role of physiotherapy of antenatal care and post natal care

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THE ROLE OF PHYSIOTHERAPY IN ANTENATAL AND
POSTNATAL WOMEN
By
IRAM ANWAR
MINOR PROJECT
Submitted to the
Amity Institute of Physiotherapy
Amity University Uttar Pradesh
In partial fulfilment
of the requirements for the degree of
Bachelor of Physiotherapy
Under the guidance of
Dr. Pragya (PT)
Assistant Professor
Amity Institute of Physiotherapy
Amity University Uttar Pradesh
Noida
July, 2019

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TABLE OF CONTENTS page
1.DECLARATION...................................................................................ii
2.FACULTY GUIDED APPROVAL…...................................................iii
3.ACKNOWLEDGEMENT.....................................................................iv
4. Introduction (THE ANTENATAL PERIOD)...................................1-10
a. Antenatal Classess
b. Earlybird class
c. Teaching neuromascular control
d.Exercise and pregnancy
5.Introduction (THE POSTNATALPERIOD)……….…………….11-17
a.Postnatal physiotherapy
b.Early postnatal class
c.inclusion of ergonomic priciples in daily activities
d.Treatment
6.LOWER SECTION CAESAREAN SECTIO………………………18-19
a. Physiotherapy role
b.Exercises
7.REFRENCES

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THE ANTENATAL PERIOD
The objectives of the modern antenatal care system are as follows: -
1. Promotion and maintenance of the optimal emotional and physical health of the mother
throughout the duration of the pregnancy.
2. Identification and treatment of the medical or obstetric complications arising during the
pregnancy as well as post partum.
3. Detection of abnormalities in the foetus as early as possible.
4. Informing both the parents about the pregnancy, the labour, the puerperium as well as the
care of the baby after birth.
5. Primary objective remains the delivery of a healthy infant and a healthy mother.
ANTENATAL CLASSES: -
Initially the antenatal education surrounded the hygiene and nutrition, as a the primarily
concern, with an aim to reduce maternal mortality rate and the infant mortality rate.
Eventually, the focus broadened to include presenting skills for helping women prepare for
and cope with the pain in labour . Currently, the scope of this system is broadened to include
the following:
. Helping couples and educating them about the physiological changes occurring in
pregnancy, labour and the puerperium.
. Educating partners about methods for coping with the physical changes occurring during
pregnancy and the related discomforts.
. Educating partners to develop a realistic understanding of pregnancy process.
. Educating partners about the lifestyle changes associated with parenthood, as well as the
emotional maturity that would be required to successfully tackle the added responsibilities.
EARLY BIRD CLASSES
The following subjects are an essential to the physiotherapeutic intervention in the sessions.
1.BACK CARE IN PREGNANCY
Educating the couples related to the postural, the hormonal changes as well as the weight
changes associated with pregnancy, and equipping them with the ergonomic education

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involving the comfortable body positions for sitting, working, etc. Modifications in activities
of daily life such as lifting, bending and the other household activities should be informed
about. The pregnant women should have a posture check performed on her, she should be
further instructed about the importance of using seatbelts while travelling, and given
information about how to access help in the future, if she experiences pain or discomfort of
any kind.
2.SYMPHYSIS PUBIS DYSFUNTION
Women mostly experience the symptoms of Symphysis Pubis Dysfunction. Hence it's
important to spread awareness regarding it's signs and symptoms and the treatment in the
antenatal classes. The national guidelines for the same condition can be accessed from the
Chartered Society of physiotherapist (CSP 1994).
3.PELVIC FLOOR AND PELVIC TILTING EXERCISE
Practising PFM exercises during pregnancy reduces the prevalence of urinary incontinence
experienced postpartum. A comparative study for PFM ability studied within a nulliparous
group and that of women 10 months postpartum suffering no symptoms of incontinence
demonstrated that the former had an greater muscle power as well as muscle endurance,
highlighting the importance of exercising these muscles after pregnancy. Tilting of pelvic can
also be demonstrated while the subject is seated on the edge of the chair. These exercises are
essential in maintaining the strength of the abdominal muscle, postural correction and can
result in relieving backache. Also these exercises can be performed in standing, crook lying
and also prone kneeling position.
3.EXERCISE FOR CIRCULATION AND CRAMP
Education regarding how pregnancy and its associated physiological changes can have an
effect on leg circulation, as well as necessary lifestyle modifications for women who have to
travel frequently and have sedentary lifestyles and jobs should be emphasised on. Such
women should be encouraged to perform foot and ankle exercises frequently. Ankle
movements such as plantar flexion, dorsiflexion and circling of foot performed for a duration
of 30 seconds, on a regular basis, should be advised.
3.FATIGUE
Most women (and their partners), experiencing pregnancy for the 1st time tend to be
surprised by the intense exhaustion experienced during the 1st trimester. Fatigue and
‘evening or morning' sickness are common complaints.

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TEACHING NEUROMUSCULAR CONTROL
This technique dictates use of the stress/ tension posture and the associated reciprocal
relaxation of the muscles. One muscle group lengthens and relaxes while the antagonistic
muscle group contacts.
1. CONTRAST METHOD
Based on the work by Edmund Jacobson, this technique dictates contracting and then relaxing
the muscles of the entire body, alternately and progressively. The goal is to make the body
aware of the undesirable tension and desired relaxation.
2. VISUALISATION AND IMAGNERY
This technique dictates patient's to imagine a peaceful and pleasant environment of choice,
for example, a sunny beach or a cool hill station cottage, aiming to incite calm feelings
resulting in relaxation.
3. TOUCH AND MASSAGE
The physiological potentials of massage in relieving pain and resulting in relaxation is well
known. Procedures such as effleurage, stroking or kneading to suitable parts of the body are
of considerable benefit when aiming at relaxation.
4. BREATHING
Exhalation tends to be the relaxing stage of the respiratory cycle. This knowledge can be used
to add to the relaxation. Varying exhalation to a slower rhythm, easy breathing and
predictability tends to be calming and relaxing.
EXERCISE AND PREGNANCY
Studies suggest that women with a more physically active lifestyle and were resultantly more
physically fit, tend to undergo easier labours compared to other women who've sedentary
lifestyles.
MATERNAL RISKS
1. There's increased proneness to risk of trauma to the musculoskeletal system because of the
hormonal changes during pregnancy which cause connective tissue laxity, specifically the
secretion of relaxin hormone. Hence an increased joint laxity and ROM; thus the
compromised joint integrity.

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2. Increased imposed demand on the cardiovascular system which is already deviated by the
physiological changes in pregnancy, such as increased cardiac output, blood volume,
increased resting pulse and decreased peripheral vascular resistance.
3. Hypoglycaemia arising by maternal exercising, is a common risk factor. This could also
result in hypoglycaemia in the foetus . This happens because pregnant women metabolises
carbohydrates faster and hence have comparatively reduced fasting blood sugar.
4. Thermoregulation- the basal metabolic rate and heat production increases during
pregnancy along with the temperature in the foetus. As an added risk, this hyperthermia can
result in teratogenic changes in the foetus.
FOETAL RISKS
1. Foetal distress: This can occur when prolonged vigorous exercises are performed by the
mother. this occurs due to selective redistribution of the blood flow away from the splanchnic
organs, including the deviating away of the uteroplacental blood flow towards the contracting
muscles.
2. In a comparative study, females who performed moderate to heavy level exercises birthed
babies averagely 86g smaller than females who didn't exercise at all. This, however had no
adverse consequences in the babies with lower-birth weight.
3. During the first trimester, a raised core body temperature in the mother can have
teratogenic effects on the foetus, causing malformations in the foetus.
4. Females who performed moderate to vigorous physical activity for a duration of 2
hours/week or <, in any month of the pregnancy, was learned to be associated with decreased
risk of a large birth weight baby for that gestational age. This, however, had no significant
risk for the comparatively smaller sized infant.
GUIDELINES FOR SAFE EXERCISE IN PREGNANT WOMEN
Avoid bouncing, jerky, ballistic activities and movements.
Exercises ranging from mild to moderate in intensity, performed regularly, at least 3x/week
are advised.

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Aerobic activities are suggested to be best suited to the pregnant female, focusing on large
muscle groups rather than individual muscles, of rhythmic nature. For example brisk walking,
aerobic dance, cycling.
Avoiding any kind of high impact exercise or activity is of prime importance.
 Avoiding stationary standing for prolonged time is essential.
. The exercise regimen should be based on the limitations imposed by gestation period.
 Competitive element of the exercise should be excluded.
EXERCISE IN WATER DURING PREGNANCY
Swimming is theoretically the most appropriate exercise for pregnancy females. It has an
added benefit of the relaxation that water induces. Buoyant force offered by the water
supports the gradually increasing weight of the mother’s body, enabling her to continue with
activity without much difficulty, which enhances her fitness and endurance status, and also
promotes her sense of well-being. Additionally, exercising in water offers added
physiological benefits to a pregnant female.
YOGA
In the recent decades, Yoga has gained increasing popularity for pregnant females. The added
emphasis of yoga on stretching and mobility may not be appropriate for pregnant females.
Hence, it's not very wise to incorporate aspects of yoga into the physiotherapeutic
intervention, without a suitable training in yoga.

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6-WEEK COURSE
WEEK 1: -
Emphasis is on establishing a balance is midst preparation for the labour and for the
approaching parenthood, along with special focus on emotional issues faced postnatally.
A short programme of general exercises focussing on the mobility and strength, comfort, and
including ankle and foot movements, pelvic floor muscle exercises, squatting, pelvic tilting in
a variety of positions, wall press-ups, ‘tailor’ sitting as well as postural correction and back
care.
WEEK 2: STAGES, SIGNS, AND LENGTH OF LABOUR, BIRTH
PLANS&CHOICES
. Labour
. First stage of labour
. Relaxation- due to the adverse effects of stress during pregnancy, coping strategies become
all the more essential. The above stated techniques of relaxation can be employed to ensure
the same.

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WEEK 3: COPING WITH THE FIRST STAGE OF LABOUR
Is inclusive of: -
Coping strategies for the overwhelming early stages of labour (usually experienced at home):
activities to distract the female such as moving around, reading, listening to music, watching
television, playing cards, playing scrabble, relaxation, taking a bath or showers, eating light
meals.
TENS
With the progression of the first stage: acquiring certain relaxing positions, visualisation
techniques, breathing awareness and massages can be used.
WEEK 4: PAIN, RELIEF AND OTHER POSSIBILITIES
Is inclusive of: -
Medically relieving the pain, by administering Entonox, Pethidine, epidurals, etc.
Important procedures performed include foetal monitoring, episiotomies, assisted deliveries,
vacuum extraction and forceps delivery.
WEEK 5: FURTHER POSSIBILITIES IN LABOUR, AND FEEDING BABY
Is inclusive of:
delivery (3rd stage), syntometrine use.
Induction of labour, LSCS delivery.
Postpartum care of woman and postnatal care of baby in hospital.
Guiding the women in breastfeeding, informing her of the benefits of breastfeeding for the

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baby and for the mother; practical guidance in the positioning of the baby and the mother
during feeding, latching on, and discussing the possible hurdles.Birthing options that are
available to the woman:water births, home based or hospital based delivery.
WEEK 6: PARENTHOOD AND GETTING BACK INTO SHAPE!
Is inclusive of:
Care of the new baby.
Transition from couple to becoming parents, and adjusting to the changes in the
relationships.
Postnatal depression.
Postnatal exercises.

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THE POSTNATAL PERIOD
During this period the newly become mother’s body begins to physiologically recover to the
on-pregnant" state. But the postpartum normal status will be very different. The body,
physiologically and mentally matures to the new postpartum normal state.
POSTNATAL PHYSIOTHERAPY
The physiotherapist plays an essential role in evaluating and treating the women during the
postpartum period. The primary aim is to contribute to the body’s recovery response as well
as encourage an interesting yet safe exercise routine.
PHYSIOTHERAPY’S INPUT INCLUDE:
A healthcare professional like a midwife evaluates the risk criteria formulated by the female's
physiotherapist.
Further a specific assessment is performed, in concern to the determined risk factor, which
can be medical, obstetric, psychological, social, etc
A healthcare professional implements the risk assessment following the education from the
women’s physiotherapist, which is updated regularly.
An appropriate facility is made available, for the referral depending upon the risk

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assessment.
ASSESMENT
The physiotherapist should examine the newly become mother post delivery, so as to
determine the priority needs of the patient. Different modes of delivery usually have a
specific set of needs associated with it, seen in majority women who have undergone that
particular mode of delivery.
Primiparas
more prone to perineal pain, and sexual problems.
Caesarean births
.more prone to exhaustion, problem of bowel, etc.
less likely to report urinary incontinence and perineal pain.
more cases of readmission.
Forceps and ventouse deliveries.
very likely to report perineal pain.
Medical symptoms to look out for:
. Diastasis recti abdominis.
. loss of voluntarily control of the pelvic floor.
. Perineal pain/discomfort.
. Pain at the Symphysis pubis, referred pain of any kind.
. Back pain.
EXERCISE
The newly become mother must be encouraged to be as mobile as possible, hence reducing
the risk of respiratory & circulatory complications. Exercising the pelvic floor muscles is
crucial to strengthen them as well as the pain-relief benefits. These exercises also speed up
the healing response by decreasing oedema and promoting blood circulation. The mother-to-
be should be taught these exercises antenatally.
Muscle re-education principles must be adhered to when exercising the muscles of the
abdomen, graduating from static (no movement), to a dynamic (joint movement) activity.

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. Side lying
. Crook lying
. Prone lying
. Sitting
. Standing
. Pelvic tilt.
. Flexion, in progressing ranges, of the lumbar spine.
It's of utmost important to equally focus on the whole musculature of lumbar spine. A
technique to aid the relief of ‘after-pains’ or backache is, performing an isometric abdominal
contraction which is to be followed by a pelvic tilt, all in a crook lying position. Gluteal
contractions, performed rhythmically, can also ease out the pain originating from
haemorrhoids or bruising.
EARLY POSTNATAL CLASS
Postnatally the female requires inference from a physiotherapist, as to return to the normal
level of functioning.
TEACHING POINTS
The starting position exercise or activity must reduce the risk to the subject, while enabling
participation at the same time. Starting positing can be standing, sitting, or lying. Additional
points to be included the different starting positions are:
SITTING
. The back should be well supported and perineum comfortable.
. muscle groups to be Exercised in sitting posture include the abdominals and the PFM.
STANDING
. the baseof supportshould bewide and stable- patientcanleanagainsta back of chair or wall for
support.
. The subjectshould bein suitable and comforting footwear
. standingpositionallowsthe strengtheningforposture andabdominals;alsoforthe exercisesof the
pelvicfloorandalsofortrunk side flexion.

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LYING
. Pillows and wedges to be provided to the subject for support.
. Spreading awareness associated with the risky movements/ exercise, such as strong side
flexions and trunk rotations with the patient in lying position, should be avoided until the
anterior abdominal wall is strengthened enough to allow these movement without shearing
effects in the spine.

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Exercises for the abdominal muscles
- Contractions of the muscles of the abdomen are practiced.
- special focus on the transverses abdominis muscle
- enhancing the time duration of hold, tilting of the pelvis.
- progression to active movements of the trunk aimed.
- Educate patients about abnormal doming.
INCLUSION OF ERGONOMIC PRINCIPLES IN DAILY ACTIVITIES
1.SITTING
. The female's thighs should be completely or minimum 2/3rd in contact of and supported on
the seating surface and positioned horizontally.
Due to risk of nerve compression, sitting surface not to span beyond the popliteal fossa.
. Feet to be rested flat on a large enough base of support, to ensure stability.
. Proper support to be provided to the trunk, corresponding to the natural curvature of the
spine to reduce risk of impingement.
2. STANDING
. Feet positioned a little apart, and slightly laterally angled
. Symmetrical weight bearing on both feet.
. Shoulders left in a relaxed posture.
. The natural spinal curvature should be Maintained.
. The head and trunk aligned in midline.
3. LYING
. Pillows placed under the head, low back as well as the knees for Full support.
. The female should be instructed to not cross her legs.
4. KNEELING
. Prolonged isometric flexion or rotation of the trunk are to be avoided.
. Attempt to limit the motions to sagittal plane only.
. Attempt to do the activities surface of a proper height.

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TREATMENT
EXERCISE OF THE PELVIC FLOOR
These exercises result in a pumping action of the aimed musculature which aids the drainage
of blood as well as interstitial fluids. This promotes flushing out traumatic exudates providing
relief in muscle stiffness and replenishes functionality. Also it's believed that this enhanced
muscle activity stimulates mechanism of the ‘pain gaiting’ as well as causes release of
endogenous opiates. The pain sensation is highest in first contraction and reduces with
successive contractions. The comfort and well being of the female is to be ensured while
doing exercises. Suitable starting positions for exercise include: stride standing or sitting as
well as crook lying.
FUNCTIONAL ACTIVITY
It is crucial for the female to be in a comfortable position while feeding, sleep and other
activities. Females should be advised to use pillows and cushions to experiment in attaining
maximum comfort.
GENITOURINARY DYSCOMFORT AND DYSFUNCTION
INCONTINENCE
Impairments of urinary or faecal regulation are commonly occurring problems post delivery.
Hence the strengthening of the musculature of the pelvic floor should be encouraged as a
means to reduce risk of incontinence.

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STRESS INCONTIENCE
It is a commonly reported postpartum problem reported early. Potential causes include
lengthening and subsequent weakness of muscles of pelvic floor and laxity in connective
tissues as well as due to nerve impairments. Exercise advise includes practicing contractions
muscles of pelvic floor, ar regular intervals, contracting slowly as well as quickly, with
progression in number of repetitions and length of hold.
URINARY RETENTION
Conditions associated with pain, such as longer labour, delivery of large baby, forceps
delivery, etc can cause retention of urine. This happens due to traumatisation of the urinary
bladder halting it's ability to function. Practising contractions of muscles of Pelvic floor
dicrease pain and oedema aiding normal functionality. Practising expiration accompanied by
relaxation, while being seated on toilet, is believed to be an effective approach.
BACKPAIN
A prevalent postnatally reported complaint is low back ache. It may be specific to a spinal
segment, such as the lumbar, coccyx, sacrum, or thorax. This pain can be severely
incapacitating and affect the quality of life of newly become mother. Therapeutic intervention
is necessary.
EPIDURAL PAIN
It is caused due to formation of small haematoma in the dura and within the enclosing
epidural space. Heat therapy or cryotherapy can be administrated as hot pack or cold packs
are effective in pain relieving.
SYMPHYSIS PUBIS PAIN
The clinician or physiotherapist plays an important role in imparting information regarding
this pain, such as:
Try not to lift heavy weights when avoidable.
Avoid asymmetrical weight bearing or abduction of the legs.
Administration of cryotherapy and ultrasonic therapy for resolving pain and oedema.
LOWER SECTION CAESAREAN SECTION

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Abbreviated as LSCS, this is a major operative procedure of the abdomen. Performed under
general anaesthesia. The to-be mother should be talked to and informed about what to as well
as what not to expect to give her a realistic image of postpartum phase.
THE PHYSIOTHERAPIST’S ROLE
Regular postnatal care is crucial for the woman, with proper management of the different
problems that the mother may face in different stages in postpartum phase. Initially while the
female is immobilised, primary focus is to reduce risk of circulatory system and common
respiratory dysfunctions.
EXERCISES
1. Slight tilting of pelvis, primarily activating the gluteal musculature.
2. gentle rolling of the knee from one side to the other.
3. Practising hitching of the pelvis.

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MASSAGE
Massage administered on self may have several positive implications, specifically if
performed post exercises of abdominal muscles. Different massage techniques employed are
vibrations, effleurage on the abdomen using 1 or both hands, in line of colon.
WOUND HEALING
Complications associated with wound healing are commonly reported. Treatment advise
includes guiding the woman to rest in extended body positions, exposing the wound to air,
and most importantly to keep the area dry.
POSTURE
The postpartum posture after an LSCS delivery is most likely of protective flexion associated
with weakened muscles of abdomen and backache.
VAGINAL DISCOMFORT
May present for as long as 6months postpartum. Therapeutic intervention is necessary and
presentation might vary in aspects such as intensity, duration, pattern, etc. Potential cause is
the healing wounds of vaginal delivery.
INCONTIENCE
STRESS INCONTIENCE
Management includes exercises of the Pelvic Floor Muscles, which should be tailored to
match individual needs of the patient. Regular follow-ups and re-assessments are essential.
Progression is an important consideration with number of repetitions and duration hold as the
2 basic factors to be worked on.
Females should be promoted to be physically active and to exercise regularly. This set of
exercises is aimed to strengthen her control over the urinary bladder and to prevent
incontinence when forceful exertions occur such as coughing, laughing, picking up
something heavy, blowing nose, etc.
BACK PAIN
Physiologically bestowed laxity of the ligaments during pregnancy and postpartum due to
release of Relaxin hormone may take nearly 6months to recoup. Postpartum these changes
occur due to low circulating levels of oestrogen. Such changes can give rise to backache, bad
posture, etc.

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REFRENCES
1. Mantle J,Haslam J,Barton S.Physiotherapy inobstetrics and gynaecology. 2
nd
edition
Edinburgh: Butterworth- Heinemann, Elsevier; 2005
2. WWW.WIKIPEDIA.COM