Physiotherapy and Postnatal period

1. Postnatal period
postnatal care, postnatal exercises, postnatal problems

2. Introduction
• It is in this period that the new mother’s body begins its
period of recovery and its return to ‘normal’.

3. Postpartum status
• The body’s ligaments and collagenous connective tissue will
still be softer and more elastic than prepregnancy and it will
take 4 to 5 months for full recovery to take place.
• The abdominal muscles, which will have been stretched, are
now elongated, and a separation between the two recti
abdominis muscles (known as a diastasis or divarification)
might be present.This can vary between a small vertical gap 2–
3 cm wide and 12–15 cm long to a space measuring 12–20 cm
in width and extending nearly the whole length of the recti
muscles.

5. The pelvic floor will almost certainly be weaker than it was prior
to the pregnancy. In addition to the stretching and trauma
sustained during vaginal delivery, its muscles and connective
tissue, will by the end of the 9 months have been partly
responsible for continuously supporting as much as 6 kg of extra
pelvic and abdominal weight (i.e. baby, uterus, placenta
and liquor).
The perineum itself will have been considerably stretched. It
may also have been cut (episiotomy) or torn and then sutured,
with resultant bruising and oedema.

6. Oedema
• Many women will complain of heavy, oedematous, aching
legs, swollen feet and ankles in the immediate postpartum
period that may not have been apparent before the baby was
born. This may be unilateral or bilateral.

7. Back pain
• Back frequently develops following the birth. The passage of
the foetus through the pelvis, and the resultant stretching and
movement of the lax joints, epidural anaesthesia, lithotomy
position (especially if the legs were not placed and removed
from the stirrups simultaneously), poor feeding or nappy-
changing postures, tension and fatigue may all be causative
factors

8. • The breasts may become engorged, full and painful (even up
into the axilla where a ‘tail’ of breast tissue lies) when
lactation begins on the 3rd or 4th postnatal day.

9. POSTNATAL CARE

10. Routine care
• There is a mandatory requirement to attend the mother for
the first 10 postpartum days as necessary; this can be
extended to 28 days.
• Monitor the mother’s vital signs, assess the mother’s breasts,
abdomen and perineum, check on the haemoglobin level at
24 hours postdelivery and repeat this at a later date as a
preventative measure against anaemia

11. Pain management
• It can be done with support, positioning, transcutaneous
electrical nerve stimulation (TENS), ice, pulsed electromagnetic
energy , (PEME), pressure-relieving cushions, etc., to establish
breastfeeding.
Ergonomic advices- postural cares

14. Further Physiotherapy Aims
• The principle aim should be to aid the body’s recovery and
encourage an interesting and safe exercise regimen .
• Ideally, the women’s health physiotherapist should assess each
new mother as soon as possible postdelivery, in order to
determine her priority needs.
RED FLAGS
• diastasis recti abdominis
• inability to voluntarily contract the pelvic floor
• perineal pain or discomfort
• symphysis pubis pain or referred pain
• back pain or discomfort.

15. • The new mother should be encouraged to be mobile and
therefore reduce the risk of circulatory and respiratory
dysfunction. If she is confined to bed for a prolonged period of
time then ‘controlled’, and deep breathing and ‘vigorous’
circulatory exercises should be encouraged.
• Pelvic floor muscle exercises are valuable for their
strengthening and pain-relieving properties.

16. • Two essential pieces of early advice to achieve physical relief
and increase confidence are:
1. Contract the pelvic floor muscles (PFM) every time the intra-
abdominal pressure increases, e.g. on coughing, sneezing or
laughing.
2. Support sutures by applying pressure (hand) to the perineum
(or using a sanitary pad )until the perineal pain subsides

17. Head –lift exercise
Patient position and procedure: Hook-lying with her hands
crossed over midline at the level of the diastasis for support.
Have the woman exhale and lift only her head off the
floor or until the point just before a bulge appears. At the
same time, her hands should gently approximate the rectus
muscles toward midline

18. Head lift

19. Pelvic Tilt Exercise
Patient position and procedure: Quadruped (on hands and
knees). Instruct the patient to perform a posterior pelvic
tilt. While the patient keeps her back straight, have her
isometrically tighten (imagine drawing in) the lower abdominals
and hold, then release and perform an anterior tilt
through very small range.
Have the woman practice pelvic tilt exercises in a variety
of positions, including side-lying and standing.

20. Leg Sliding
Patient position and procedure: Hook-lying with pelvis in
a posterior tilt. Instruct the woman to hold the pelvic tilt as
she slides one foot along the floor until the leg is straight
or to the point at which she is unable to maintain the pelvic
tilt. Have her slowly slide the leg back to the starting position,
then repeat with the other leg. Breathing should be
coordinated with the exercise so that abdominal contractions
occur with exhalation.

21. Trunk Curls
Curl-downs and curl-ups are classic abdominal exercises
for rectus abdominis strengthening and can be used if
tolerated and no diastasis recti is present. Have a pregnant
patient protect the linea alba with crossed hands
while performing trunk curls.