There is a gesture almost everyone makes sooner or later, in front of the mirror: running a finger along the scar. And discovering two things at once. The first is that in one spot you feel nothing, as if that strip of skin belonged to someone else. The second is that a little further on, when you bend down to pick up the baby, something pulls.
Then a third arrives, around the third or fourth month: above the cut a ridge has formed that does not go away even when the weight has gone.
Here are the short answers first. Almost everything you feel is expected and has a name. Adhesions exist and are common, but they explain far less than you have been told. And on the evidence for scar massage, we need to be honest: it is weak. Not non-existent, but weak. I am telling you this up front, not at the end.
How a scar really heals, and how long it takes
A wound does not simply "close and that's it". It heals by passing through four phases in a precise order: haemostasis, inflammation, proliferation and remodelling. This is why infection, smoking, diabetes, obesity, stress and diet all appear among the factors that slow tissue repair.
What nobody tells you is that the first three phases concern only the closure. Remodelling, when collagen is reorganised and the scar changes colour, thickness and elasticity, continues for months after the wound looks fine. Large surgical wounds, a 2024 review reminds us, take weeks just to close and still leave fibrous tissue that can affect the function of the area.
Put simply: the scar you look at during the six-week check is not the final one. Red, raised, stiff and unpleasant to the touch are words that describe a phase, not an outcome.
Adhesions: how common they really are
Adhesions are bands of fibrous tissue that make surfaces that normally glide over each other stick together: the uterus and the abdominal wall, the bowel and the peritoneum. They are not an invention of the internet, and they are not rare.
The most solid count comes from a review of records of 1,283 women with repeat caesareans, plus 203 at a first caesarean, with adhesions recorded in the operating theatre, the only place where they can really be seen:
| Operation | Women with adhesions |
|---|---|
| First caesarean | none |
| Second caesarean | 24.4% |
| Third caesarean | 42.8% |
A series of 160 women with more than two caesareans, however, looked at individual histories rather than averages: women who had significant adhesions at the second caesarean had a 1.88 times higher risk (95% CI 1.3 to 2.7) of having them at the third as well. The authors' conclusion: individual predisposition matters more than the number of operations. Some women develop them, others do not, and it does not depend on how well you massaged.
The finding that should change the conversation
That adhesions exist is certain. That they are the cause of the symptoms you are being attributed is a different claim, and when tested it did not hold up. A blinded randomised trial published in The Lancet took patients with chronic abdominal pain attributed to adhesions, performed a laparoscopy on everyone and, only after confirming that adhesions were present, randomly assigned 100 people to surgical division of the adhesions or to no treatment. At one year both groups were clearly better, but with no difference between them: 3 points out of 100 on the pain scale, p = 0.53 (95% CI −7 to 13).
In other words: cutting them for real, with a scalpel, did not beat doing nothing. If this is the result of the most radical version of the procedure, no manoeuvre on the skin can claim to "break" them. This does not mean your pain is imaginary. It means the label "it's the adhesions" explains little, closes the search too early, and costs years for women who had a different problem, often one that is simpler to treat.
The symptoms that all end up under that label
They are worth separating, because they have different origins and different responses.
The pulling. The most common. The scar is less elastic than the surrounding skin, at a point that folds with you dozens of times a day. It is not an alarm, it is stiffness.
The numbness. The incision also cuts small cutaneous nerves, and the area they served stops reporting. It is common, usually recovers slowly over months, and sometimes does not return exactly as before.
The burning and the shocks. A pain that burns, tingles or starts at the scar and radiates towards the groin, pubis or iliac crest is the picture of cutaneous nerve entrapment. The most recent review places procedures with a Pfannenstiel incision, the caesarean one, among those most associated with this problem, and indicates the ilioHypogastric, ilioInguinal and genitoFemoral nerves as the most involved. It is confirmed by an anaesthetic block that removes the pain. It is not treated by kneading the belly, and above all it is not "the adhesions".
The pain that lasts. In a prospective study of 527 women, persistent pain was present in 18.3% at three months, 11.3% at six and 6.8% at twelve; an earlier review puts the range between 1% and 18%. The curve goes down, but it does not reach zero. The full picture with the predictors is in abdominal pain after childbirth: what is normal.
The ridge above the scar: what it is, and why it is almost never a hernia
Until recently this symptom did not even have a name. Now it does: a review article published in the American Journal of Obstetrics and Gynecology in 2026 calls it the "caesarean apron": an excess of skin and subcutaneous fat that bulges above the scar, from a modest rise above the pubis down to a fold that drops below the mons. It appears even in women who are not obese and even after perfectly successful caesareans, and it is dismissed as a cosmetic issue or blamed on pregnancy weight, while it can cause real physical discomfort, skin irritation and a psychological burden that is far from minor.
The authors propose a mechanism: the Scarpa's fascia, the membrane that separates superficial from deep fat, is often not sutured when the caesarean is closed. Left open, the edges retract, deep fat rises into the superficial plane, and fibrosis anchors the scar downwards. Hence the proposal to close it routinely, as in abdominoplasty.
A necessary caveat: this is a paper that proposes an explanation, and the authors themselves write that studies are needed. But one thing you can take away already: that ridge is not your fault and it is not fat to "burn off". It is a consequence of how the wound was closed, and no set of abdominal crunches removes it. If you wonder why the belly in general has not gone back, the wider topic is covered in belly after childbirth: why it stays and what works.
And the hernia? That is something else, and it is rare. Here is how the three situations differ:
| Caesarean apron | Incisional hernia | Scar endometriosis nodule | |
|---|---|---|---|
| Consistency | soft, uniform along the whole cut | localised swelling | hard, well-defined nodule |
| Changes with coughing? | no | yes: appears or grows | no |
| Goes down lying flat? | no | often yes | no |
| Pain | rare, if anything skin irritation | variable, sometimes absent | typically cyclical, with periods |
| Frequency | common | 0.197% within 10 years | rare |
On hernia numbers the sources agree, and it is good news. A Danish cohort of 57,564 women with no previous abdominal surgery found that hernias operated on within ten years of a caesarean were 0.197% (95% CI 0.164 to 0.234), roughly 2 per 1,000, with the risk concentrated in the first three years. An Australian study of 642,578 women confirms it: 0.47% among those who had at least one caesarean against 0.12% among those who had none (adjusted hazard ratio 2.73; 95% CI 2.45 to 3.06), rising to sixfold after five caesareans. A real relative risk, with a low absolute risk.
The painful nodule that is cyclical deserves a separate mention: scar endometriosis is an extra-pelvic form in which endometrial cells implant along the path of the operation. The sign is a tender mass on the line of the cut, with pain that returns with the period. Diagnosis is histological and treatment is surgical. If this sounds like you, you do not need a physiotherapist: you need a medical visit.
Massage and mobilisation: what the evidence really says
Now the real question. Does it need touching at all?
Let us start with how little we know. The reference review on scar massage found 10 publications and 144 patients across the literature, with protocols ranging from 10 minutes twice a day to 30 minutes twice a week. 45.7% improved; among the 30 surgical scars, 27 (90%) showed an improvement in appearance or POSAS score. But the conclusion that matters is the other one: the evidence is weak, the protocols inconsistent, and the outcome measures neither standardised nor really objective.
For burn scars, not caesarean ones, and the difference should be kept in mind, there is a more structured meta-analysis: 7 studies and 420 participants, sessions of 5 to 30 minutes once to three times a week for 12 weeks. Massage reduced pain (standardised mean difference −2.39; 95% CI −3.96 to −0.83), itch (−1.89) and anxiety (−1.52), and thickness by a very small amount (mean difference −0.05; 95% CI −0.1 to −0.0). On depression, no effect.
On the caesarean scar there is an exploratory study of 32 women: two sessions of standardised soft-tissue mobilisation. Stiffness (d = 0.43), flexibility (d = 0.52) and the participants' own rating (d = 0.62) on the POSAS improved, with higher elasticity and improved pressure pain thresholds: effects from small to moderate. But there was no control group: it cannot separate the effect of the hands from the simple passing of time.
The same limit appears in the most recent study, on 60 women with pain for at least three months after a low transverse caesarean, randomised to three active treatments: acupuncture on the scar, lidocaine infiltration or physiotherapy. At twenty weeks the pain had fallen in all three groups (−42.7% with physiotherapy, −54.4% with acupuncture, −63.6% with infiltration), but the differences between groups were almost all not significant. Without an untreated arm, "everyone improves" does not show that the treatment was the cause.
The most telling statement comes from the protocol of a French trial published in 2025: in France, where caesareans were 21.4% of births in 2021 and 15.4% of these women still have pain at three months, self-massage of the scar is the only treatment currently recommended. We recommend something while we are still studying it: that is a snapshot of the state of the art.
The honest verdict. Touching and mobilising the scar is reasonable: it costs nothing, the risk on a closed wound is almost nil, and it plausibly acts on stiffness, local sensitivity and your relationship with that part of your body. What it does not do is release internal adhesions.
On silicone sheets, since you will be offered them: the Cochrane review of 20 studies and 873 people found fewer hypertrophic scars in predisposed individuals (relative risk 0.46; 95% CI 0.21 to 0.98) and improvements in thickness and colour in scars already formed, but it describes the evidence as weak, because the studies are of poor quality. Use them if you like, but do not expect miracles.
When you can start, and how
There is no proven date, and anyone who gives you a precise one is improvising: in the available studies the start ranged from suture removal to more than two years later, with no comparisons on which moment was best. The useful rule is not about the calendar, it is about the wound.
The criterion. You start when the wound is completely closed: no scabs, no discharge, no redness, no increasing pain. If in doubt, ask at the postnatal check (care after a caesarean is an explicit part of the NICE guideline), not on a forum.
The progression, from least to most demanding. It is reasonable clinical practice, not a proven protocol:
- Before touching it at all, work around it: a flat hand on the belly, above and below the cut, without pressing. It helps you rediscover an area you have stopped considering yours.
- Simple contact, once the wound is closed: one finger resting on the scar, still, until you stop tensing.
- Gliding the skin above the scar: small movements in all directions, with the skin moving together with the finger.
- Mobilisation: you take it between thumb and index finger and move it in all directions, looking for the stiffest areas.
- Desensitisation, if the area is numb or hypersensitive: different textures passed over the skin (cotton, sponge, a rough towel), a few minutes, several times a day.
- Loading back in, the piece almost everyone skips: breathing, trunk control and a gradual return to movement. That is where the scar actually stops pulling, not in the massage. The order in which to restart is in postnatal exercise: where to really start.
When to stop: if after the session the pain increases and stays increased, if the area reddens, if any discharge appears. Scar massage should not hurt.
The signs that need a doctor, not a massage
In the first weeks these are signs of a wound infection, which is not an unusual event: the global meta-analysis of 180 studies and over 2.1 million women estimates surgical site infection after caesarean at 5.63% (95% CI 5.18 to 6.11), with large geographical differences.
- redness that spreads, heat, growing swelling;
- discharge, especially if thick or foul-smelling;
- fever;
- pain that increases rather than fading after the first few days;
- the wound opening, even at one point only.
The two emergencies not to postpone. They have nothing to do with the scar, they are rare, and they do not wait.
The first is venous thrombosis. After a caesarean it is about four times more likely than after a vaginal birth (odds ratio 3.7; 95% CI 3.0 to 4.6), with an incidence of 2.6 cases per 1,000 caesareans (95% CI 1.7 to 3.5). If a calf or thigh swells, hurts and is warm on one side only, or if you suddenly become short of breath or have chest pain, go to A&E, and with breathlessness call 112.
The second concerns the nerves, and it is not the burning on the scar we discussed. After spinal or epidural anaesthesia, a weakness in a leg that appears or worsens, a numb area that spreads, difficulty passing urine or severe back pain with fever need to be seen the same day: these are how an epidural haematoma or abscess presents, and they are confirmed by MRI. They are exceptional events (in British surveillance, roughly 2 and 3.6 cases per million births), but it is precisely because they are rare that they need naming.
Later on:
- a swelling that appears or grows when you cough, push or stand, and goes down lying flat;
- a hard, tender lump on the line of the cut, especially if the pain comes and goes with the period;
- pain that burns or gives shocks towards the groin and does not improve over months.
These all need checking, not massaging. And a fever with a wound that is leaking needs to be seen today.
What we can do, and what we cannot
Let us start with what we cannot do. We do not treat an infection, operate on a hernia, perform a nerve block or diagnose scar endometriosis. If you are in one of those situations we will say so straight away and send you where you need to go, rather than letting you lose months.
What we can do well, and can do by video call from home, is the rest: working out which of the four symptoms you have in front of you (stiffness, numbness, irritated nerve, structural ridge), because the answer changes completely; teaching you how to get up and how to pick up the baby without loading the area; and bringing the abdominal wall and pelvic floor back under load in a sensible order, which is the part nobody ever explains.
There is also a concrete reason why online works here: going out of the house with a newborn is often the real reason the assessment never happens. With Ri-Hub you start with a free twenty-minute first consultation: you tell us how the caesarean went and what shape the discomfort takes, we look at a couple of movements together, and we tell you whether a programme is needed, whether time alone is enough, or whether you should see a doctor first. Follow-up sessions cost 29,90 €.
One last thing. That scar is the doorway your child came through. If you have stopped looking at it and touching it, starting again is not an exercise: it is the part of recovery that does not appear on any measurement scale, and that almost everyone describes as the most important.
Sources
- Factors affecting wound healing, Journal of Dental Research, 2010
- Cellular and molecular mechanisms of skin wound healing, Nature Reviews Molecular Cell Biology, 2024
- Adhesion development and morbidity after repeat cesarean delivery, American Journal of Obstetrics and Gynecology, 2009
- Adhesions at repeat cesarean delivery: is there a personal impact?, Archives of Gynecology and Obstetrics, 2015
- Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial, The Lancet, 2003
- A Comprehensive Review and Update of Post-surgical Cutaneous Nerve Entrapment, Current Pain and Headache Reports, 2021
- Prevalence and risk factors for chronic pain following cesarean section: a prospective study, BMC Anesthesiology, 2016
- Chronic pain after childbirth, International Journal of Obstetric Anesthesia, 2013
- The cesarean apron: description, proposed pathophysiology, classification, and prevention through Scarpa fascia closure at cesarean delivery, American Journal of Obstetrics and Gynecology, 2026
- Incidence of incisional hernia after cesarean delivery: a register-based cohort study, PLoS One, 2014
- Incisional hernia repair after caesarean section: a population-based study, Australian and New Zealand Journal of Obstetrics and Gynaecology, 2015
- Caesarean-section scar endometriosis (CSSE): clinical and imaging fundamentals of an underestimated entity, Clinical Radiology, 2023
- The role of massage in scar management: a literature review, Dermatologic Surgery, 2012
- Effects of scar massage on burn scars: A systematic review and meta-analysis, Journal of Clinical Nursing, 2023
- Exploring the Effects of Standardized Soft Tissue Mobilization on the Viscoelastic Properties, Pressure Pain Thresholds, and Tactile Pressure Thresholds of the Cesarean Section Scar, Journal of Integrative and Complementary Medicine, 2022
- Physiotherapy in the sequelae of cesarean childbirth. A systematic review, Revista Española de Salud Pública, 2023
- A Comparison of Scar Infiltration, Scar Deactivation, and Standard of Care for Treatment of Chronic, Postsurgical Pain After Cesarean Section, Pain Research and Management, 2026
- A sham-controlled randomised trial of Tecar therapy for painful caesarean scars: the NOCEPAIN study protocol, BMJ Open, 2025
- Silicone gel sheeting for preventing and treating hypertrophic and keloid scars, Cochrane Database of Systematic Reviews, 2013
- Risks of Venous Thromboembolism After Cesarean Sections: A Meta-Analysis, Chest, 2016
- Neurological complications following obstetric neuraxial anaesthesia: a four-year United Kingdom population-based study of epidural haematoma and epidural abscess, International Journal of Obstetric Anesthesia, 2025
- Global incidence of surgical site infections following caesarean section: a systematic review and meta-analysis, Journal of Hospital Infection, 2023
- Caesarean birth (NG192), National Institute for Health and Care Excellence, 2021
Last source check: September 2026.
