Rebuilding Core Strength After a C-Section: Where to Start
A c-section is a major abdominal surgery, yet most women are given very little guidance about what to do to support their recovery. C-sections affect 7 layers of tissue including skin, fat, fascia, and multiple layers of abdominal muscles. Recovering from a c-section is different from healing after vaginal birth. The incision needs time to heal and remodel so intentional exercises are important to rebuild connection and restore strength and function of these muscles.
Healing Timeline
You see your doctor for a 6-week check up, and (most likely) they tell you everything is looking good and healing well. While this might be true for the superficial scar (the layer that we can visually see), it’s not representative of how healed the deeper layers of tissues are. At 6 weeks postpartum, the abdominal fascia is only at 51-59% of its original tensile strength. At 6 months postpartum, it’s only 73-93% of its original tensile strength (Bo et al 2017). Healing takes time!!!
It takes up to about 2 years for the tissue to fully remodel and mature. Therefore, getting told “everything is looking good” at 6 weeks isn’t your clearance to return to all of your activities. This guide is to get you started.
Scar Anatomy
Because a c-section is not a single incision, there are multiple layers that have to heal simultaneously. We need these different layers to be able to slide and glide and move freely over one another for the core to function properly. Adhesions occur when these distinct layers heal on top of each other and are not able to move independently. Adhesions after a first c-section are approximately 7%. The risk of adhesions increases significantly after subsequent c-section – up to about 68% (Lubczynska & Wcisto-Dziadecka 2023).
Restrictions between layers make it more difficult for the abdominal muscles to function and can give the appearance of the c-section “shelf” or lower belly pooch. These adhesions can also affect organ motility, nerve function, and core weakness. Scar mobility restrictions can affect more than just the appearance and muscle function though - it can also lead to symptoms like bladder irritation, incontinence, constipation, pain, numbness, or pelvic floor issues. Therefore, working on the mobility of your c-section scar is critical to restoring your abdominal strength and decreasing your risk of other pain/issues popping up.
Scar Massage
Weeks 0-4: No direct scar work
Your only job in these first few weeks is to protect the healing tissue and follow your medical team’s activity and lifting restrictions.
Weeks 4-6: Indirect Desensitization
As your incision heals, you can begin some indirect desensitization work in the areas around the scar. Start with something very soft like a cotton ball and gently guide it around the lower abdomen - above and below the scar but not directly on the scar. As this area becomes less sensitive, progress the texture of what you’re using to desensitize the area: cotton ball → wash cloth → soft denim → wool. This can help restore normal sensation and teach the nerves of what should and shouldn’t be sensitive.
Weeks 6-9: Gentle Scar Mobilization
After you receive clearance from your doctor of physical therapist that the surface is fully closed (ie. no scabbing or open areas), you can begin direct work on the scar. Using your finger tips, gently guide the tissue up/down, side to side, and in circles. Notice any areas that feel sticky or tight. Aim for daily sessions at a gentle intensity.
Weeks 9-14: Deeper Scar Work
Around this time, your physical therapist will start to use firmer/deeper pressure to work through the deeper layers of tissues and may utilize tools like cupping or visceral massage.
Exercise
*Please note that this is a general guideline. Please consult with your pelvic floor physical therapist for exercises specific to your body and your recovery. If any of these exercises cause lasting discomfort around the incision site, reduce the intensity.
Before we start core exercises, it’s important to master our breath. Our diaphragm and pelvic floor move together on every breath so this must be the first step. After pregnancy and a c-section this system can get disrupted. The ribs widen during pregnancy so often postpartum the ribs can be stuck in a widened or flared position through the front and compressed through the backside of the body.
Weeks 0–2: 360-Degree Breathing
360-degree breathing is a way to gently reconnect with your breathing and core muscles after a C-section. As you breathe in, imagine your breath expanding in all directions: into your chest, belly, sides and back of your rib cage, and pelvic floor. As you breathe out, your ribs will naturally move inward and your belly may gently flatten. This should feel easy and relaxed, without straining or forcing the movement.
Pay attention to how your body is already breathing. Does your breath move easily into all of these areas, or do some areas feel harder to reach?
Many people find it difficult to breathe fully into the sides or back of their rib cage. If this feels challenging, try 360-degree breathing in different positions to see what feels most comfortable. Lying on your side or on your back can be good places to start.
If you're having trouble fully breathing out, try gently guiding your rib cage inward with your hands as you exhale. Breathing out through an open mouth, as if making a gentle “ha” sound, may also help. Aim to let your breath out fully without forcing it. You may notice your core muscles gently engage toward the end of your exhale. This is normal!
Weeks 2–6: Reconnecting With Your Core
During this stage, the goal is to continue restoring comfortable breathing patterns while gradually reconnecting with your deep core muscles. We'll also begin working on gentle movement, posture, and the muscles that help support your body throughout the day.
Some exercises and movements to explore during this stage include:
Gentle upper back mobility: Open book stretches or thread-the-needle stretches to improve rotation through your upper back. Stay within a comfortable range and avoid any pulling or discomfort around your incision.
Posture and upper back strength: Wall angels to gently open your chest and seated shoulder blade squeezes to activate the muscles in your upper back.
Deep core connection: Heel slides, gentle core activation on all fours with an arm reach, and tall-kneeling ball squeezes.
Lower body strength: Glute bridges to begin strengthening your glutes and supporting muscles.
Walking: Short walks to gradually reintroduce movement and build your activity level.
Weeks 6–10: Building Strength and Control
As you begin to feel more connected with your body and movement becomes more comfortable, you can gradually increase the challenge to your abdominal muscles. During this stage, we'll continue working on mobility and posture while building strength and control through your core and lower body.
Some exercises and movements to explore during this stage include:
Mobility: Cat-cow movements, along with continued upper back rotation exercises.
Posture and upper back strength: Low rows with a resistance band, while continuing wall angels.
Deep core strength: Supine marches (lifting one foot at a time while lying on your back), bent-knee fallouts (gently letting one knee move out to the side), and arm or leg reaches on all fours. As you get stronger, you may progress to bird dogs, where you reach one arm and the opposite leg at the same time. Tall-kneeling press-downs can also help build core strength.
Lower body strength: Bodyweight hip hinges, squats, and lunges to build strength for everyday activities and more demanding movement.
Week 10 and Beyond: Progressing Your Core Strength
This stage looks different for everyone, depending on how your body has responded to the earlier phases. Some people will continue building on the basics by gradually adding resistance, increasing their range of motion, or trying more complex movements. Others may be ready to progress to more challenging core exercises.
Returning to running, jumping, and heavy lifting should be guided by how your body moves and responds to physical demands, rather than by the number of weeks since delivery alone. Functional tests can help determine whether you're ready to safely progress to these activities.
Most women are not ready to return to running, jumping exercises, or heavy lifting until at least 14–16 weeks postpartum, and many need more time. The goal is to build a foundation of strength and control that prepares your body for these higher-impact and more demanding activities.
