Postnatal exercise• The aim of exercising after the baby is born is

gradually to regain and then improve the former level of fitness.

• Once the baby is born, women should return to exercising as soon as they feel able but this should be a gradual process

• Postnatal depression is less likely in women who return to exercising relatively soon after birth but only if the exercise sessions are positive rather than negative experiences

Postnatal exercise• High impact exercise should be avoided for a

few months after birth to allow musculoskeletal changes of pregnancy to normalize.

• In women who experienced pregnancy-related pelvic girdle pain, there may be residual associated pelvic muscle imbalance.

• Increased caution and possible physiotherapy referral is necessary for these women

Postnatal exercise

• Athletes may be able to return to their sport more quickly.

• Pregnancy necessitates a reduction in maximal training but should not have a significant adverse impact on postnatal training regimes.

Abdominal exercises

• It work in the deepest layer of muscles within the abdominal corset

Abdominal exercises

• TrA is important in postural control, controlling the neutral spine position and giving support to the weight of the growing baby.

• By its attachment to the aponeurosis, rectus sheath and linea alba, it may help to limit DRAM.

Abdominal exercises

• The mother should adopt a pain-free position with good postural alignment. Sitting, standing, side-lying or four-point kneeling are good positions.

• but she should avoid lying on her back after 16 weeks of pregnancy, because of the risk of supine hypotension.

Abdominal exercises

• illustrates the transversus exercise, and Instruction in pelvic tilting and Instructions for the TrA exercise provide instructions for pelvic tilting and the TrA exercise.

Transversus exercise

Instruction in pelvic tilting• • Place your hands on your abdomen• • Gently tighten your tummy muscles and

buttocks and allow the back of your waist to slump backwards. Your pubic bone rocks up towards you. Breathe normally and hold the tilt for 5–10 s

• Relax and allow your back to hollow• • Repeat a few times. This is pelvic tilting• • The mid-way position is the neutral spine

position and is safest for your back• • Practising the abdominal exercise is best done

in the neutral spine position.

Instructions for the TrA exercise• Place your hands on lower part of abdomen• • Take a gentle breath• • As you breathe out, gently draw in and lift the lower tummy

away from your hand, this time not allowing your back to move• • Keeping the tummy in, continue to breathe normally a few

times• • Feel the muscle working under your hand as it supports the

weight of your baby• • Relax• • Repeat up to 10 times, trying to hold each lift for 10 s, but

don't hold your breath• • Repeat this set 6–8 times a day• • Try in different positions, and try to use this muscle during

activity requiring effort.

Coping with common problems in pregnancy

Leg cramps• Leg cramps are common and it can disturb

sleep• Inadequate fluid intake, inactivity, prolonged

sitting or wearing high heeled shoes may make the symptoms worse.

Leg crampsAdvice: take a gentle walk, do foot and ankle circling, and gently stretch out the calf muscles. Have a warm bath before going to bed, and drink plenty of liquid.

Swollen ankles and varicose veins

• Varicose veins are swollen, twisted, painful veins that have filled with an abnormal collection of blood.

• Prolonged standing and increased pressure within the abdomen may increase susceptibility to the development of varicose veins or aggravate the condition

• Painless swelling of the feet and ankles is also a common problem.

Swollen ankles and varicose veins

Advice: rest with feet in elevation, take gentle exercise, avoid standing for long periods and consider wearing support tights.

Carpal tunnel syndrome

• Fluid retention causing pressure on the median nerve within the carpal tunnel at the wrist .

• may cause swelling, numbness, tingling or pain in the hands and fingers.

Advice: avoid repetitive movements, keep the hands cool and, if not resolving, refer

to a women's health physiotherapist.

Postnatal exercises and advice

• Rest• Adequate rest for the new mother is essential

immediately after birth. The health professional may be able to suggest positions of ease in side-lying, with pillows under the abdomen and between the knees, or lying on the back with a soft pillow under the knees. If the new mother has learned a relaxation technique, she should use it to help her rest.

Postnatal exercises and advice• Getting in and out of bed• Rolling over and getting out of bed is easiest if she

bends her knees, one at a time, supports her abdomen with a hand, especially if she has had a caesarean section draws in the low tummy muscles and rolls knees, hips and shoulders all over as one onto the side.

• To get out of bed, push the body up by pressing down onto the mattress and allowing the feet to drop down to the floor. Sit for a few moments before standing by pushing up with both hands and standing tall.

• Reverse the above instructions to get back into bed.

Postnatal exercises and advice

• Sitting and feeding• Posture when feeding is important to protect

the back. Aim for a pain-free, neutral spine posture and if sitting, use adequate pillows to lift baby to the breast or bottle, so that the mother's back is supported and shoulders relaxed.

Postnatal exercises and advice• Pelvic floor exercises and pelvic floor care• The pelvic floor muscles have been under

strain during pregnancy and stretched during birth and it may be both difficult and painful to contract these muscles postnatally. Mothers should be encouraged to try the exercise as often as possible in order to regain full bladder control, prevent incontinence and prolapse and ensure normal sexual satisfaction for both partners in the future.

• Studies have shown that women who had instruction by the physiotherapist on the postnatal ward and had been compliant with the exercises had reduced incidence of stress incontinence up to 1 year postnatally

Pelvic floor exercise advice• Start exercises as soon after birth as possible, but if

a urinary catheter is in place, wait until it is removed.

• Try drawing in the muscles in varying positions; if the area is painful, side-lying is probably the most comfortable. If the area is painful and swollen, gentle rhythmical tightening and relaxing of the muscles will ease discomfort and promote healing.

• Once the mother is more comfortable she should exercise the muscles as in the antenatal section, aiming to continue with a regular exercise regime for several months.

Other advice

• Women should inform the midwife if they have not passed urine within 6 hrs of birth. It is the responsibility of the midwife to ensure local post-birth voiding protocols are adhered to and perinatal continence risk assessments completed, action taken as indicated and that any urinary incontinence is noted.

• Empty the bladder regularly in first day or two after birth, but do not get into the habit of going to the toilet ‘just in case’. Do not stop then start the flow of urine. Drink plenty of water for a healthy bladder, especially if breastfeeding.

• When having a bowel movement, it may help to support the perineum with a pad or a hand on the abdomen if a caesarean section has been performed.

3rd and 4th degree tears

• Faecal incontinence affects approximately 10% of female adults, with anal sphincter laceration during childbirth being the major risk factor, and accountable for 45% of incidence of postnatal faecal incontinence.

• Following 3rd or 4th degree tears, 13% of primiparae and 23% of multiparae have on-going symptoms of urgency and/or faecal incontinence 3 months after birth.

3rd and 4th degree tears

• All 3rd and 4th degree tears should be documented and a local care plan put in place to manage and review these women. A multidisciplinary team approach for these women is essential as pain management, advice regarding hygiene and care should be given postnatally and women should be advised about diet and position of defaecation to protect the anal sphincter. Compliance with the pelvic floor exercise programme is essential.

3rd and 4th degree tears

• Faecal incontinence may also be caused by damage to the pelvic and pudendal nerves during vaginal birth and subsequent weakness of the pelvic floor and anal sphincter.

3rd and 4th degree tears

• It is a distressing and disabling condition, especially for new mothers but found that only 14% of women with new faecal incontinence after childbirth had consulted a doctor and those doing so were unlikely to report incontinence voluntarily as one of their symptoms.

• All postnatal women should be encouraged to exercise the pelvic floor and be asked about bladder and bowel function.

Abdominal exercises:

• The abdominal muscles become stretched and weakened by pregnancy. It is advisable to begin abdominal exercises to regain tone as soon as possible after birth in order that they recover to support the spine, prevent and relieve back pain and help the mother regain her ‘former figure’.

Abdominal exercises:

• Pelvic tilting as described in the antenatal section helps to locate the neutral spine position and also assists the relief of wind and nausea following caesarean section

The TrA exercise:

• It is important to begin by exercising the deepest layer of muscles, the TrA, as described in the antenatal section.

• The woman may now practice this exercise lying down with knees bent up and feet comfortably flat on the bed, with just one pillow beneath her head and arms by her side and in neutral spine position. This position is termed crook-lying..

The TrA exercise:

• She should be advised to progress to exercising the muscle when sitting and standing, aiming for 10, 10 secs holds, three times a day and also to draw in the lower tummy when lifting, or bending forward to dress and change baby. This can be progressed further by trying the above exercise in four-point kneeling if comfortable. Women who have had a caesarean section should wait until this position is comfortable

Progressing further

If, when trying the following exercise, abdominal doming occurs, the woman should revert to just the TrA

exercise . *If the doming persists after a few

days, this may indicate that the rectus muscle has separated and the linea alba overstretched as in DRAM

• Contact should be made with the woman health physiotherapist who will advise on safe abdominal exercise and back care .

Knee bends:

*In crook lying, draw in the lower tummy, keeping the back still and bend one hip and knee up as is

comfortable . *Hold for 10 secs. and slowly lower .

*Breath easily throughout and repeat with the other leg.

*Knee rolling:

*In crook lying with lower both knees to the right as far as is

comfortable. *Bring them back to the middle and

relax breathing easily throughout.

*Draw in the lower tummy and easily and repeat to the other side

*Head lifts: *This is not advisable for anyone who has

neck pain. *In crook lying take a gentle breath in

then after the breath out ,draw in the lower tummy and pelvic floor muscle and lift head from the pillow, hold for 3 secs, lower and relax.

*Repeat up to 10 times. *Progress by lifting the head and s

shoulder simultaneously. *Woman should be advised to aim to

practice abdominal exercise three times daily for at least 3 months

after child birth.

Care of the back after the birth

• It may take up to 6 months before the ligaments completely resume

their normal functions, so it is vital that new mothers receive advice on

back-care in relation to everyday activities.

• The mother should sit well supported to feed the baby. To prevent the mother from slouching forward, the baby should rest raised up on pillows. Nappy changing and bathing are best carried out on a surface at waist level or with the mother kneeling at a surface of coffee-table height.

Lifting anything heavier than the baby for the first 6 weeks should be avoided if at all possible, but if unavoidable, good advice is:

• • always try to bend the knees• carry the toddler or object close to the

body• • draw in the low tummy and pelvic floor

muscles• • breathe out as you lift

• Baby chairs are heavy and are best carried by holding underneath and close to the body instead of by the carrying handle which puts a strain on one side of the body. Whenever possible, the chair should be carried empty and placed in the position required before the baby is put in it.

• Baby slings should be comfortable and not cause an arched back. The weight should be well and the mother should use her TrA and pelvic floor muscles to ensure a good posture and prevent back ache.

• If back or pelvic girdle pain persists postnatal then referral to the women's health physiotherapist is indicated.

When /what to refer to the physiotherapist-:

Physiotherapist can advise on the following conditions :- Antenatal problems may include :-• Pregnancy – related pelvic girdle pain (PGP) which

include symphysis pubis dysfunction and lower back pain.

• Divarication of RA. • Coccydynia• Carpal tunnel syndrome (CTS).• Co-existing disability with pregnancy.• Incontinence.

Postnatal problem may include-:

• Pregnancy – related pelvic girdle pain(PGP)and lower back pain.

• Divarication of RA.• Incontinence.• CTS.• Co-existing disability.• 3rd/4th degree tears following birth.• Coccydynia.• Perineal pain including dyspareunia and scarring.

Promoting health and fitness-:

• Opportunities for liaising with and sharing good practice with other health professionals to develop both specific and general health care measures should never be missed. Physiotherapists, midwives and health visitors have a duty of care to promote health and fitness to women and this may be possible in a variety of settings .

Promoting health and fitness-:• During pregnancy, labour and the puerperium,

midwives and other healthcare professionals have many opportunities to influence parents-to-be, incorporating a sensible approach to exercise within the broader sphere of healthy routines for all family members. Walking, cycling, swimming and other forms of exercise should be encouraged as part of a general lifestyle as well as learning relaxation techniques as appropriate.

Promoting health and fitness-:

• Specific exercises for strengthening the pelvic floor and abdominal muscles, especially TrA, will have relevance far beyond the months of child bearing. Parents-to-be are an extremely receptive audience so opportunities to develop and promote specific and general healthcare measures should be optimized Health professionals are well placed to encourage all women and their families to continue exercising for life.

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