THE POSTNATAL SHS.

509 Lec-12

PERIOD Dr.Maria Mustafa

POST NATAL CHANGES
Physical
Psychological
Social
Emotional
POSTPARTUM PHYSICAL/MENTAL
CONDITION

Muscles and ligaments

The body’s ligaments and collagenous connective tissue will still be softer and more
elastic than pre-pregnancy and it will take 4 to 5 months for full recovery to take place.
The abdominal muscles, which will have been stretched, are now elongated , and a
separation between the two recti abdominis muscles (known as a diastasis or
divarification) will almost certainly be apparent in any woman who was at ‘term’ prior
to labour.
The women’s health physiotherapist should be aware that there may be neurological
damage to the pelvic floor during the birthing process, resulting in temporary (days or
weeks), longer-lasting (months) or permanent loss of sensation or muscle weakness, or
both.
Edema
Many women will complain of heavy, edematous, aching legs, swollen feet and ankles
in the immediate postpartum period that may not have been apparent before the baby
was born. This may be unilateral or bilateral.
The cause can only be speculated as probably prolonged pushing during labour, pelvic
congestion, dysfunctional urinary tract, or the temperature on the postnatal ward
Psychological state
mother’s attention is fixed on her baby and she is often hypersensitive of its behaviour.
Her initial elation can change after a few days to a ‘flattening’ of her mood. She may
well be more concerned with her baby than she is for herself. This could potentially be
an issue for the physiotherapist attempting to achieve rehabilitative aims.
POSTNATAL CARE
Pain management
The women’s health physiotherapist must be alert to the pain of women who have
experienced intervention deliveries, as this can often prevent the mother being
relaxed and comfortable.
A major role of the physiotherapist is to use her specialist knowledge, skills for
example with support, positioning, transcutaneous electrical nerve stimulation
(TENS), ice, pulsed electromagnetic energy (PEME), pressure-relieving cushions,
etc., to establish breastfeeding.
POSTNATAL
PHYSIOTHERAPY
Symptoms to look out for:
 Diastasis recti abdominis

 Inability to voluntarily contract the pelvic floor

 Perineal pain or discomfort

 Symphysis pubis pain or referred pain

 Back pain or discomfort

Exercise:
 Encouraged the mobility
 Reduce the risk of circulatory and respiratory dysfunction
 If confined to bed for a prolonged period of time:
 Controlled and deep breathing exercises
 Vigorous circulatory exercises
 Pelvic floor muscle exercises
 Strengthening
 Pain-relieving properties
 Speed healing by reducing oedema
 Encourage good circulation
A more efficient contraction may be obtained by contracting the transversus
abdominis, before engaging the pelvic floor.
Two essential pieces of early advice to achieve physical relief and increase
confidence are:
1. Contract the pelvic floor muscles (PFM) every time the intra-abdominal
pressure increases, e.g. on coughing, sneezing or laughing.
2. Support sutures by applying pressure (hand) to the perineum using a sanitary pad
or pad of soft toilet paper when defaecation is attempted, and until the perineal pain
subsides
For some women the memory of the postpartum perineal pain is more prominent
than their memory of labour pain; it has been called the ‘fourth stage of labour’!
The principles of muscle re-education should be followed:
 Progress from static (no joint movement), through to dynamic (joint movement)
 The anterior abdominal wall should be drawn in on expiration, thereby increasing
muscle tone
 Then progress through to static contraction plus active range of movement:
 Pelvic tilt
 Flexion, in progressing ranges of the lumbar spine
 Rhythmical gluteal contractions may help ease the pain from haemorrhoids or
bruising
THE EARLY POSTNATAL
CLASS
Teaching Points:
 Enable all participants to:
 Physically take part
 Interact with each other and the physiotherapist
 Starting position should minimise risk to participants

Sitting:
 Well supported back and comfortable perineum
 Exercises in sitting for posture, abdominals, pelvic floor muscles
 Regular reference to daily activities in sitting, e.g. feeding baby, in order to minimise
symptoms
THE EARLY POSTNATAL
CLASS
Standing:
 Stable base of support
 leaning against something to increase stability, e.g. wall, back of chair
 Appropriate footwear
 Exercises in standing for:
 Posture
 Abdominals
 Reduce the abdominal girth by up to 12 cm, especially if also standing
tall
 Pelvic floor muscle exercises
 Trunk side flexion
THE EARLY POSTNATAL
CLASS
Lying:
 Pillows and wedges for support and exercise progression
 Teach checking for separation of recti abdominis muscles
 Raise awareness regarding ‘at risk’ movements or exercises
 Strong side flexions and trunk rotations while lying should be omitted until the
anterior abdominal wall is strong enough to allow these movements without shearing
 Exercise abdominal muscle
 Abdominal muscle contraction, emphasis on transversus abdominis
 Increasing length of ‘hold’, with pelvic tilting
 Progress to include active trunk movement, e.g. head raising and then head and
shoulders raising
 Raise awareness regarding abdominal doming
 Posture, pelvic floor muscles
THE EARLY POSTNATAL
CLASS
Relaxation:
A short period of relaxation
To reduce tension and maternal fatigue
The environment must allow for comfort of the participants
Sufficient space for adequate pillow use
Appropriate temperature, etc.
Simple relaxation suggestions linked with:
Deep, calm, slow breathing
Result in women falling asleep
Facilitates the ‘let-down’ reflex for breastfeeding
THE EARLY POSTNATAL
CLASS
Teaching Ergonomic Principles:
 Sitting:
 Thighs fully supported (at least 2/3) and horizontal
 The sitting surface should not extend as far as the popliteal fossa to
avoid potential impingement
 Feet flat on the floor, stable base of support, fully supported
 Weight evenly distributed over both buttocks
 Sitting on ischial tuberosities
 Sore perineum/ haemorrhoids may require cushioning
 Sitting surface depressable to allow for pressure distribution
 Trunk fully supported maintaining natural spinal curves
THE EARLY POSTNATAL
CLASS
Standing:
 Feet slightly apart, and angled (lateral rotation at the hips)
 Weight evenly distributed over both feet
 Soft knees (not flexed, just ‘off’ full extension – do not ‘lock’ them back)
 Shoulders relaxed (not retracted or elevated)
 Arms held loosely at the side
 Maintain natural curves of the spine
 Head in line with trunk
Lying:
 Fully supported (s.ly., pr.ly., ly.) with pillows – head, knees, low back, etc.
 Legs not crossed
THE EARLY POSTNATAL
CLASS
Kneeling:
 Avoid sustained, isometric trunk flexion, rotation
 Try to keep movement within the sagittal plane
 Perform activities at an appropriate height surface
 High. kn.
 Knees hip-width apart
 Knees directly under hips – maybe on a cushion
 Maintain natural spinal curves
 Kn. Sitt.
 Bilateral – maybe cushion to the back of the knees
 ½ Kn. Sitt.
 Unilateral – sitting on one heel, other hip forward flexed with foot flat on the floor
THE EARLY POSTNATAL
CLASS
– Feeding:
THE EARLY POSTNATAL
CLASS
– Nappy Changing:
SUMMARY
Pt plan of management for LSCS and SVD pt postnataly
QUESTION
What is diastasis recti?
Assessment?
management?
THANKS