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Physiotherapy Protocol: Post Lower Segment Caesarean Section (LSCS)

Important Precautions Before Starting:

• Always obtain medical clearance before progressing exercises
• Avoid any exercise that causes pain, dizziness, or increased vaginal bleeding
• Monitor wound healing — no direct pressure on incision site until fully healed
• Watch for "DRAM" (diastasis rectus abdominis) before loading abdominal muscles
• Per NICE Caesarean Birth Guidelines (p. 33): Routine respiratory physiotherapy post-GA caesarean is NOT recommended as it does not improve respiratory outcomes

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Overview of Rehabilitation Phases

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PHASE 1: Day 1–3 (In-Hospital)

1. Respiratory System

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2. Cardiovascular / DVT Prevention

✦ Note: Compression stockings (TED) should be worn until mobile. LMWH (pharmacological thromboprophylaxis) may be prescribed concurrently — physiotherapy does not replace this.

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3. Pelvic Floor System

✦ No straining, no Valsalva. Avoid if catheter is still in situ.

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4. Abdominal System

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5. Lower Limb System

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PHASE 2: Week 1–2 (Early Home Recovery)

1. Respiratory System

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2. Cardiovascular System

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3. Pelvic Floor System

✦ Rest = equally important as contraction. Fully relax between each rep.

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4. Abdominal / Core System

⚠️ Avoid: Sit-ups, crunches, double-leg raises, or any exercise causing "doming" or "coning" at the midline — this indicates diastasis recti. Refer for DRAM assessment if suspected.

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5. Posture and Musculoskeletal System

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6. Lower Limb

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PHASE 3: Week 3–6 (Progressive Rehabilitation)

Wound should be healing well. Begin more active core and pelvic floor loading. Walking distance increases.

1. Cardiovascular System

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2. Respiratory System

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3. Pelvic Floor System

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4. Abdominal / Core System

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5. Posture and Musculoskeletal

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6. Lower Limb

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PHASE 4: Week 7–12 (Functional Strengthening)

Typically after postnatal check (~6–8 weeks). Progress loading systematically.

1. Cardiovascular

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2. Core and Abdominal System

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3. Pelvic Floor

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4. Strength Training

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PHASE 5: Week 12+ (Return to Sport / High-Impact Activity)

Criteria-based return — NOT purely time-based.

Return-to-Running Criteria (all must be met):

• ✅ No urinary/bowel leakage with exercise
• ✅ No pelvic organ prolapse symptoms (heaviness, bulging)
• ✅ No pelvic or back pain
• ✅ Can single-leg bridge 10 reps with no pain
• ✅ Can single-leg squat 10 reps with good control
• ✅ Can walk briskly 30 min without symptoms
• ✅ Can hop on one leg 10x without symptoms

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Scar Management Protocol (Starting Week 6–8)

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Posture Correction Program (Ongoing Throughout All Phases)

• Forward head posture (from feeding)
• Rounded shoulders
• Anterior pelvic tilt / lumbar hyperlordosis
• Protective flexion posture guarding wound

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Red Flags — Stop Exercise and Seek Medical Review

• 🔴 Increased or bright red vaginal bleeding (lochia)
• 🔴 Wound dehiscence, discharge, or signs of infection
• 🔴 Chest pain or shortness of breath
• 🔴 Calf pain, swelling, or redness (possible DVT)
• 🔴 Pelvic heaviness or bulging (possible prolapse)
• 🔴 Urinary/fecal incontinence not improving
• 🔴 Severe or worsening abdominal/pelvic pain
• 🔴 Doming/coning of midline during exercise (DRAM)

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Quick Reference Summary Table

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Positioning Guide — Post LSCS: POD 1 to POD 7

Core Principles Throughout:

• Every position change should protect the wound (no direct pressure, no sudden trunk flexion)
• Use the log-roll technique every time the patient moves from lying to sitting
• Support the incision with a folded pillow or abdominal binder when moving, coughing, or feeding
• Comfort + function + DVT prevention guide all positioning decisions

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POD 1 (Day of / Night After Surgery)

Patient is largely bed-bound; catheter in situ; IV lines may be present; epidural/spinal wearing off

Primary Positions

Key Points — POD 1

• Do NOT prop patient fully upright (90°) abruptly — gradual elevation only
• Keep knees slightly flexed in all supine positions to reduce abdominal wall tension
• Log-roll technique must be taught and used for any position change:
  1. Bend knees
  2. Roll shoulders and hips together as one unit to the side
  3. Lower legs off the bed
  4. Push up with arms to sit — avoid pulling up with trunk muscles
• Perform ankle pumps and foot circles in all positions to prevent DVT
• Pillow splinting of wound taught for cough/sneeze

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POD 2

Catheter usually removed; patient begins assisted standing and short walks; appetite returning

Positions

Key Points — POD 2

• Encourage 2-hourly position changes to prevent pressure injury
• When sitting in chair: avoid low, soft sofas — difficult to rise from without straining wound
• Teach patient to use arms to push up from chair, not trunk flexion
• Breastfeeding position option: Side-lying feed (baby facing mother, tummy-to-tummy) — avoids all direct wound pressure

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POD 3

Increased mobility; oral analgesia; wound dressing may be reviewed; lochia being monitored

Positions

Key Points — POD 3

• Address wound-guarding posture early: patients naturally flex forward to protect the scar — this leads to lasting postural problems
• Teach upright walking with gentle core brace
• Sitting posture correction: pelvis neutral, not posteriorly tilted; lumbar support encouraged

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POD 4

More independent; may be preparing for discharge (in some units); increased walking tolerance

Positions

Breastfeeding Positions (Applicable POD 2 Onwards)

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POD 5

Likely at home (if not already); fatigue is significant; doing more but needs to rest strategically

Positions at Home

Key Guidance — POD 5

• Rest between activities — lying down with legs elevated is acceptable
• Avoid sitting for >45–60 min without a short walk or position change (DVT, stiffness)
• Pillow hugging for all coughing, sneezing, laughing — still essential
• Avoid stairs more than necessary; use one hand on railing

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POD 6–7

Increasing independence; wound tenderness reducing; fatigue may fluctuate; lochia normalizing

Positions

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Summary: Position Change Schedule (POD 1–7)

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Positions to AVOID — POD 1–7

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Log-Roll Technique — Step-by-Step (Teach on POD 1)

1. Bend both knees, feet flat on bed
2. Cross arms over chest (or hold pillow to wound)
3. Roll entire body as ONE unit to one side
   (shoulders and hips move together — no twisting)
4. Let legs drop off the edge of the bed
5. Simultaneously push UP with the lower elbow and upper hand
6. Come to sitting using ARMS, not abdominal muscles
7. Pause at edge of bed 30 sec before standing
8. Stand slowly, holding bed frame or nurse's arm

Reverse the technique when lying back down.

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