Do you plan to get pregnant and/or are pregnant, and want to ensure that you keep dancing? Do you want to plan the recovery from a cesarean section?
Then read this blog by Kathak dancer/ Dance Scientist Seema De Jorge-Chopra, MSc and Specialist Women’s Health Physiotherapist Marta De Oliveira PG Cert, MCSP for useful information to help you recover better and faster.
The aim of this blog is to share the cesarean section recovery process from the perspective of Kathak dancer; the information will collectively inform the dancer of the physiological and physical changes that occur in the body and the importance of a full pelvic recovery before returning to dance. We will highlight a number of useful resources to encourage a positive and healthy return to activity.
My journey: Seema De Jorge-Chopra
During my pre-pregnancy phase I was at my personal peak fitness and wellbeing, and upon the completion of the MSc Dance Science at Trinity Laban Conservatoire of Music and Dance and the Foundation in Strength and Conditioning with the UKSCA, I was motivated to apply this new found knowledge to my practice.
I believed that the lifestyle that I had developed through dancing, running, strength work, swimming and yoga, would positively determine my chances of getting pregnant and experiencing a natural delivery. My viewpoint was informed by the National Health Service (NHS) and studies that suggest that well-trained women managed the birth better, had a higher rate of vaginal deliveries or a lower rate of caesarean sections (1). Researchers have found that trained women with higher aerobic fitness and muscular strength have a reduced time for the birth and reduced risk of childbirth complications. Moreover, trained women recover faster postpartum than the women who did not train (1).
I successfully got pregnant in August 2016 and subsequently followed the NHS guidelines to train aerobically and to practice kegels, or pelvic floor exercises throughout the three trimesters (3). At two weeks passed my due date, I experienced an induction of labour, three days of contractions, followed by an emergency c-section due to the reverse dilation of my cervix. This had all come as a surprise to me when I had prepared my body so well for pregnancy and labour. I had certainly demonstrated endurance during the process, but I needed to understand why my cervix did not allow for a natural birth.
Currently at five months postpartum, I have developed a further understanding of the factors associated with the birthing process and the resources available to prepare and rehabilitate the body.
We will now discuss some of the issues with the current recommendations:
Pelvic floor exercises during pregnancy and postpartum: The need for specificity.
During labour, the pelvic floor muscles have a very important role as they help to support the baby's head while the cervix of the uterus is dilating to allow the delivery of the baby.
Pelvic floor muscle training during pregnancy results in improved muscular control and strong muscular flexibility. Researchers have found that well-trained women had a lower rate of prolonged second-stage labour than women who did not participate in pelvic floor muscle training. The pelvic floor exercises also prevented urinary incontinence during pregnancy and after childbirth (1).
Online pregnancy resources (3,4) make the assumption that the pelvic floor requires strengthening, but does not consider the pregnant individuals specific state.
Women can present with different levels of weakness on the pelvic floor muscles. In some cases, the pelvic floor muscles can present with reduced strength, a predominately a fast-twitch fiber disorder. In other cases the muscles can present with reduced endurance, mainly a slow twitch fiber disorder, where the muscles get easily tired and fatigued and they can’t sustain a contraction for long (9). The muscles can also be overactive, hypertonic and painful and in these cases manual therapy treatment to release the tension before commencing the pelvic floor muscle training program is fundamental. Thus, it is extremely important to have a pelvic floor assessment after 6 weeks postpartum so that an adequate exercise plan can be prescribed.
It is well accepted that the gold standard, before starting a training program for the pelvic floor muscles is to have a pelvic floor muscles assessment with a trained women’s health physiotherapist. This will ensure the correct technique is taught and a correct exercise program is designed to meet the patient’s needs and avoid more dysfunction (5).
During the internal examination of my pelvic floor muscles with Marta, it was found that my musculature was too tight and lacked endurance. This meant that I was able tighten my pelvic floor, but was unable to relax the group of muscles to their original state. This had contradicted my perceptions as a dancer of what a healthy pelvic floor should be. I had always aimed to develop a strong pelvic floor but had not thought about the possible adverse effects of this.
Could the tightness of my pelvic floor have been the cause of the reverse dilation of my cervix during labour and the reason why I was unable to deliver naturally?. Furthermore, could a tight pelvic floor present a common issue for dancers during labour?.
The Caesarean section itself
Not only was I surprised at the outcome of the healthy nine months of pregnancy, I had also not prepared myself for what the recovery process entailed and what this would mean for me as a dancer.
A Caesarean section is a major abdominal surgery which leads to scar tissue, restrictions and adhesions in the fascia and altered pattern of recruitment of the abdominal muscles. There are many different techniques for C-sections and that can depend on a number of aspects (8).
In general, in a C-section the incisions are made to the skin and abdominal fascia of the muscles and uterus but not directly to the abdominal muscles themselves. This allows the muscles to recover better but still leaves them with moderate injury, nerve damage, loss of blood supply, swelling, pain and scar tissue. In addition the scar tissue from the wound can result in intra-abdominal adhesions, similar to other types of abdominal surgery.
Since Caesarean section affects the fascia of these muscles, it causes changes to the stability of the lower back and pelvis by changing the muscle tension or the control of movement patterns.
In my experience, after the Caesarean section, I experienced lower back pain, abdominal pain, tightness of groins, the hamstrings, achilles tendons and other muscles along the ‘back superficial line’ (10). An understanding of the fascial networks of the body this has allowed me to focus on the restoration of the different areas and to redevelop these movement patterns efficiently.
The recovery process
The NHS website recommended that post c-section the individual must embark on 6 weeks of complete rest (no driving, exercise or carrying anything heavier than your baby), before the postnatal check with a General Practitioner to ensure that the recovery process is going well (2).
After a very brief external examination of my general upper body, I had received the go-ahead from my GP; this however did not instill the confidence in my body to undertake the heavy footwork of Kathak and running, especially since I was still in a lot of pain.
In the postpartum period, it is still very uncommon for women to give themselves permission to find help and care or to be referred to a women’s health physiotherapist. In order to start the recovery process and improve muscle function and lumbo-pelvic stability it is important to see a women’s health physiotherapist, especially for Kathak dancers.
With the help of Marta, I was able to understand the generalisation of the NHS recommendations and the importance of specificity to best facilitate my recovery.
We collectively decided that an additional 6 months would be required to rebuild my strength and power for dance and fitness related activities.
See below our guiding principles:
1. Start gentle exercise and mobilisation
As a dancer, I found it incredibly difficult to rest during the initial 6 weeks. However, It is incredibly important to listen to your body at this stage. If you are presented with pain, discomfort and extreme fatigue, it is vital to sleep and rest to allow for restoration of your energy and physicality.
However, a simple walk around the hospital ward will help you to start your recovery. Gentle mobilisation of the joints and activation of your muscles on a daily basis will facilitate your recovery and encourage a positive attitude. As soon as your scar has healed you can partake in swimming to activate the major muscle groups without putting too stress on your body.
2. Have a six-week check up with your General Practitioner
Please do not expect this to be a thorough examination of your pelvic floor, but it your opportunity for you to assess your progress, to have your scar examined and to express any concerns with your physicality.
3. Visit a specialist women’s health physiotherapist
Many women forego this stage and miss out on the opportunity to understand their individual physical needs bodies postpartum. Everyone is unique and possesses different needs; this examination will initiate the recovery process and improve muscle function and lumbo-pelvic stability.
Start more vigorous exercise and introduce strength and weight training to promote strength, mobilisation and improved psychological well being.
Strength training will increase the bone strength and density that may be lost during inactivity during pregnancy and post pregnancy phases and breastfeeding. Introducing training with resistance bands into your programme will allow you to workout in the comfort of your own home and around your baby.
It must be emphasised here that breastfeeding mothers should not expect to lose weight through exercise alone in the first 6 months. Research studies have evaluated the effects of exercise on weight loss within this population and have found that exercise does not promote body weight or body fat loss unless calorie restriction is specifically encouraged. ‘A possible explanation is that exercise may promote a spontaneous increase in energy intake and/or a reduction in non-exercise energy expenditure, which would thereby prohibit negative energy balance and weight loss’ (11).
4. Return to dance
I am yet to engage in regular dance activity, but I am rebuilding the confidence in my physicality with a strong core foundation and flexibility to meet the demands of dance. I no longer have any water retention which had caused a swelling to my ankles for many months, so tying 5kg brass bells around my ankles will no longer be an issue.
What is the importance of pelvic floor rehabilitation for Kathak?
The pelvic floor muscles are part of a complex group of muscles that work together to help regulate the intra-abdominal pressure (IAP) and improve control of
the core, lumbar spine, pelvis and sacroiliac joints (SIJ) during movement and
breathing (7). They have a postural activity and work together as a sling to help maintain continence by closing the sphincters of the bladder and bowels and give support to the pelvic viscera and the lumbopelvic complex to create stability while we breathe, stand and move (7).
These muscles need to be functional, resistant, and flexible as well as work in perfect coordination with each other to provide effective support and bracing to the SIJ and lumbopelvic complex for an efficient load transfer to the legs (6).
In Kathak dance this perfect synchrony assumes an extreme importance as dancers need to have good core stability to be able to do rapid footwork, with increased weight bearing on their
legs as well as fast spins and complete stops.
Kathak dance requires sudden increases in the IAP due to impact with fast footwork, fast movements and stops. If the pelvic floor muscles aren’t functional enough to help close the sphincters then one can conclude that stress urinary incontinence may become a problem amongst Kathak dancers during pregnancy or postpartum.
The postpartum guidelines are not the same for everybody; each individual presents a unique level of physicality that may contribute towards their experience of birth.
My main advice is to visit a Women’s Health Physiotherapist such as Marta to learn about the characteristics of your pelvic floor. I learnt that the inhalation is just as important as the exhalation, or in other words, the squeeze of the pelvic floor muscles is as important as the relaxation.
I am sure that many dancers train their core musculature (which connects to the lateral walls of the cervix) to facilitate their dance, but forget to counteract this with relaxation. This information will contribute towards my full recovery and in the preparation of my next pregnancy, with the confidence to dance again.
If you have any questions regarding the caesarian section, recovery, pelvic floor, strength training, please contact either Seema or Marta for guidance.
Manzur, K., Naim-Shuchana, S. (2014). Physical activity and exercise during pregnancy. European Journal of Physiotherapy 2014, Vol. 16 Issue 1, p2.
Bø, K. and Freeman, R. (2015). Evidence-based physical therapy for the pelvic floor. Edinburgh: Churchill Livingstone.
Vleeming, A., Albert, H., Östgaard, H., Sturesson, B. and Stuge, B. (2008). European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal, 17(6), p.794-819.
Richardson, C., Hodges, P. and Hides, J. (2004). Therapeutic Exercise for Lumbopelvic Stabilization. Edinburgh: Churchill Livingstone.
Hofmeyr, G., Mathai, M., Shah, A. and Novikova, N. (2008). Techniques for caesarean section. Cochrane Pregnancy and Childbirth Group.
Laycock, J. and Haslam, J. (2002). Therapeutic management of incontinence and pelvic pain. London: Springer and Baessler, K. (2008). Pelvic floor re-education. London: Springer.
Myers, Thomas W. (2011). Anatomy Trains. London: Urban & Fischer.
Larson-Meyer, D. E. (2003). The effects of regular postpartum exercise on mother and child. International Sportmed Journal, 4(6), 1-14.
Marta De Oliveira: https://www.martadeoliveira.com/
How the pelvic floor works: https://www.youtube.com/watch?v=vlo7D4kndfU
Pelvic floor exercise app: http://www.squeezyapp.co.uk/get-the-app/index.html
Bruijn, Melissa J. & Gould, Debby A. (2016). How to heal a bad birth : making sense, making peace & moving on. [Kenmore, Queensland] : Birthtalk