PTY3051 Week 8: Physiotherapy for the pregnant & 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)

Pelvic girdle pain & LBP in pregnancy: signs & symptoms

- 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)

Pelvic girdle pain & LBP in pregnancy: management

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

- SIJ stability belt

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

- Gait aid (if severe pain in SLS)

- Education: most will resolve spontaneously at birth

- Limited evidence: acupuncture, osteomanual therapy, craniosacral therapy

Abdominal diastasis: definition and impact

Definition: Midline separation of rectus abdominis along linea alba

Impact:

- Weaker abdominal muscles

- Predisposition to LBP & PGP

- ↓ Health related QOL

- Pelvic organ prolapse

Assessment for DRAM

- Patient in crook lying, performing a mini-sit up

- 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)

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

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?

Activities to avoid in pregnancy

- Lying supine (due to compression of inferior vena cavae)

- 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

Process of labour

Stage 1:

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

- Baby moves down into pelvis

Stage 2:

- From full cervix dilation to baby delivery

- Contractions are less frequent but stronger

Stage 3:

- 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

Pain relief during labour

- Positions of ease / companionship

- Mobility, breathing

- Relaxation / music / acupuncture

- Massage / warm baths or showers

- Epidural / opiates (Entonox / Pethidine)

Antenatal injuries

- Levator ani defect (stretch due to large baby / forceps)

- Anal sphincter tear (e.g. due to episiotomy / instrument use)

Postnatal physiotherapy

- 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

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