Van Vuuren Physiotherapist


PREGNANCY



During pregnancy, a woman’s body goes through obvious physical changes that literally shift their organs and bones, change their center of mass and redistribute their blood flow. The physical changes of pregnancy are so normal, yet they are also extreme. Our bodies are incredible and are designed to accommodate and adapt to these changes. But sometimes, the process is not as comfortable as we’d like it to be.


Then comes childbirth.There is often tearing, stretching and cutting that requires sewing back together and may lead to debilitating scar tissue formation or weakness. Just like any muscle in the body that gets torn, stretched or cut, proper rehabilitation can help guide the healing process and protect the injured tissue so that it can return to its strongest state.


The natural changes during pregnancy and delivery have an impact on the pelvic floor muscles and the connective tissue. It can cause discomfort and pain either during the pregnancy or after the pregnancy.



Ante-Natal



Physiotherapy during pregnancy can treat any pregnancy related pain or discomforts and can help to prevent perineal treating and optimizing delivery.

Treatment:


o Muscular skeletal pain

o Pelvic girdle dysfunction (45% of pregnant women)

o Low back pain (40-60%)

o Neck pain and Headache due to postural changes

o Stress Incontinence (19.9%- 70%)  Chest/ lung and sinus

o Perineal massage: massaging the perineum around the vagina in preparation for vaginal birth.it is theorized that perineal massage improves flexibility, decreases resistance, and therefore reduces tearing and the need for episiotomy.

- Preparing the pelvic floor muscles for vaginal birth to minimize the change for tears or injuries. The pelvic floor muscle must be free from trigger points, must be able to contract and relax and lengthened.

o Exercises during pregnancy:

- In pregnancy the aim should be to maintain, or moderately improve, the level of fitness whilst in the post-natal stage is to regain, then improve the former level of fitness.

- Pregnancy should not be a state of confinement, and pregnant woman with uncomplicated pregnancies should be encouraged to continue and engage in physical activities

- THROUGHOUT YOUR PREGNANCY, BE AWARE THAT YOUR HEALTH AND THE HEALTH OF YOUR FETUS MAY CHANGE, THUS AFFECTING YOUR ABILITY TO EXERCISE OR EXERCISE AT SPECIFIC INTENSITIES. ALWAYS EXERCISE UNDER THE CONTINUED GUIDANCE OF YOUR HEALTH SPECIALIST


This advice is only a guide, for more specific information relating to your own situation, speak to your doctor.


Exercise in Pregnancy & Post-Partum:

In the absence of contra indications, a pregnant lady can start with regular, moderate intensity physical activity to continue to derive the same associated health benefits during pregnancy as before pregnancy.

Potential benefits of exercise

o Helping you to stay within a healthy weight

o Reducing your risk of pregnancy related diabetes (gestational diabetes)

o Reducing your risk of pregnancy related hypertension

o Reducing your risk of a preterm birth

o Reducing your risk of developing varicose veins

o Reducing your risk of developing a deep vein thrombosis (a blood clot in your veins which normally results from excessive pressure on your veins and if the clot dislodges from the wall of the vein, it may result in a heart attack)

o It may also reduce the length of your labour

o It may also reduce your pregnancy related fatigue, stress, anxiety, and depression

o It may also increase your sense of well-being

o Improvement of body awareness, balance, co-ordination and posture

o Suggestion of a more rapid post-natal recovery

Absolute contra indication to aerobic exercise during pregnancy


o Serious heart, lung, renal or thyroid disease

o Poorly controlled type 1 diabetes

o Incompetent cervix - When a woman’s cervix is weak, her cervix is prone to shorten and open too early resulting in premature labour and child birth – i.e. a baby born before 37-38 weeks.

o Multiple gestation at risk for premature labour

o Persistent second or third trimester bleeding

o Placenta praevia after 26 weeks - where the placenta partially or completely obstructs the neck of the uterus.

o Ruptured membranes

o Pregnancy induced hypertension

o Premature labour during the current pregnancy

o Acute infectious disease

o Severe rhesus isoimmunisation

o Sudden swelling of ankles, hands or face


Warning signs to terminate exercise during pregnancy


o Abdominal pain

o Vaginal bleeding

o Dyspnoea before exertion, dizziness, faintness, palpitations or tachycardia

o Persistent severe headache

o Chest pain

o Muscle weakness

o Calf pain or swelling

o Preterm labour

o Decreased foetal movement

o Amniotic fluid leakage


Avoid after first trimester


o Avoid starting a new exercise programme until after 13 weeks' gestation

o Supine lying should be avoided as much as possible during exercise and rest from 16 weeks’ gestation. This position increases the risk of a reduced cardiac output (less oxygenated blood pumped out with each heart beat) and positional hypotension (low blood pressure) due to a pregnant woman’s enlarged uterus, which may obstruct venous return (blood flow back to the heart from the body’s tissues) or legs).

o Motionless standing

o Overstretching because of hormonal changes in ligaments

o Exercising to the point of fatigue.


Advice


o Eat for energy, although not immediately before exercising

o Use a chair , wall to help balance

o Beginning with reduced weight bearing exercises such as swimming, static cycling and the gym ball

o Start with simple and basic levels of exercise

o Exercise at least 3x per week for 30 minutes


Basic exercise prescription


o Improve cardiorespiratory level

- Aerobic exercise- large muscle groups in continuous rhythmic manner e.g. walking, swimming, cycling, dancing and jogging

o Musculoskeletal status

- Resistance exercise

o Flexibility exercise



Post-Natal



Physiotherapy after your pregnancy can be helpful for the following conditions:

o Cracked nipples, engorged breast, mastitis.

o Advice regarding breastfeeding

o Wound healing of the caesarean section or the episiotomy. Scar tissue can cause persistent pain and pain during intercourse. A tight caesarean scar can contribute to urgency and frequency.

o Diastasis rectus abdominis is the separation between the two Rectus Abdominis muscles that can cause low back pain, stress urinary incontinence and pelvic organ prolapse

The rectus abdominis muscle connects from the sternum all the way toward the pubic bone. The left and right Rectus abdominis muscles are separated by a dense band of connective tissue known as the linea alba. The linea alba is made from a continuation of our internal obliques, external obliques, and the transverse abdominal muscles.


The function of the abdominal musculature is to resist changes in intra-abdominal pressure (IAP), and transfer forces between our right and left sides during movement such as lifting our legs, twisting, etc. When there is a widening of these muscles and the linea alba becomes lax, we lose this ability, and it is possible that we may experience low back pain, weakness, pelvic girdle pain, urinary incontinence, and in time, even pelvic organ prolapse may occur.


During research done by Paul Hodges and Diane Lee they found that doing a draw-in maneuver (activating the Transvers Abdominus muscle) with a crunch decreased the narrowing of the IRD compared to what would occur with an abdominal crunch alone. This still technically does not close the DR as well as we’d like, but it does increase the tension on the linea alba, which they propose is necessary to support the abdominal contents and to transfer force between the two sides of the abdominal wall.


Currently, the goal of rehabilitating a DR is to reduce the IRD. This is based on the assumption that closing the gap will restore the function of the core and improve cosmetic appearance. Lee and Hodges showed the opposite in their study, and demonstrated that while we are closing the gap, we are creating more laxity or distortion on the linea alba, which makes us less likely to restore the function of our abdominal wall; this will lead to potentially poorer cosmesis of the abdominal wall.


It seems that closing the gap may not matter as much as we previously thought, and instead of focusing on the width of the gap, we should be focusing on optimizing the functional ability of our abdominal wall to generate enough tension to stabilize us in order to perform the activities we do on a regular basis and this will vary individually.


If you suffer from a DR and have not been assessed by a physical therapist, start there! During their evaluation, the physical therapist will be able to identify functional and structural impairments that may be contributing to ongoing symptoms, and can either help you to continue to improve your function, or have the resources to refer you to a surgeon if conservative approaches have been exhausted.


Below is a list of criteria that would identify a good surgical candidate, your physical therapist can help determine if you would benefit from a surgical consult.

According to Dianne Lee, the criteria for referral to a surgeon are summarized below:

o The woman should be at least 1 year postpartum and has failed appropriate therapeutic approaches to restore function, resolve lumbopelvic pain and/or urinary incontinence.

o The abdominal contents are easily palpated through the midline fascia.


It is beneficial for women to have their pelvic floor evaluated after delivery, preventing future pelvic floor dysfunctions e.g.:

1. Stress incontinence

2. Anal incontinence: difficulty controlling gas or bowel movements.

3. Pelvic floor muscle injury after vaginal delivery.

4. Pelvic Girdle- or lower back pain.

5. Pelvic pain: some women experience pain during sex after childbirth. Vulvar pain can also be experienced or even pain during bowel movements. This symptom is often caused by tight pelvic floor muscles leading to irritated tissues and nerves.

6. Pelvic organ prolapses due to the weakened pelvic floor muscle.


Exercise in the post-partum period

Exercise regime may be resumed only gradually after pregnancy and should be individualised. Many of the physiological changes of pregnancy persist for four to six weeks’ post-partum.



Van Vuuren Physiotherapist


Suite 13, Netcare Pretoria East Hospital
Cnr Garsfontein Road & Netcare Ave
Pretoria East