exercise following

1. Exercise prescription in
Post-natal period
-Ms Lenita
Moderator- Ms Sidhi Mohopatra

3. • Post- after Natalis- birth
• The period beginning immediately after the birth of a
child and extending for about six weeks.
• The average hospital stay for spontaneous vaginal
delivery (SVD) is 1–2 days, and the average caesarean
section postnatal stay is 3–4 days.
• The mother is monitored for bleeding, bowel and bladder
function, and baby care.

4. Post-partum phases
• (Postpartum period: three distinct but
continuous phases. Journal of Prenatal
Medicine 2010; 4 (2): 22-25. Mattea Romano,
Alessandra Cacciatore , Rosalba Giordano
and peatrice La Rosa.)

5. Phase Duration Main features
Phase 1 (acute phase) 6-12 hours Period of crisis
Phase 2 (sub-acute) 2-6 weeks Major changes
Phase 3 (delayed post-
partum)
Up to 6 months Residual complications

7. Musculoskeletal Neurological
Laxity of ligaments and
muscles
Nerve traction injuries
Diastasis Nerve plexus injuries
Decreased mechanical control
of abdominal corset
Compression syndromes
Weakened pelvic floor
muscles
Bladder/ bowel dysfunction
Back pain Analgesia induced sensory
and motor deficit

8. Musculo skeletal adaptations
• Anatomical and physiological changes during pregnancy have
the potential to affect the musculoskeletal system at rest and during
exercise.
• The most obvious of these is weight gain.
• The increased weight in pregnancy may significantly increase the
forces across joints such as the hips and knees by as much as
100% during weight bearing exercise such as running.
• Such large forces may cause discomfort to normal joints and
increase damage to arthritic or previously unstable joints.
• Because of anatomical changes, pregnant women typically develop
lumbar lordosis, which contributes to the very high prevalence
(50%) of low back pain in pregnant women.
• Balance may be affected by changes in posture, predisposing
pregnant women to loss of balance and increased risk of falling

9. • Numbness of the perineum in the first few hours.
• Pain caused by labial tears, episiotomy, oedema and
haematoma.
• PFM contractures.
• Increased urine output.
• Urgency, pain on micturation, stress incontinence,
retention of urine and occasionally faecal incontinence.
• Women who have had an epidural may have impaired
bladder sensation.
Genito-urinary

10. Vascular Psychological
edema Postpartum depression
Varicose veins Baby blues
DVT Baby pinks
Pulmonary embolism
thrombophlebitis

11. Impairments Tool
Pain VAS
Pelvic floor weakness digital examination
Abdominal muscle
weakness
Palpation
Urinary incontinence Pad method, voiding
diary.
Fatigue Brief fatigue inventory
Impaired bladder
sensation/ volition
Bowel/ bladder exam
Diastasis Palpation
Compression injuries Sensory, motor exam,
NCV
Activity Limitation
Impaired bed mobility
Difficulty in moving out of
bed and ambulation
Discomfort while laughing
or sneezing
ADL dependence

12. Thomson`s et al (2002) study proposed (n=1295)
that: -
- Primiparas= were most likely to report perineal
pain and sexual problems.
-Caesearean births (when compared to unassisted
vaginal deliveries) .Were most likely to suffer
exhaustion and bowel problems.Reported less
perineal pain and urinary incontinence .Were most
likely to be readmitted.
-Forceps delivery (when compared to unassisted
vaginal deliveries) Reported more perineal pain

13. Symptoms to look out for / consider referral
on include: - Diastasis rectii abdominis-
Inability to voluntary contract the pelvic floor
- Perineal pain or discomfort - Symphysis
pubis pain or referred pain - Back pain or
discomfort

17. • Mother should be encouraged to be mobile and thereby reduce the
risk of circulatory and respiratory dysfunction
• If confined to bed for prolonged period of time- controlled and deep
breathing exercise and vigorous circulatory exercises should be
encouraged
• Pelvic floor muscle exs- for strengthening and pain relieving
properties.
• Finding the right starting position for the exercise will be the key to
effectiveness.

18. essential point-
•Contract the pelvic floor muscles every time
the intra-abdominal pressure increases
•A more efficient contraction may be obtained
by contracting the transverse abdominus,
before engaging the pelvic floor muscles.

19. Type Mode Intensity Frequency Duration Progression
Aerobic walking,
aerobic
dance,
swimming,
cycling.
Moderate 3-
4 METS. 50-
60% VO2
max.
RPE: 12-16
30 minutes
per day most
days of the
week.
20-60
minutes as
per patient
tolerance.
Increase
exercise
duration
slowly.
Flexibility
Aquatic
exercise
ROM ex’s
full mobility
Strength Light
weights/incre
ased reps.
12 reps,
individually
tailored with
monitoring.
Precautions: supine position, increased joint compression.

20. Procedure indications Precautions
“Squeeze and
lift”
Slow and fast
contractions
3 sets of 8-12
contractions.
Urinary
incontinence
Faecal “
Bladder/urethr
al prolapse
Nerve injuries
Hypertensive
patients.
Full bladder
Prevent breath
hold

21. Stage Procedure Precautions Progression
Stage 1 The deep
abdominals
breathing control Prone, side-lying
and quadruped.
5-10 reps.
10 second holds
10 times
Stage 2 the pelvic
tilt.
Avoid tightly
flattening
abdomen.
Stage 3 the head
lift
Avoid sit-up,
twisting
Progress to
shoulder lift

22. • ABSOLUTE CONTRAINDICATIONS TO EXERCISE (ACOG)
• Haemodynamically significant heart disease • Restrictive lung
disease • Functional weakness of cervix • Premature labour during
the current pregnancy • Ruptured membranes
• REALTIVE CONTAINDICATIONS (ACOG)
• Severe anaemia • Unevaluated maternal cardiac arrhythmia • Chronic
bronchitis • Poorly controlled type I diabetes • Extreme morbid
obesity • Extreme underweight (body mass index <12) • History of
extremely sedentary lifestyle • Poorly controlled hypertension •
Orthopaedic limitations • Poorly controlled seizure disorder • Poorly
controlled thyroid disease

24. • Head should be in line with the trunk
• Maintain natural curves of the spine
• Avoid hyperextension
• Avoid in toeing
• Asymmetrical weight
• Shoulders relaxed and arms held loosely at the side

25. • Fully supported with pillows.
• Uncross legs
• Avoid sustained isometric trunk flexion, rotation.
• Keep movement within sagittal plane
• Perform activities at an appropriate height

26. • Kneel Sitting:
• Bilateral
• Half kneel sitting:
• Unilateral-sitting on one
Heel,other hip forward flexed
With foot flat on the floor

27. • Nappy changing-
-Nappy changing is a another activity that can result in pain
-Positions that increase the risk to the mother should be
avoided for eg sitting with knees extended and trunk
flexed
-erogonomic positions should be explained to the mother
-suggested positions for nappy changing could be sitting
standing and kneeling

28. • Meditation
• Mental imagery
• Deep breathing
• Yoga
• Jacobsson’s Technique
• Progressive relaxation technique

29. Musculoske
letal
Genitourina
ry
Neurogenic psychologic
al
Circulatory
Conditions Diastasis
Recti
Back pain
Coccdynia
Symphysis
pubis pain
After pains
Stress
incontinencef
aecal
incontinence
Perineal
tears
Lacerations
Genital
prolapse
Plexus
injuries
Compression
syndromes
Postpartum
depression
Maternity
blues
Puerperal
psychoses
PND
Varicose
veins
Edema
Superficial
vein
thrombosis
DVT
Pulmonary
embolism
Treatment Thermal/cold
modalities,
Mob,
Relaxation,
muscle re-
education
PF ex’s,
timed voiding
techniques,
catherterizati
on.
NMES,
muscle re-
education,
Hospitalizati
on, anti-
psychotic
drugs,
counseling.
Stockings,
elevation,
ATM’s,
general ex’s.

30. Perineal pain
• Pelvic floor muscle exs- - repeated voluntary contraction and
relation will relieve the pain..............repeated pumping action assist
venous and lymphatic drainage and the removal of traumatic
exudates, thus relieving stiffness and restoring function.
• Ice ( moore & james 1989) compared 3 topical agents with cold
therapy in the treatment of post episotomy position. Ice gave better
pain relief
• Crushed ice wrapped in a damp disposable gauze or a disposable
wash cloth and applied to the affected are for 5-10mins (plastic acts
as an insulator therefore effectiveness is reduced)
• Ice cube massage-an ice cube held in a tissue and used by the
woman herself while on the bed or sitting in the toilet can give
excellent pain relief

31. • Ultrasound –
• To increase temp, in turn increases blood flow and increases repair.
Twice daily and does not interfere with functional acivities -
Treatment is best in crooked lying or sidelying position (for better
visualisation of area) - Ultrasound head is then appled through a
coupling gel medium, and in accordance with local infection
guidelines - Pulsed ultrasound is used for analgesic and exudates
removing properties - Initial treatment- 3MHz, 0.5W/cm, and 2mins
per head sized area was used.

32. • Effectiveness of physical therapy for pregnancy-
related low back and/or pelvic pain after delivery: A
systematic review. 2012. (1)
• Pain showed consistent decrease.
• Stabilization ex’s performed under supervision showed
better results.
• The Efficacy of a Treatment Program Focusing on
Specific Stabilizing Exercises for Pelvic Girdle Pain
After Pregnancy A Randomized Controlled Trial. (2)
2004.
• Significant improvements in pain, QOL and function
compared to placebo.

33. •Stabilization exercises in postnatal low back pain.
2011.
--The second group showed statistically significant
differences in pain reduction.
An alternative intervention for urinary incontinence:
Retraining diaphragmatic, deep abdominal and pelvic
floor muscle coordinated function. 2010
Improved self reported symptoms
Improved quality of life
Decreased leakage
No change in PFM strength

35. • A comparison of high- versus low-intensity, high-
frequency transcutaneous electric nerve stimulation
for painful postpartum uterine contractions. 2007
• Women treated with HI TENS experiences lesser pain
and discomfort than LOW TENS.
• However discomfort of stimulation was higher in HI
TENS group.
• Transcutaneous Electrical Nerve Stimulation After
Caesarean birth. 2007.
• Decreased pain
• Parameters used: carbon electrodes, frequency: 100 pps
and pulse duration: 140-170 msec.

36. • Effect of behavioural training with and without pelvic floor
electrical stimulation on stress incontinence in women. 2003.
• No significant improvement in NMES group in terms of
decreased leakage.
• Parameters: Frequency: 20 Hz, Current: biphasic, pulse
width: 1 millisec, duty cycle: 1:1 and intensity: 0-100 mA.

37. • Therapeutic ultrasound for postpartum perineal pain and
dyspareunia. Cochrane review. 2009
• Decreases in acute pain and edema
• Increased bruising at 10 days
• Decreased long term discomfort.

38. • A randomised controlled trial to compare the
effectiveness of icepacks and Epifoamwith cooling
maternity gel pads at alleviating postnatal perineal
trauma. 2000.
• Ice packs showed greater beneficial effect on pain,
bruising and oedema.
• Comparison of application times for ice packs used
to relieve perineal pain after normal birth: a
randomised clinical trial. 2007.
• 10, 15 and 20 minutes application showed no significant
differences in pain.

39. • Adverse events from spinal manipulation in the
pregnant and postpartum periods: a critical review
of the literature. 2012.
• SMT could be performed safely in post-partum women
with precautions.

40. PT treatment
interventions

41. • 5-10 reps of each exercise.
• Bridging
Progression: weight
shifts
Progression: single leg bridge

42. Alternate with
opposite UE and LE

47. • 1. Ferreira CWS, Alburquerque-Sendn F. Effectiveness of
physical therapy for pregnancy-related low back and/or pelvic
pain after delivery: A systematic Review. Physiotherapy Theory
and Practice, 2012; 1-3. (published online).
• 2. Stuge B, Lærum E , Kirkesola G, Vøllestad P. The Efficacy of
a Treatment Program Focusing on Specific Stabilizing
Exercises for Pelvic Girdle Pain After Pregnancy A Randomized
Controlled Trial. SPINE Volume 29, Number 4, pp 351–359, 2004.
• 3. Vairajothi K, Chitra TV, Baranitharan R, Mahalakshmi V. A
comparative study of the therapeutic effect of pelvic floor
exercises and perineometer among women with urinary stress
Incontinence. IJOPT, 2005, volume 5; number 1, pg 33-36.
• 4. Amar TA. Stabilization exercises in postnatal low back pain.
Indian Journal of Physiotherapy and Occupational Therapy. 2011,
Vol. 5, No.1.

48. • 5. Hsiu-Chuan Hung et al. An alternative intervention for
urinary incontinence: Retraining diaphragmatic, deep
abdominal and pelvic floor muscle coordinated function.
Manual Therapy 15 (2010) 273–279.
• 6. A randomised controlled trial to compare the effectiveness of
icepacks and Epifoamwith cooling maternity gel pads at
alleviating postnatal perineal trauma. Midwifery, 2000; 16, 48-55.
• Hay-Smith J. Therapeutic ultrasound for postpartum perineal
pain and dyspareunia. Cochrane Database of Systematic Reviews
1998, Issue 3.
• 7. Doumulin C et al. Pelvic floor rehabilitation , Part II: Pelvic
floor re-education with interferential currents and Exercise in
the Treatment of Genuine Stress Incontinence in Postpartum
Women --A Cohort study. PHYS THER. 1995; 75:1075-1081.
• 8. Goode PS et al. Effect of behavioural training with and
without pelvic floor electrical stimulation on stress
incontinence in women. 2003. JAMA 2003- vol 290, no 3.

49. 9. Stuber KJ, Wynd S, Weis CA. Adverse events from spinal
manipulation in the pregnant and postpartum periods: a critical
review of the literature. Chiropractic & Manual Therapies 2012,
20:8
10. Sonia MJV Oliveira et al. Comparison of application times for
ice packs used to relieve perineal pain after normal birth: a
randomised clinical trial. PHYS THER. 1995; 75:1075-1081.
11. Hay-Smith J. Therapeutic ultrasound for postpartum perineal
pain and dyspareunia (Review). 2009 The Cochrane
Collaboration.
• Textbook of obstetrics and Gynaecology Jill Mantle.
• Jeffcoate’s principles of obstetrics and Gynaecology.