Childbirth is a natural, joyous, and miraculous event, but sometimes with consequences for the mother’s pelvic function, as well as long-term overall health. The aftereffects of even a “normal” delivery can lead to instability, pain, and all kinds of dysfunction to the pelvic area. Here, we examine some of these issues that are within the reach of the manual therapist, particularly strategies for easing scars from cesarean section deliveries and restoring pelvic floor integrity.

There is simply no doubt that the female pelvis is subject to more “insult,” as it is called, than the male counterpart. Between pelvic exams, menstrual cycles, birth control, terminations, miscarriages, molestation, shaming, and male-centered obstetrics, women decidedly bear the greater burden in pelvic issues. Much of bodywork applies equally to both male and female pelves—opening the adductors, easing the deep lateral rotators, and extending the hip flexors, essentially balancing an upright tentpole over a couple of stilts.¹ But no man (so far) grows a baby in his abdomen, and no man will ever (I’m on safer ground on this one) push a baby through his pelvic floor.

Part of my surety on this has to do with sexual dimorphism of the human pelvis. Although there are overlaps, men tend toward an “android” type of pelvis with a heart-shaped birth canal that is ill-suited to childbirth. Leaving aside whatever advantages the android shape provides to men, the gynecoid shape is seen as the most propitious for childbearing, with the anthropoid and platypelloid as viable though occasionally problematic variants (Image 1).

The entire process of bearing a child can leave lasting changes that do not resolve with those two great healers—time and movement. It is to those mothers with persistent problems that the following thoughts and practices are dedicated. We hands-on practitioners are neither surgeons nor physicians, but we can add two additional elements—tissue release and restorational awareness—that are also powerful stimulants to healing. 

The rounder birth canal and wider hips that (taken as a whole) characterize the female gender in every race, worldwide, does not mean childbirth is easy for any of them. The human ape has more trouble giving birth than any other primate because of the changes in the hips required by our upright stance and bipedal gait, which diverged from the bonobo and chimpanzee some 6 million years ago. The Bible gets to it early: in Genesis 3:16, God curses Eve—“in pain shalt thou bring forth children”—as part of the punishment for eating the apple. In reality, it seems to be part of the “punishment” for walking upright.

So, as a species, we have a harder time than most mammals giving birth. Added to that ancient genetic disadvantage, we can add the modern elements of industrial urbanization and the medicalization of birth, both of which lead to many of the difficulties that now show up at our door.

The Medicalization of Birth

Childbirth is a natural physiological process, done without medical assistance for most of our animal and human history. Women help women, of course, so midwifery and the use of doulas have ancient roots, despite being currently marginalized.

The concept that “birth is a disease, delivery is the cure” is a very recent one. It couples with the idea of death, which again is a natural physiological process that has been turned into a “failure” by modern hospitals. Check the records: How many death certificates read “natural causes?” Not many these days; it is nearly always “renal failure,” “hepatic failure,” “pulmonary failure.” I have every intention that my death will be a complete success, so I am not going somewhere that presupposes it will be a failure.

Childbirth, though different, suffers from a similar process of medicalization. No one is advocating a return to a premedical past where women died because modern obstetrics and hygiene were not available to the women who need it. It is absolutely the mother’s choice what kind of support to seek out when birthing.

Even hospitals who innovate birthing centers with tubs and soft music, however, have the unfortunate tendency to do a soft or hard sell on the services and procedures that constitute the “active management of labor”—essentially taking over that sovereignty from the mother and the family. In a short 100 years, we have moved from treating a birth as an event in the family’s sexual life to a disease to be cured by vaginal or abdominal extraction.

The widespread use of Pitocin, epidurals, episiotomies, forceps, vacuums, and cesarean sections, amid a raft of beeping monitors, may have made childbirth safer (though the figures in the US are equivocal on that score²). But such innovations—all administered with the best intentions—have not made life easier for the mother’s pelvis.

Then there is another, harder-to-measure result of perinatal medicalization: the alienation from feminine empowerment as natural (and critical) breathing, bearing, and bonding rhythms are disturbed at the very entry into breath and life for the baby and entry into motherhood for the woman.³

To be fair—no desire here to paint the medical system as a bogeyman—we must add the decline in fitness for the average modern mother to this picture. Where expectant mothers once toiled in the fields or hunted, gathered, and tended their way into general fitness, we of the new homo domesticus species tend to sit for long periods, compensating (but inadequately) for our prolonged stillness by going to the gym or yoga class for a few hours a week.

Many urban (and increasingly rural as well) mothers arrive at labor unprepared for the marathon that a natural childbirth often is. Without good birth preparation—stretching, strengthening, breathing, and emotionally resilient social support—mothers are more likely to tire and need to resort to active management techniques and their ultimate expression, the cesarean section.

Bodywork and Perinatal Issues

There are too many positive approaches to too many perinatal issues to cover in a short article, but we can point toward a few, and then concentrate on what we can do with C-section scars.

Preparation

If you are fortunate enough to participate in an expectant mother’s birth prep, you can be her cheerleader for lots and lots of movement. In addition to birth prep classes themselves:

• Yoga and martial arts can produce a lithe and aware body with open joints and essential but unmeasurable “presence” in the pelvis.

• Exercise—both strength training and the sustained exertion that produces cardiovascular resilience—is great prep for the marathon of childbirth and the ultra-marathon of early parenthood.

• Loaded and unloaded squatting with attention to the pelvic floor and abdomen serves most expectant mothers well.

• Belly dance—fundamentally the ability to roll the pelvis fully around the ball of the femur—was originally developed in the harem, the women’s quarters, as great hip mobility preparation for expectant mothers, not as entertainment. But it is fun too—even for the narrow pelvis of cis gendered males.

Of course, each mother is different, and your influence may be limited, but my experience associates more movement, right up to delivery if possible, with better outcomes.

If you are treating the expectant mother manually, before or during the pregnancy, techniques to free and improve awareness in the adductors, deep lateral rotators, and lumbar spinal erectors are great anytime, but are especially helpful during pregnancy. Obviously, once a pregnancy has begun, working in the abdomen on the psoas or iliacus is out of bounds.

Working toward a neutral pelvis is helpful. A strong anterior or posterior tilt of the pelvis on the femurs can be problematic in creating both excess shortness and lack of resilience in the pelvic floor (Image 2). Side tilts, where one side of the pelvis is higher than the other, can also lead to problems (Image 3). 

Minor rotations in the lumbo-pelvic area do not seem to affect childbirth, but strong spinal rotations absolutely do pose a potential difficulty. If you can “awaken” and balance the two psoas major muscles and their nearby friends, this can be very helpful to free the twisted spine.

Hard or Soft Body?

In both preparation and restoration work, it is important to know your client’s tissue type. We all exist along a genetic spectrum of general tension in the fascial net. Those at each extreme of the range have been termed “Vikings” and “Temple Dancers.” Test yourself to see where you are, and then test your clients to see where they are (see the “How Loose is Your Net?” test and Image 4).

Those at the Viking end of the range tend to be stronger and less flexible and are thus more likely to tear during crowning. But Vikings are faster at repairing such tears or episiotomies. Lots of stretching and lengthening bodywork are called for in the Viking. The ultimate expression of the Viking type would be ankylosing spondylitis and related (thankfully rare) conditions where the soft tissue becomes calcified and rigid.

Those at the Temple Dancer end of the range (what used to be called “lax ligaments”) tend to stretch out more easily and have less trouble opening the pelvis to let the baby through. They also have more trouble healing from tears and surgeries, as remodeling happens more slowly in the looser body types. Lots of overall toning of opposing muscle groups (such as you get in standing yoga poses) are important for the Temple Dancer. The pathologic expression of the soft-body type are the many forms of Ehlers-Danlos Syndrome, where the ligaments are so elastic they are insufficiently toned to keep the joints together.

Obviously, either of these difficult pathological conditions should lead us to guide the expectant mother to more expert help, but meanwhile it is very helpful to know where your client—any client, not just those in the pregnancy year—lies on this spectrum. It changes how you will work with them.

Since this discovery is so new, it is too early to tell whether diet or other lifestyle choices can affect this basic fascial “tonus-stat.” We do know, although there is plenty of overlap, females tend to be a little looser and men a little tighter.

We also need to be aware that in the later stages of pregnancy, most women move along the scale toward being Temple Dancers—their fascia is “relaxed” by a close cousin of oxytocin. This additional hormonally driven softness persists throughout late pregnancy, birth, and the breastfeeding period. This allows the sacroiliac joints and the pubic symphysis to open a bit to ease delivery, and even allows the bones themselves to bend more easily. It also allows old injuries and new imbalances to exacerbate in a painful way in the last months of carrying and the first months of handling an infant.

Of course, all women are different in how all this is manifested, but for the experienced practitioner, this period of extra softness between the third trimester and weaning—often a period of aches and pains with no time to tend to them—is at the same time a unique opportunity to reestablish order in the body, the skeletal frame, and the myofascialature.

Because I believe in the healing power of this period, I have a very baby-friendly practice. You want the baby on the breast? Sure. Cuddled next to you on the table? No problem. Fussy? Worry not—just get on the table so we can work toward balanced joints while you are still “under the influence” of the relaxin. Yes, it’s a time when imbalances can run rampant, but it is equally a time when a new balance can be set in place for the long, rewarding, endless, intriguing—and did I say long?—road through motherhood.

Restoration

Again, the resources for postpartum restoration are thankfully plentiful but sadly not as available to all mothers as they should be. We will realize our social values are coming back into play when midwives are paid more than bank presidents in recognition of the relative value of the treasure each of them guard.

Many of the problems that come to us derive from the overstretching of the pelvic floor and surrounding ligaments during delivery, as well as perineal cuts and tears, which vary widely. Programs to restore the pelvic floor abound, and for space reasons I will not rehearse them here.⁴ Manual therapy to restore the pelvic floor requires going beyond our scope of practice into intrapelvic work and, thus, needs to be left to those with special training, including pelvic physiotherapists and those trained in the urogenital portion of Jean-Pierre Barrall’s Visceral Manipulation.⁵ Bless them for their work, and bless you if you get trained in this vital but neglected area.

In addition to such manipulations as may help postpartum, and exercises to strengthen and tone the pelvic floor itself, practical experience dictates that the final (and most effective) intervention is to strengthen the abdominopelvic balloon as whole, not as individual muscles. The ability to hold urine is not so much taxed in the relaxed situations in which we often learn PC pumps and Kegels. It is rather when we reach into the back seat and take the weight of a bag of groceries or a sleeping child that we need the valves to automatically close. This works better if the whole balloon works as a unit.

So, although I will sometimes refer out to trainers who are better at functional movement than I am, I often get new mothers started by reacting first to a balloon I am batting their way to get them coordinated to respond in a way that keeps the respiratory and pelvic diaphragms in connection with each other. Once the recruitment looks more “together”—back toward pre-mother form—we graduate to a bounced ball, then a tossed ball, and finally to a heavier ball. Most women who can catch and contain a 5-pound medicine ball thrown in random ways will be able to negotiate the activities of daily life with urine retained and sexual pleasure enhanced.

The belly wall can also be overstretched in late pregnancy as well, leading to diastasis recti, a common problem confronting massage therapists. Again, manipulation for serious separations between the rectus muscles requires specialty training, and specialized exercise programs—a much better route for most of these problems than stretching or massage alone—are available for mothers and trainers to follow.⁶

Lateral Pelvic Tilt

While we are against formulaic applications of “if-then” statements to the individualities of soft-tissue therapy, side tilts of the pelvis often respond to the following strategy. If we picture a right-side tilt of the pelvis—in other words, the left hip is high—we have found the following helpful or at the very least clarifying:

Work with the abductors (gluteals and tensor fasciae latae) on the right (low hip) side, and the adductors and the quadratus lumborum on the high hip side. This does not preclude working the corresponding tissue on the opposite side, but suggests that more work, intention, time, or pressure-stretch be applied to the illustrated tissues.

How Loose is Your Net?

To test where you or a client lives on the scale of resilience, flex your wrist as far as you comfortably can, and then press your thumb down toward your forearm. No way? You are a Viking. Easy-peasy? You are a Temple Dancer. Most of us lie somewhere in the middle. This exercise is just one of several “Beighton” tests for ligamentous laxity, but it is really a check of the whole fascial net, not just the ligaments.

To see how this works, let’s look at a couple more examples. For instance:

• Does your elbow go past 180 degrees when you open it? Do your fingers bend way back when you pull them? Do you ache after a long plane ride? You are likely a Temple Dancer type.
• Can’t touch your toes without bending your knees? Lose all your gains in yoga class if you miss two weeks? Long plane rides are a pain but you’re fine with a stretch and a shrug while you wait for your luggage? You are a Viking.

C-Sections

By far the most radical medical development related to birth is the successful cesarean section. Only with the advent of modern sterile surgical practice and the development of anesthesia did any mother survive the abdominal extraction of a baby. In one brief century, this impossible feat has become the way into the world for increasing numbers of families. In the US and China, one-third of all births are C-section. In Brazil, more than half the births are by this method that was unknown to the world mere decades ago. The long-term implications of this trend have yet to be measured, but given that the rate of C-sections has doubled since just 2000, we may find out soon.⁷

Procedures vary depending on whether it was an emergency or elective C-section. Whichever, surgeons take what care they can in entering and leaving. Nevertheless, scars are formed and lubrication between myofascial layers is lost wherever there has been a cut or stitch—both inevitable.

To tackle a C-section scar, first thing to know is you will be right on top of the pubic bone, so (1) this is not the place to go on your first session, but only after good rapport is established; and (2) make sure their bladder is empty first.

With the client lying supine with her knees up (better with feet on the table rather than just a bolster under the knees), locate the scar and go into the belly a bit above it. My clients are wearing underwear, so usually I have a layer of fabric between me and the skin, but that is between you and the client. Explore the scar from above, checking its length and breadth and density. Vikings will on average have tougher and larger scars than Temple Dancers, but this varies with the birth.

Often the surgical incision gets torn or overstretched at one end in the process of extracting the baby, and this often presents as a larger nubbin at one end of the scar. The last few stitches from the incision can also present as an extra hard spot at one end of the scar’s surface.

Explore how deeply the scar penetrates. The surface scar is in the skin, fat, and abdominal fascia. The cut through the muscle wall and peritoneum is likely down the center line of the linea alba, so check whether this has involved that area in extra adhesions. If your palpatory skills are good, you can perhaps feel the fundus of the uterus behind the muscle wall, which will also inevitably have scar tissue from the incision. The uterine wall, however, is so strong and good at healing that many women can have a subsequent child vaginally (VBAC—vaginal birth after cesarean) if they so choose.

Once you have gently and carefully taken the scar’s measure, compress it between your fingertips and the upper surface of the pubic bone. The object here is not to smush it out of existence, but to “comb” or brush out the scar’s tangled fibers. The collagen fibers around scars are like the wool in felt—they are stuck willy-nilly in all different directions. The native fascia in your abdominal wall is very directional, so your idea as you contact the scar is to brush it out as you would your child’s hair.

As with a child’s hair, the idea is to untangle it a little at a time. Go for one big stroke and you will get tears. Gentle combing and brushing around the edges of the scar are what is called for. Any kind of biting pain is a contraindication—something else besides scarring is going on. Perhaps a nerve is trapped in the scar, or the scar is adhered to an organ. However, some level of sensation or soreness when you are working and after is par for the course, as there are almost certainly nociceptic cytokines trapped in that scar.

Because the scarring is accompanied by a varying amount of sensory-motor amnesia in the area of the surgery, the way to progress this treatment is not for you to press harder, but to do it under load. Once you are satisfied with the scar as it presented itself in the relaxed supine position, progress to a chair or the side of your table, with your client’s feet on the floor. Now do the same method, finding the scar, pinning it toward the bone, combing out its edges.

For full kinesthetic restoration, have the client put her hands on her opposite shoulders and rotate her spine right and left in the seated position, but slowly, and with the chest up. Again, keep exploring the scar as she moves, melting the edges and getting stretch through the scar and the entire area. For those who want or require further loading, they can stretch their arms overhead during the rotation or go into a bit of a backbend. For most, this is usually a sufficient load for you to feel when an even tone spreads throughout the abdomen. For the athlete, you can additionally load the arms with a medicine ball or weights.

Many women have unconsciously pulled in around the scar, so the restoration of movement there can be a revelation—and some help when dealing with any other problems in the abdomen or pelvic floor. Sometimes there is an emotional component to the tension stored in the area, like color changes and sweating, so be sensitive to signs of autonomic stress. Give the client every chance to express her feelings—often for the first time since the birth.

One final aspect of C-section scars—of most serious scars, in my findings—I am reluctant to say because I have no proof beyond what my hands find. At one end (usually) of the scar, there will be a little wire or guitar string—tough to find but distinct when you do locate it—of fascia that joins the scar to whatever bone is nearby. In the case of C-section scars, this is nearly always the pubic bone (Image 5).

I find that the dissolution of the harder tissue is greatly facilitated by finding this little “tornado funnel” (how this fascia feels energetically) from the scar to the bone. Pinpoint it on the bone and press (slowly but with sustained intent) on the periosteum (the plastic wrap around the bone) precisely where it attaches. This will often result in the dissolution of the band from the scar to the bone, and the subsequent relenting of the scar back toward normal tissue.

I know—it is odd, and I have never seen it reported, but I have had great clinical results by adding the “attachment point” at some nearby periosteum to my scar work agenda. These attachments are very difficult to find in the small round scars that accompany laparoscopic surgery, but are commonly found tethering scars of any length such as C-section scars.

A Final Thought

I hope this small tour has been helpful to you in helping the mothers of this world. Until there is a social revolution around how we handle motherhood, many mothers have to guide their own journey back to full function after childbirth. Your hands can be a valuable assist.

Notes

See Anatomy Trains’ “Balancing the Pelvis” program for an approach to balancing the muscle groups around all human pelves. Our “Deeper Ground” program focuses more on the issues specific to feminine life cycles. See these and other movement-positive webinars at www.anatomytrains.com/product-category/on-demand-learning.

Save the Children, The Urban Disadvantage: State of the World’s Mothers 2015 (Fairfield: Save the Children, 2015), www.savethechildren.org/content/dam/usa/reports/advocacy/sowm/sowm-2015.pdf.

Michel Odent, Primal Health (East Sussex: Clairview Books, 2007); Michel Odent, The Scientification of Love (London: Free Association Books, 1999); or anything else by the incomparable French obstetrician Michel Odent, MD.

Diane Lee, The Pelvic Girdle (New York: Elsevier, 2011); Diane Lee, Diastasis Rectus Abdominis (Diane Lee, 2016).

The Barral Institute, n.d. “Home Page,” accessed November 3, 2020, www.barralinstitute.com.

Katy Bowman, Diastasis Recti program, www.every-mother.com.

Jacqueline Howard, “C-Section Deliveries Nearly Doubled Worldwide Since 2000, Study Finds,” CNN Health, October 11, 2018, www.cnn.com/2018/10/11/health/c-section-rates-study-parenting-without-borders-intl/index.html.