Hello everyone and welcome to the Barbell Mamas podcast.

My name is Christina Frevitt.

I'm a public school physical therapist researcher in exercise and pregnancy, and a mom of the two who have competed in CrossFit, powerlifting, or weightlifting pregnancy, postpartum, or both.

In this podcast, we want to talk about the realities of being a mom who loves to exercise.

Whether you're a recreational exerciser or an athlete, we want to talk about all of the things that we go through as females going into this motherhood journey.

We're going to talk about fertility, pregnancy, and postpartum topics that are relevant to the active individual.

While I am a pelvic floor physical therapist, I am not your pelvic floor physical therapist and know that this podcast does not substitute medical advice.

All right, come along for this journey with us while we navigate motherhood together.

And I can't wait to get to it.

Hello everyone and welcome to the Barval Balmas podcast.

My name is Christina Previtt, and today we are going to be talking about early return and return to exercise post-Caesarean section.

I have been posting about a client of mine, but I've had a couple of clients recently who I have gotten to return early, meaning prior to six weeks, to some amount of exercise in the postpartum period.

So before I get started on this topic, this is an area, and I I've been here before when we start challenging narratives in the pregnancy and postpartum space that tends to be very charged.

So I posted a reel about my client Ashley, who was returning to hanging and gymnastics.

She was just at six weeks, she'd already been lifting.

And I had somebody on Facebook who was like, don't do this, like, check with your doctor, all this kind of thing.

And what she didn't know is that Ashley was checking in with her midwife, and she was checking in with me.

And so we were all kind of in this coordinated care pathway.

And she was doing really great.

But she was saying, like, you know, do bird dogs and like your core needs to get fixed and all these types of things.

And just so you know, I had two C-sections, and so I know I've been here.

And what can happen in pregnancy and postpartum, and I understand why, is that your pregnancy, your labor and delivery, your transition into motherhood, your postpartum recovery, these are such emotional and life-altering journeys, right?

So often people feel blindsided because they kind of knew what they were gonna expect in pregnancy.

Maybe they'd been anticipating a vaginal delivery, had never really been talked to about birth injuries, or never expected that their delivery would end in C-section.

And then there was their post-op recovery, right?

What we see in clinical practice, and my goodness, do we need more research in this space?

I am putting out ideas as a clinician who is in the research trenches and acknowledges the research gaps.

What I see clinically is that post-op recovery after cesarean section is so wildly uh variable.

I have some people who have a really tough time getting out of bed, who are really kind of holding on to their bellies and splinting for weeks after cesarean delivery, where they do need a lot of help in that early postpartum recovery.

And then I have others who have that pain of discomfort, but it is not as significant.

And they feel like, especially if they stay stacked where their ribs are over their pelvis and they're not kind of in flexion or extension, it feels tight for the first week or so, and then it really starts to loosen up and they feel a lot better.

Like there's still, you know, that sharp pain at end range and things like that, but it's not as intense as they thought it would be.

I've had some people who say that early cesarean recovery was a cinch and was easier than their vaginal delivery.

I have had other people that have said that that was the worst experience of their life.

It was so much harder than a vaginal delivery.

I do not want to ever have to do that again.

We don't know right now who's gonna be in the this is really hard.

This is gonna take me a lot of time to recover from camp, and who is in the this is easier to handle camp.

If I had to guess, I would say that there's probably some sort of protective factor of maintaining strength in the lower body and core wall so that it takes more for that incision to be placed under strain after surgery.

And we're seeing this in other areas around building resiliency around the muscles that are about to go into surgery so that post-op recovery feels a little bit easier.

So if I had to guess, those with a bit more strength in their core wall may, again, I'm saying may, or there may be a stacking of the deck, a relative risk change in those humans.

I think the psychological aspect of going into a C-section is probably also going to be a predictive factor of was this something that I was expecting?

Was this something that was traumatic?

How do I feel about my birth?

What was my baby's health upon caesarean section?

All of those mental health pieces can create a uh sensitization around your scar that is very real.

So I think that may be a factor uh and an influencing factor.

And then when we are thinking about recovery, obviously there's going to be like surgical considerations where I am seeing in Ontario, we are seeing a lot more people on the skin use glue for their incisions rather than using um sutures.

I've had some people say that they're still using staples, which I didn't think that very many people were still doing that.

But I have seen a lot easier recovery on the skin incision when um our hospital network went to a glue-based incision on the skin on that horizontal scar.

Those are gonna be my guesses.

We definitely still need to do some work in understanding why there's so much variability.

But I just saw a study that came out of Ireland that said that we've been acknowledging how we have likely an elevated cesarean section rate.

And instead of C-section rates going down in four major hospitals in Ireland, they actually went up from 31 to 35%.

So we know that a lot of birth stories, one and three, end in cesarean section, and we know now that there's a huge amount of variability.

If you all have followed me online, what I have been trying to do, especially recently, is in the background of complications or adverse outcomes.

A lot of people, you know, surgical needing a C-section is considered in some cases an adverse outcome, like the goal was vaginal delivery, and now we're having surgical management.

But when we are looking in the background of those considerations, complications in pregnancy and surgical management, most often the knee-jerk reaction is to restrict exercise, right?

Because there's a higher risk associated with the complication.

And therefore, a lot of times our mindset is to freeze.

What that freezing and what that response from medicine, understand why it's there, but what naturally happens is that there is a fear around moving the body.

Where I am coming from, and my research team is coming from a lot of times as we start to try and poke holes in this argument, and this is true in pregnancy complications and in cesarean section recovery, is that the presence of complications often also have an increase in inflammatory cytokines, like for example, in things like gestational diabetes and uh hypertensive conditions of pregnancy, and in the stress from a surgical intervention, right, with a C-section.

What we know is that exercise is a very potent anti-inflammatory stimulus, and blood flow to that area may actually be helpful.

What people will say to me is, what is the point?

It's not worth the risk of returning to exercise early post-caesarean section.

But I think that's the wrong question, or it could be the wrong question.

Instead of saying, What's the point?

Like I can wait, what if the narrative is, what if this actually helps you recover faster?

What if this actually reduces the risk of this complication getting worse or helps prevent this complication from getting worse in pregnancy?

What if the answer was the exact opposite of what we were trying to do?

Where when we bubble wrap humans, that we can actually make it worse because we know that sedentary behavior and low physical activity are huge risk factors for our health in other scenarios.

But it's so interesting that in pregnancy and postpartum, um, our research team and Margie, for a lot longer than me, has been fighting this narrative for a really long time.

So, in that early post-Caesarean section component, what I think really highlights this well is that we had a newer study come out that was looking at rates of post-operative complications.

When we look at AC section, AC section is a major abdominal surgery.

They go through seven different layers of fascia and um, you know, adipose tissue, butyan, wall, skin, etc.

And that means that our body needs to recover from that very big stress that was incurred on the body.

If you have any other surgery, heart surgery, knee replacement, urogenital surgery, et cetera, most often you are getting up, if not doing a little bit of walking around the day of the surgery.

And so we have data that those who walk around more on the maternity ward post-Caesarean section do better, have lower rates of postoperative complications like blood clots, DBT, than those that move around less.

And so that makes sense.

It's in line with all of our other surgical considerations.

Then once we get out of that very acute post-op phase, we need to think about what our return to movement and return to exercise considerations are post-aesarean section.

On the barbell mamas, we posted a framework based on last week's video of me talking through a framework of a person with a relatively uncomplicated vaginal delivery, though, even with more complications, I kind of have have gone through this framework as well of early return to movement starting from about two weeks post up or two weeks post-delivery.

And inevitably, what the question was that came up from that is what about after C-section?

And the way I responded was that my differences in what I do are not actually that different.

And so I want to take a little bit more time to kind of explain some of those thought processes and what I would do if I was working with you and returning to exercise early postpartum was something that was really important to you.

So, kind of all this to say, and I I want to give this disclaimer, is that everybody is going to be different.

I also challenge that sometimes I believe that our restrictive protocols are more likely to increase sensitivity and pain around that incision when we are so scared to move our bodies.

Not to not listen to our bodies, but the way that you are talked to about your incision, et cetera, I think matters.

I I get I'm trying not to go on a tangent, but like when we think about post-pelvic surgery, for example, we have restrictive blanket guidelines that are often said nothing in the vagina for six weeks, don't do any lifting over 10 to 15 pounds.

And this can be true for midurethral slings or other mesh surgeries for prolapse.

When we look at where those guidelines are coming from, our physicians acknowledge that they know that these are not based on evidence, and it is largely based on the culture and the environment at which that doctor is practicing.

Right?

Either my attending said this way, we've always kind of done it this way, and we've never really thought to question it.

Now come to 2025, and we have systematic review-level evidence that giving liberal restrictions after pelvic surgery, which is nothing in the vagina for six weeks, but here are the symptoms to look out for and return to activity based on how you are feeling, compared to that restrictive blanket protocol.

When we compare those two groups, the liberal restriction group, where you can kind of understand what you're looking out for, but return based on how you are feeling, not only is there no increase in adverse outcomes or complications post-operatively, but those groups do better and their resultant pelvic floor dysfunction is lower than in our blanket restriction group.

I think this is gonna be so true post-Caesarean section, right?

Where when we have this liberal group of here's what we need to look out for, here's what I want you to start rehabbing, when, how, and at what volume you rehab that is going to be very individual to you, but it's important for you to listen to your body.

I'm gonna help you understand what to listen for.

I think that's gonna lead to better outcomes because we're not 100% here anymore, but you know, I have had clients that have friends of theirs who they delivered a 11 or 12 pound baby, their lifting restriction was 10 pounds, and the doctor said, don't lift the baby or have somebody hand the baby to you.

But her partner was going back to work.

So that didn't, that didn't actually make sense for the context at which she was living.

There are still a lot of restrictions around driving, and your newborn has their two-week appointment.

Again, you don't have a person at home to drive you to that appointment, it doesn't make sense, right?

And some people are gonna have a hard time reacting quickly with driving or turning to take a look at blind spots, etc., and others are not.

So when we kind of ease off the blanket statements and lean into that, here's what I need you to look out for, here's how your recovery process is gonna look.

And then you fill in your timelines based on how you're feeling, I think that's gonna lead to much better outcomes and much better satisfaction from um from a maternal health perspective.

And so lots of, I've kind of got a lot of different directions on this already.

Um, but this is why I love the long form podcast, because I think all of this background information is super relevant to where we're going now.

So I have talked a lot about how I really enjoy, and it is perfect for me if I get to see you at two weeks postpartum.

When I am working with someone post-Caesarean section, um, that two-week postpartum visit is a really great time to start one, looking at your C-section scar, two, uh start having conversations with you or investigating your thoughts and feelings about that scar being on your body.

When you have a Caesarean section, especially one that you did not want, you were not expecting, and that was very traumatic, the scar on your body can be such a reminder and representation of that day.

And there can be a lot of emotions that come up around that incision.

Understanding what those are, giving you space, time, and sitting with you as you explore those emotions, or giving you homework to explore those emotions can be kind of step one.

Usually I'm also uh I am looking at your scar to see how you are healing, how well you are doing, and what you've done for a movement so far, and what your goals are.

At that visit, I can also understand.

And I if I've been seeing you in your pregnancy, I I probably already know the answers to this, but in that visit, I will be able to understand what your goals are, what your timelines are, how important or how much you feel like you want to prioritize movement and rehabilitation early.

And then we can kind of make a game plan from there.

At that two-week visit, I am teaching bracing and core co-contraction, starting to work on core strengthening in that visit.

I am not afraid of contracting your abdominals with that new scar.

I'm not going through flexion and extension at that two-week visit.

I am oftentimes working on core contraction, like making sure that all of your muscles are working at the same time.

And I am working on resisted ranges, keeping your ribs stacked over your pelvis.

So this is where something like progressing, a dead bug or a bird dog.

I love paleoff presses with light resistance, early post-c-section, working on side plank hip dips, progressing to side plank on knees, hold ditto with planks on knees.

Like those are all things that we can start integrating or bringing in to your exercise routine post-c-section as early as two to four weeks post surgery.

I also love giving green lights.

So much of our communication around exercise in the postpartum period and during pregnancy relates to all the things not to do, which are important parts of the education process.

But I also really enjoy allowing you to have green lights.

Walking is often a conversation in that early postpartum visit.

Love that.

But also doing some strength training and introducing body weight movement or movement with baby is great.

From a resistance training perspective, in my recovery trajectory, sometimes it's actually easier for a person to get back to some heavier loads post-C-section, especially if there wasn't a long trial of pushing before C-section happened than after vaginal delivery, just because of what areas of the body had the most amount of trauma and are healing.

With C-section, if it was a planned C-section or there wasn't a long episode of pushing in that second stage before transitioning to C-section, returning to lifting may be easier, but sometimes the gymnastics piece that requires a lot of stretching or some yoga positions or Pilates position, make positions may be a little bit more challenging because of the range of motion and the control in that range of motion that's required.

So getting a talking about walking, starting early core recovery is a priority in that visit.

And then also I'm giving some freedom of how to move your body.

Usually I'm trying to give things like tabatas or emams, really easy ways to get in a couple of minutes to 10 to 20 minutes of movement in in that early post-op recovery.

In that way, I am also like kind of edging into some intensity.

It's not high intensity by any means, but it's not low intensity either.

Um, and that again, if you are open to that intensity, I'm gonna give that green light to you in a kind of buoyed way.

And if you are not, that's totally fine too.

Fast forward, right?

You've done a little bit of work on that core rehab, then you can start adding in some of that lifting.

For some of my clients, as early as four to five weeks postpartum, they are starting to have that barbell in their hand.

Again, with traditional resistance training, a lot of times that neutral straight line position is very well tolerated by my clients post-C-section.

Because when you're not going into that flexion extension range, you're often not feeling any strain on your incision.

As load increases, you're gonna have this core recruitment that's gonna increase.

But oftentimes that's very well tolerated by my clients.

And so they're not going, you know, crazy high.

But we are starting to put a barbell or some load into their hands if they want to, you know, in that four, five weeks postpartum visit.

When they're at six weeks, when that is when I start to feel a lot more comfortable with moving them through flexion and extension.

Um, that was the reel that I posted this week of my client Ashley, um, who I had doing hanging and beat swings, which is going from an uh extended position to a flexed position, um, and starting to work on some gymnastics-based movements in yoga.

This would be working on getting into Sphinx pose, getting into some of that extension, breathing through those motions and movements, and just starting to add some more intensity um to those movements.

And then depending on how they're feeling, just kind of stacking in intensity, volume, increases in load, whatever aspect of fitness we are working on trying to improve.

When we post some of that, that what can happen from uh a timing perspective, know that there are so many ins and outs around you know what that timeline looks like.

And part of it is recovery, of course.

Like if there's any postpartum, post-operative complications, blood loss is gonna be another one I posted about how blood loss can create an inverse relationship with the number of steps that a person is taking in the day.

I totally have felt that post-miscarriage.

So absolutely, this would be mirrored in some of our understanding of movement variability in the post-op period, um, post-caesarean section.

But what we are starting to see, um, and again, this is clinically, and I'm it's on my list of things that I want to be researching from a primary research perspective, but there's a lot of benefit that we can see from being very intentional with early post-op recovery.

And I've been doing this for a couple years now in terms of like really promoting earlier movement um for individuals post-c-section.

I haven't had anybody have any type of complication.

Um, when I talked to some of my obstetrical colleagues at my local university, they were asking about incisional um dehiscence or any issues with scar healing, um, which is a big reason why so many people are worried about early return x-ray.

So it's a fair comment.

When we think about our early healing, this is why I'm saying I'm starting at two to three weeks post op in terms of how much stress I'm putting on it.

A lot of our healing cytokines, a lot of our healing substances are flooding to the site of the incision in that first week.

Um, we're getting a lot of those healing chemicals that kind of compound there.

And then they kind of refine and become stronger.

Tensile strength increases over that first six weeks.

And there's a huge amount of variability in what that looks like in terms of timelines for tensile strength of that scar tissue.

And I believe one of the big variabilities is progressive mechanical strain because our body responds to the strains and stresses that we put on it.

And so I think that progressive overload is actually a net positive.

And then, secondly, the metabolic health of the tissue at which that scar is trying to form around.

What I mean by that is that if we are um adhering to more healthy lifestyle buckets, postpartum, post op, that scar is gonna have more chance and a higher likelihood of healing well versus being in a highly or more highly sedentary nutrition's off.

You can't control sleep in the postpartum period.

So sleep's already kind of promoting pro-inflammatory states, but putting some of our anti-inflammatory health promoting buckets and optimizing as many of those as possible again, I think is gonna be a net positive, even in that early healing phase, because it's gonna just help that healing environment.

So we have the positive kind of inflammatory state of a person who is healing.

And then we also have the gradual mechanical stress that's gonna promote this remodeling in a way that's going to provide more function and more resiliency early on.

So that's kind of usually my response.

Um, and then obviously, you know, the rate at which we progress and and how we work on this is gonna be very different depending on the human that is in front of us.

But really, you know, where my goals are with this.

And I was like, maybe this will be a 15 minute episode.

It is not.

Um, but where I really want to go with this is is to really challenge that in my research, I am looking at those who are in the highest level of physical activity or higher than most in our population.

And if I can see that they get green lights, that gives a lot of option for many of my recreationally active moms, right?

If we have these larger buoys, then there's a lot more wiggle room for our client and comfort on the provider to allow for this movement.

In the lower range of movement quadrants, those who are moving less or those who are in more unhealthy states with complications, et cetera, what that reframe looks like is what if exercise was medicine in the presence of healing post-op or in the presence of complications?

And I think both of those ranges, and I think both of those things on either side of the movement spectrum are really important things for us to be considering and having conversations about.

And I think, you know, I'm coming at from it as a researcher and a physical therapist, but this is where I need my uh maternal fetal medicine, my REI docs, my OBs, my family docs, my midwives to um all kind of collaborate together to really think about how we can move the needle forward in this.

All right.

That is all I got for this week.

If you have any other questions, comments, uh, please let me know.

Otherwise, enjoy your week and we will see you all next time.