Physiotherapy in the Postnatal Setting 2026

take home messages

physios have a large role in helping women with maternal birth trauma

referring women with pelvic floor trauma an diastasis of the rectus abdominis for early assessment on the ward is key

the role of physio in following up patients with 3rd and 4th degree tears (OASI) is crucial

return to exercise in the postnatal period can help improve QOL in the new mother- physios play a large role in guiding this process

post natal physio care concern areas

pelvic floor dysfunction

encourage to mobilise

c-section precautions

breastfeeding positions

ADL’s

urinary and faecal incontinence

rectus diastasis check

OASI (obstetric anal sphincter injury)

good bladder and bowel habits

perineal care

baby advice

urinary retention and overflow incontinence

** perineal tears **

1st degree: injury to perineal skin only

2nd degree: injury to perineum involving perineal muscle only

3rd degree: injury to perineum involving anal sphincter complex

• 3a: less than 50% EAS torn

• 3b: more than 50% EAS torn

• 3c: both EAS and IAS torn

4th degree: injury to perineum involving EAS, IAS, and anal epithelium

= 3c and 4 = worst outcomes

EAS / IAS

external anal sphincter

internal anal sphincter

OASI

obstetric anal sphincter tears

• 3rd and 4th degree perineal tears

risk of OASI

long second stage

not having epidural (having 1 is protective of PFM dysfunction)

2.6x more likely to have an OASI if you don’t have an epidural

levator ani avulsion

tear of levator ani muscle at its insertion on pubic rami

can cause long term PFM dysfunction, prolapse, urinary incontinence, pain

occurs in 10-30% of women

no consensus regarding surgical management

no effective treatment at this time

aim for prevention

risk of levator ani muscle (LAM) avulsion

13-36% of women after vaginal delivery (primarily first birth)

VE marginal increase in risk

forceps 4.5 increase risk compared to vacuum

forceps compared to NVD 7x more likely

fundal pressure more likely to have LAM avulsion

• larger genital hiatus - may lead to POP complications later

• not the role of physio to tell patients how to deliver - give research based education

  • just be aware if they have had this, the risk of them having avulsion is higher

total trauma of pelvic floor

Caudwell et al (2020)

• Looked at both LAM and OASI

• The following delivery mode specific trauma rates:

  • Caesarean section 0%

  • Vacuum 46%

  • NVD 32%

  • Forceps 97%

PATIENTS AT RISK OF PELVIC FLOOR DYSFUNCTION

Long second stage (>90 min)

Baby >4kg (>3.5 kg in southeast Asian and Indian women)

Instrumental delivery, e.g. Neville Barnes forceps

3rd or 4th degree tear, especially 3c and 4th

Maternal age

Multiparity

History of constipation / urinary incontinence / faecal incontinence

CLINICAL CARE STANDARD- 7 QUALITY STATEMENTS

1. Information, shared decision making and informed consent

2. 2. Reducing risk during pregnancy, labour and birth

3. Instrumental vaginal birth

4. Identifying third and fourth degree perineal tears

5. Repairing third and fourth degree perineal tears

6. Postoperative care

7. Follow-up care post-discharge

prevention of birth trauma

identify who might be at risk

work to help facilitate stretch and opening of genital hiatus

education and awareness of contract/relax and bear down- using tools such as U/S

perineal massage

the acute postnatal patient - things to consider

what day post natal ?

how is the baby doing?

emotional response to mode of delivery (ie. anger, disappointment)

have they had major trauma ? how are we going to change our education?

what can they take in at this time?

length of stay

variable from hospital to hospital

during COVID-19 LOS is hours in some circumstances

• generally public vaginal delivery stay overnight

• low risk / not first childbirth - may go home sooner (4h min); LSCS 3 days

• private: vaginal delivery 4 days, LSCS 5 days

management of perineal trauma

1. rest the pelvic floor, avoid strengthening for up to a week / months

   1. circulatory exercise and the knack for pain management

   2. may need IDC for first 24-72h

2. ice for the first 24-48 hr. not directly to perineum. can do inside a pad or cold gel back. warning given. 5-10m. dry after removal

3. elevation. lie prone with 1 pillow under head, 1 under abdomen and 2 under hips

4. compression, firm underwear with pad

OASI management

should be repaired in OT

1. educate patient about injury- right to know - what this means for them (compliance)

2. early Rx = RICER

3. wound support (protect stitches) not a strain, positioning, brace and bulge, wound support for perineum, on urge voiding. bristol stool scale

4. ADL advice during recovery period, no swimming, positioning to breastfeed, sit etc. ADL’s including sex

5. PFMT- would this be appropriate if there is also a risk of a an avulsion

6. hygiene, pain relief, healing time- straining and infection are the enemy and biggest threat to stitches

PFM and 3rd and 4th degree tears

increased likelihood of larger tear:

• baby’s shoulder becomes stuck behind pubic bone

• greater than 90m 2nd stage labour

• first vaginal birth

• no epidural

• large baby (greater than 4kg)

• instrumental delivery (forceps)

• increasing maternal age with first SVD

episiotomy

usually comparable to 2nd degree

should be 60deg from midline, medial-lateral or lateral (not midline)

in operative delivers: reduce OASI- 40% reduction in OASI overall

if using forceps, reduce risk of OASI by 68% in 1/8 women particularly in first babies

caution - shouldn’t be done routinely

post natal pelvic floor Rx

rest and elevation (not overdoing PFMT)

ice

compression

the knack

avoid straining

good hygiene

allow for natural recovery

education

good bowel habits

good toilet position (squat)

avoid constipation

empty on 1st urge

don’t strain

stool softeners may have a role post partum

good bladder habits

drink 2L of fluids

4-6 per day normal voiding

0-2 per night

300-500mll volume

ignore first urge

sit! don’t hover

rule out retention and overflow if complaining of urinary incontinence

other issues you may see on the maternity ward

c-section usually LSCS (lower segment c-section)

DRAM

mobility issues (pubic symphysis rupture during delivery, coccyx #)

mastitis

bed rest for incompetent cervix

epidural headache

foot drop

incontinence - over flow and retention

post partum incontinence

Urethral hypermobility from fascial softening

Urethral sphincter dysfunction from pudenal neuropathy

post C- SECTION precautions

no lifting heavier than baby 6/52

no driving 2-3 weeks

early abdominal binder for comfort and pain relief

check to make sure mother is voiding after catheter removed

early mobilisation (show them how)

no heavy ADL’s 6 weeks

recovery post c-section

supportive cough

DVT prevention - circulatory exercises

stand upright - scar formation

scar massage

mobilising

correct bed transfers

use support /support

DRAM- rectus diastasis

increased distance between RA bellies

70-100% in third trimester

tx: bird-dogs, crunches, dead bugs

DRAM size

mild <3cm

moderate 3-5cm

severe >5cm

assessing for DRAM

palpation of medial borders of rectus on head lift

can use finger width measures, tape, calipers, and U/S (gold standard)

unreliable?

still is used most commonly in clinical practice as it is easy and quick

dial calipers have been found to have intra-rater reliability

DRAM- testing technique

patient supine, no pillow, legs straight/knees up

fingertips placed at umbilicus with hand perpendicular to the abdominal wall

ask woman to raise her head as as comfortable off the bed

linea alba will feel soft under fingertips

palpate firm medial borders of the RA on either side of fingers

measure:

• 5cm above and below umbilicus and at umbilicus

• or document where you have measured n

• check with local hospital protocol

DRAM treatment

research improving

tubigrip resulted in 7% decrease in the IRD at rest

trunk curl reduced it by 19%

early postnatal - curl up

after 2-3 months - maybe more abdominal wall work - broad training program

coccyx fracture

wedge cushion, cut out area for coccyx (no ring cushions)

no PFM exercises in the first few months

impossible to immobilize so delayed recovery

show how to get in and out of bed

change feeding positions

post ruptured pubic symphysis

immobilize PS for 48h legs together

bed rest for 48h with IDC

ice every 4 hours

after 48h- mobilize with walking frame and progress to crutches

support belt to support the joint

educated to minimize at the joint

abdominal bracing

mastitis- inflammation in the lactating breast

rx may include therapeutic U/S, lymphatic massage, education

return to exercise post partum

3x / week, 30m at 6/52 post partum

no difference at 12/12 on PFM strength / endurance

no difference in SUI and POP at 12/12

BMI 25-30 twice as likely to have SUI

BMI> 30 3x more likely to have SUI

low impact probably better

return to activity post partum

wk 0-6 - return to exercise

• pelvic floor muscle training

• gradual return to walking- start with 10m/day, increase by 5m/ week

• monitor for signs and symptoms that may be indicative of risk factors for other health concerns

wk 4-8 - return to exercise

• general body weight

• progress to weighted for all major muscle groups

• low impact cardio- monitor for signs and symptoms

wk 6-10 - return to participation

• begin adding in activity specific functional exercises, increase aerobic capacity by progressing the duration before intensity

wk 10-14 - return to sport

• begin return to sport specific training/practices, progressing intensity, make it goal specific

wk 12+ - return to competition

• physical and mental readiness

• follow up if showing signs and symptoms

post natal return to exercise assessment part 1

for high impact, high velocity activities (running, skipping, etc) includes levator hiatus diameters at rest and on Valsalva, avulsion risk factors such as forceps delivery and maternal age of first NVD

post natal return to exercise assessment part 2

for stationary exercise like UL weights / lunges / squats

includes PFM contraction strength, peritron pressure, current PF disorders

gives a risk of high, medium or low risk for returning to exercise

all good objective guide for the clinician

Risk Factors for potential issues to return to running- 2019 guidelines

Less than 3/12 post natal

Pre-existing hypermobility

Breastfeeding

Pre-existing PF dysfunction

Psychological issues which may predispose a postnatal mother to inappropriate intensity and/or duration of running as a coping strategy

Obesity

Caesarian section or perineal scarring

Relative energy deficiency in sport ( RED -S

2019 RETURN TO RUNNING-POSTNATAL GUIDELINES- additional factors to consider

weight BMI > 30

fitness

breathing

psychological status

DRAM

breastfeeding

professionally fitted sports bra

scar mobilization- c/s and perineal scars

supportive running shoes

supportive underwear

sleep deprivation

RED-S

WHEN TO REFER TO WH PHYSIO IN OUTPATIENTS

pelvic pain, pain with sex, vaginal pain, and any suspicion of an overactive pelvic floor

suspected PFM dysfunction that is not jsut weakness

frequency and urgency

the need for vaginal exam

post partum with OASI tear, forceps delivery

anything not responding to your initial suggestions and unsure where to go next

FLAGS FOR PELVIC FLOOR DYSFUNCTIONS

any loss of urine / faeces / flatus

urgency

feelings of heaviness or dragging sensation

low back ache

unable to use tampons

pain with sex

birth trauma / forceps