right and left sides

• • Left TAM (total abdominal muscle – EO + IOP + TA) was thinner in VA women compared to nulliparous women mainly due to left internal oblique

• • Right internal oblique in CS subjects was significantly thicker compared to VA women

• IO in CS women presented with significant differences between the left and right sides.

In regard to fascial measures:

 

• • CS women had a wider inter recti distance compared to nulliparous women

• • No difference between the 3 groups in regard to thickness of the linea alba

• • Looking at Rectus sheath

     

    • • CS women had significantly thicker right rectus sheath compared to nulliparous women
    • • Loose connective tissue between sublayer of the posterior rectus sheath on the right and left sides in CS women were significantly thicker than the VA women

• Left and right sides of abdominal perimuscular fascia was significantly thicker in CS women compared to the nulliparous women and the VA women.

What about pain outcomes:

 

• • For CS women

     

    • • 100% complained of scar pain (15% mild rating, 54% moderate rating and 31% sever rating)

         

        • • 5/13 women reported pain for less than 1 month
        • • 4/13 reported pain between 1-3 months
        • • 4/13 reported pain more than 6 months

    • • 12/13 women suffered from abdominal pain that was widespread across the abdominal wall and even at sites distant to the c-section incision site (13% mild rating, 46% moderate rating, 15% sever rating)

         

        • • 69% experience this pain for less than 1 month
        • • 15% experience this pain for 1-3 months
        • • 8% (1 subject) experienced this for longer than 6 months

    • • 10/13 women complaint of LBP (31% mild rating, 38% moderate rating, 8% severe rating)

         

        • • 5/13 experienced pain for less than 1 month
        • • 3/13 experienced pain for 1-3 months
        • • 2/13 experienced pain for longer than 6 months

    • • Pelvic pain was defined as feeling pain in the lower abdomen and the perineal or genital area of which 8/13 suffered from this (5 rated as mild, 3 moderate)

         

        • • 6 of them experienced pain for less than 1 month
        • • 1 experienced pain between 1-3 months
        • • 1 experienced pain for longer than 6 months

• • For VA women

 

• • • Only 1 woman complained of pelvic pain in moderate form for 1 week, the others had no pain
  •  

What were the correlations between abdominal thickness of the affected abdominal muscles and fasciae and clinical measures?

 

• • The duration of scar pain correlated moderately with inter recti distance

• • The duration of abdominal pain correlated moderately with R and L side rectus sheath thickness as well as left loose connective tissue between sublayers of the P-RS

• • The duration of low back pain correlated moderately with right rectus sheath and left abdominal perimuscular fascia

• • There were no significant correlations between the thickness of the affected abdominal muscles and fascia and pain intensity.

 

WOW… that is a lot of random results and when I read it out loud it felt a bit confusing and somewhat pointless from an exercise perspective.

So how can we apply this clinically? 

 

There are 4 key takeaways for me:

 

• • The abdominal wall and tissues can be impacted differently between the left and right sides of the body. We see in this paper that significant dyssymetry between the same tissues on the left and right sides of the body in quite a few measures. This becomes really important when we are rehabbing the abdominal wall, healing DRAM, resolving one sided pelvic floor tightness and even dealing with one sided low back or hip pain. We need to bring as much symmetry to muscular strength and function to both sides of the body to get the best outcomes for our clients.

• • C-section deliveries impact both the muscles and the fascial tissues whereas the VA deliveries seemed to only show alterations in muscles. When we are helping clients recover from C section deliveries we have to consider how the scar has impacted the function of fascia. It is important for fascial layers to slide well over each other and the presence of scar tissue adhesions or tightness in the area may impact this. When I am teaching women core retraining and they struggle with connecting to the TA muscle the first thing we look at is any abdominal scar (C section or incisions from major surgery). Mobilising this and encouraging more fascial gliding really helps muscle function in these women.

• • The abdominal wall muscles are all impacted differently. RA and IO showed the most changes in this paper which means we might need to look at specific core exercises that target these muscles groups more than the others. Obviously you need to assess this, but good to keep in mind that specificity in programming could be key

• CS women experience more pain then VA women that can last anywhere between 1 month and longer than 6 months. CS recovery is not a stock standard timeline and our clients need to know that their body will heal in its own time. We can do lots to foster recovery, but it may take a while and they should not compare their recovery to others.

So there you have it, June research spotlight. A little insight into how muscles and fascia can be affected by delivery types. I hope you found this as interesting as I did and take away something useful for your clinical practice.