Week 8 (Physiotherapy for the pregnant and post-natal client)

Cardiovascular adaptations during pregnancy

- ↑ blood volume

- ↑ HR & CO

- ↓ systemic vascular resistance (can cause ↓ BP)

Respiratory adaptations during pregnancy

- ↓ thoracic cage expansion & high diaphragm (ribs have expanded & diaphragm lifted due to presence of baby)

- ↓ lung volumes

- ↓ oxygen availability for prolonged strenuous exercise

Biomechanical adaptations during pregnancy

- Weight gain & expanding uterus

- Relaxin: ↑ flexibility & joint mobility

- Shift in COG

- Lumbar lordosis & thoracic kyphosis

- Gait changes: shorter & wider stance, ↑ double support phase

- ↓ balance (↑ falls risk)

causes of PGP and LBP

• multifactorial

• secondary to postural changes

• load on ligaments

• hormonal changes (Relaxin)

signs and symptoms of pelvic girdle pain & LBP in pregnancy

- Pelvic pain (front or back)

- One-sided / bilateral or moving

- May have referred pain to the buttock or posterior leg

- Aggravating factors include lying supine (due to load on sacroiliac ligaments), STS, hip abduction, or single leg movements (e.g. stairs)

management of PGP and LBP

- Core stabilisation (i.e. TA activation) with exercise (especially LL): Can ↓ LBP, sick leave & improve functional disability

- note: whole body active exercise required not just core stability (major muscles of LL to provide support for increased load)

- SIJ stability belt

- Advice on lumbopelvic posture, especially in driving, lifting & other ADLs

- exercise for posture and reduction of thoracic kyphosis (seated rows, bent over rows)

- Gait aid (if severe pain in SLS)

- Education: most will resolve spontaneously at birth

- Limited evidence: acupuncture, osteomanual therapy, craniosacral therapy

Abdominal diastasis

• Midline separation of rectus abdominis along linea alba

• associated with weaker abdominal muscles, predisposition to LBP & PGP, pelvic organ prolapse

Assessment for DRAM

- Patient in crook lying, performing a mini-sit up (pt lifts head and shoulders off plinth)

- Distance between borders of rectus abdominis is measured 2cm above and below, and at level of umbilicus

- > 2.3 - 3.3cm is significant

Management of abdominal diastasis

- Abdominal & PFMT exercises commonly used clinically (for return to functional strength)

- note: abdominal exercises must train ALL muscles not just TA and IO (prevent widening of gap as opposed to narrowing)

- May use abdominal compression stockings in first 6 - 12/52

- may require surgical management if conservative not effective

medical conditions to be aware of during pregnancy

• gestational diabetes (exercise can help)

• cervical incompetence (risk of premature labour)

• antepartum haemorrhage

• placental abruption

• placenta praevia

• intrauterine growth restriction

• pre-eclampsia/eclampsia (pregnancy induced hypertension)

exercise guidelines during pregnancy

include:

defining physical activity intensity in pregnancy

• moderate intensity: HR 125-146bpm in those under 29, 121-141bpm in those over 30

• vigorous intensity: HR 147-169bpm in those under 29, 142-162 in those over 30

Absolute contraindications for exercise in pregnancy

Can perform ADLs, but may not tolerate exercises

- Poorly controlled T1DM, HT or thyroid disease

- Cervical incompetence (thin / weakened cervix)

- Pre-eclampsia (pregnancy induced hypertension)

- Persistent 2nd / 3rd trimester bleeding

- Placental abruption (separation of placenta before birth)

- Placenta praevia (low placenta, close to or over cervix)

- Intrauterine growth restrictions

Relative contraindications for exercise in pregnant women

- Gestational HT

- Cardiovascular (e.g. anaemia) / chronic respiratory diseases

- T1DM

- Poorly controlled seizure disorder

- Recurring pregnancy loss

- History of spontaneous miscarriage, preterm birth or foetal growth restrictions

Exercise guidelines for pregnant women

- Should all be physically active in absence of contraindications (which they should be aware of)

- 150 - 300/60 moderate intensity PA or 75 - 150/60 vigorous intensity PA weekly (consult OB for risks)

- Appropriate intensity: "Talk test" / Borg 12 - 14

- 2x strength training weekly

- Minimising prolonged sitting periods

Benefits of exercise in pregnancy

- ↑ cardiovascular fitness, muscle strength & endurance

- ↓ risk of gestational diabetes & pre-eclampsia

- ↓ excess weight gain, helping with body image

- Improved pelvic floor function

- May help with management of LBP & PGP?

screening tool for exercise during pregnancy

ESSA

Activities to avoid in pregnancy

- exercising in supine (due to compression of inferior vena cava)

- Contact sports / risk of falling or trauma (e.g. footy, water skiing), though can participate in non-contact drills

- Hot, humid or if febrile

- Skydiving / scuba diving

- Valsalva manoeuvre (heavy lifting)

- Ballistic / jerky movements, or taking joints to end of range

Stage 1 of labour

• From onset of contractions to full (10cm) cervix dilation

• baby moves down into pelvis

Stage 2 of labour

• From full cervix dilation to baby delivery

• Contractions are less frequent but stronger

Stage 3 of labour

From baby delivery to placenta delivery

Differences between Braxton-Hicks contractures and labour contractures

Braxton Hicks: irregular, painless contractions

Labour: painful and regular (interval shortening) contractions

positioning during labour

• stage 1: upright posture, pelvis open

• stage 2: posterior pelvis not fixed (not supine)

• stage 3: position most comfortable for mother

Pain relief during labour (coping strategies)

- Positions of ease / companionship

- Mobility, breathing

- Relaxation / music / acupuncture

- Massage / warm baths or showers

- Epidural / opiates (Entonox / Pethidine)

conservative pain relief during labour

• TENS

• acupuncture

• hypnosis

pharmacological pain relief during labour

• entonox (NO and O2)

• pethidine

• epidural

levator ani muscle (LAM) defect

• due to stretching of LAM to 3x of its normal length

• partial or full avulsion from origin near pubic symphysis (may also cause damage to pudendal nerve)

risk factors for LAM defect

• large baby (>4kg)

• forceps delivery

• large fetal head circumference

• prolonged second stage labour

• 3rd/4th degree perineal tear/sphincter rupture

anal sphincter tear

damage to perineal body and anal sphincter

risk factors for anal sphincter tear

• episiotomy

• instrumental deliveries

• posterior presentation

• associated with anal incontinence

Postnatal physiotherapy (on ward)

- Postnatal exercise classes

- Assessment of DRAM and PFM contraction

- PFMT exercise prescription

- Advice on posture, back care, breastfeeding positions and warning signs of pelvic floor dysfunction

- Wound care for vaginal & caesarean delivery

- Mastitis management

Postnatal physiotherapy (6 weeks-6 months)

• assessment of symptoms of PFD

• assess PFM (Strength, endurance, correct contraction etc)

• return to sport/exercise advice

• management of mastitis

• exercise advice

post-natal pelvic floor recovery timeline

includes:

Return to sport / exercise in postnatal periods

0 - 6/52:

- Gentle walking as tolerated (+/- static cycling if able)

- Focus on recovery & PFMT

6/52 +:

- Gradual ↑ in exercise levels (e.g. resistance) to prenatal levels

- Refer to PF physio for return to high-impact sports

- Dependent on PFD & DRAM

considerations for return to sport/exercise

• pelvic floor muscle function and passive tissue integrity

• pregnancy/birth related complications

• exercise load