Chapter 24: Women's Health: Obstetrics and Pelvic Floor

Throughout a woman's life cycle, specific gender differences need to be recognized for their relevance to rehabilitation. Recent research has shown repeatedly that women have specific and distinct physiological processes that extend beyond the obvious considerations of anatomy and hormones, including differences in symptoms of heart attacks and in metabolism of medications.⁵⁸ Clearly, the pregnant or postpartum patient presents a unique gender-based clinical challenge for the physical therapist. Although pregnancy is a time of tremendous musculoskeletal, physiological, and emotional change, it is nonetheless a state of wellness. Pregnant women are typically well motivated, willing to learn, and highly responsive to treatment suggestions. For many women, the therapist is able to assess and monitor the physical changes with the primary focus on maintaining wellness. The ability to educate women about the role of exercise and health promotion during this key life transition provides a significant professional opportunity and responsibility.

In cases of musculoskeletal impairment related to pregnancy, the therapist is able to examine and treat the patient by incorporating knowledge of injury and tissue healing with knowledge of the changes during pregnancy. By considering a broader perspective, it is recognized that all female patients can benefit from education regarding the role of the pelvic floor muscles in musculoskeletal health, specifically in trunk stabilization. Specialized treatment of pelvic floor dysfunction is critical to quality of life for women experiencing incontinence, pelvic organ prolapse, and a variety of pelvic pain syndromes. Although all physical therapists can fairly easily incorporate activation of the pelvic floor muscles as a key component of trunk stabilization exercises, true expertise can come only with further training and mentoring. Advanced study of pelvic floor anatomy, evaluation, and treatment is highly recommended for therapists who wish to specialize in this area.

This chapter provides readers with basic information about the systemic changes of pregnancy as a foundation for the development of safe and effective exercise programs. In addition, a review of pelvic floor anatomy, function, and dysfunction serves as an introduction to the treatment of pelvic floor disorders. The chapter emphasizes modification of general exercises to meet the needs of the obstetric patient and provides information to assist in the development of an exercise program for an uncomplicated pregnancy. Cesarean delivery, high-risk pregnancy, and the special needs of patients with these conditions are also discussed.

Characteristics of Pregnancy and Labor

Pregnancy

Pregnancy, which spans 40 weeks from conception to delivery, is divided into three trimesters, with characteristic changes during each.^36,53,74,82

First Trimester Changes

During the first trimester (weeks 0 through 12), the following occur:

• Implantation of the fertilized ovum in the uterus occurs 7 to 10 days after fertilization.

• The mother is very fatigued, urinates more frequently, and may experience nausea and/or vomiting ("morning" sickness).

• Breast size may increase.

• There is a relatively small weight gain of 0 to 1455 g (0 to 3 lb is normal).

• Emotional changes may occur.

• By the end of the 12th week, the fetus is 6 to 7 cm long and weighs approximately 20 g (2 oz). The fetus now can kick, turn its head, and swallow and has a beating heart, but these movements are not yet felt by the mother.

Second Trimester Changes

During the second trimester (weeks 13 through 26), the following occur:

• The pregnancy becomes visible to others.

• The mother begins to feel movement at around 20 weeks.

• Most women now feel very good. Nausea and fatigue have usually disappeared.

• By the end of the second trimester, the fetus is 19 to 23 cm (14 in.) in length and weighs approximately 600 g (1 to 2 lb).

• The fetus now has eyebrows, eyelashes, and fingernails.

Third Trimester Changes

During the third trimester (weeks 27 through 40), the following occur:

• The uterus is now very large and has regular contractions, although these may be felt only occasionally.

• Common complaints during the third trimester are frequent urination, back pain, leg edema and fatigue, round ligament pain, shortness of breath, and constipation.

• By the time of birth, the baby will be 33 to 39 cm long (16 to 19 in.) and will weigh approximately 3400 g (7 lb, although a range of 5 to 10 lb is normal).

NOTE: Although pregnancy typically lasts 40 weeks, the range of 38 to 42 weeks is considered full term.

Labor

Labor is divided into three stages, each containing specific events.^16,54,78,80 The exact mechanism that initiates labor is not known. Regular and strong involuntary contractions of the smooth muscles of the uterus are the primary symptom of labor. True labor produces palpable changes in the cervix, which are known as effacement and dilation (Fig. 24.1).⁸⁰

• Effacement is the shortening or thinning of the cervix from a thickness of 5 cm (2 in.) before onset of labor to the thickness of a piece of paper.

• Dilation is the opening of the cervix from the diameter of a fingertip to approximately 10 cm (4 in.).

Labor: Stage 1

Some women experience initial cervical dilation and effacement before they are in true labor. However, by the end of this stage, the cervix is fully dilated, and there is no doubt that a baby is about to be delivered. Stage 1 of labor is divided into three major phases.

Cervical dilation phase. The cervix dilates from 0 to 3 cm (0 to 1 in.) and will almost completely efface. Uterine contractions occur from the top down, causing the cervix to open and pushing the fetus downward.

Middle phase. The cervix dilates from 4 to 7 cm (1 to 3 in.). Contractions are stronger and more regular.

Transition phase. The cervix dilates from 8 to 10 cm (3 to 4 in.), and dilation is complete. Uterine contractions are very strong and close together.

Labor: Stage 2

Stage 2 involves "pushing" and expulsion of the fetus. Intra-abdominal pressure is the primary force expelling the fetus; it is produced by voluntary contraction of the abdominal muscles and diaphragm. Relaxation and stretching of the pelvic floor during stage 2 are also necessary for successful vaginal delivery. Uterine contractions may last as long as 90 seconds during this stage.

Fetal descent. Position changes (cardinal movements) by the fetus allow it to pass through the pelvis and be born (Fig. 24.2).⁷⁸ The position changes are described as:

• Engagement. The greatest transverse diameter of the fetal head passes through the pelvic inlet (the superior opening of the minor pelvis).

• Descent. Continued downward progression of the fetus occurs.

• Flexion. The fetal chin is brought closer to its thorax; this occurs when the descending head meets resistance from the walls and floor of the pelvis and the cervix.

• Internal rotation. The fetus turns its occiput toward the mother's symphysis pubis when the fetal head reaches the level of the ischial spines.

• Extension. The flexed fetal head reaches the vulva; the fetus extends its head, bringing the base of the occiput in direct contact with the inferior margin of the maternal symphysis pubis; this phase ends when the fetal head is delivered.

• External rotation. The fetus rotates its occiput toward the mother's sacrum to allow the fetal shoulders to pass through the pelvis.

Expulsion. The fetal anterior shoulder passes under the symphysis pubis, and the rest of the body follows.

Labor: Stage 3

Placental stage (expulsion of the placenta). After delivery, the uterus continues to contract and shrink, causing the placenta to detach and be expelled.

• As the uterus decreases in size, the placenta detaches from the uterine wall, blood vessels are constricted, and bleeding slows. This can occur 5 to 30 minutes after the baby is delivered.

• A hematoma forms over the uterine placental site to prevent further significant blood loss; mild bleeding persists for 3 to 6 weeks after delivery.

Uterine involution. The uterus continues to contract and decrease in size for 3 to 6 weeks after delivery; the uterus always remains slightly enlarged over its prepregnant size.

Anatomical and Physiological Changes of Pregnancy

Considerable changes occur in the woman's body as the pregnancy progresses.^{16,53,74,80,86,91}

Weight Gain During Pregnancy

Current recommendations for weight gain during pregnancy are an average of 25 to 35 lb^48,52 with a distribution as shown in Box 24.1.

Changes in Organ Systems

Uterus and Related Connective Tissue

Uterus. The uterus increases from a prepregnant size of 5 by 10 cm (2 by 4 in.) to 25 by 36 cm (10 by 14 in.). It increases five to six times in size, 3,000 to 4,000 times in capacity, and 20 times in weight by the end of pregnancy. By the end of pregnancy, each muscle cell in the uterus has increased approximately 10 times over its prepregnancy length⁹¹ Once the uterus expands upward and leaves the pelvis, it becomes an abdominal rather than a pelvic organ.

Connective tissues. Ligaments connected to the pelvic organs are more fibroelastic than ligaments supporting joint structures. The fascial tissues, which surround and enclose the organs in a continuous sheet, also include a significant amount of smooth muscle fibers.²⁷ The round, broad, and uterosacral ligaments in particular provide suspensory support for the uterus.

Urinary System

Kidneys. The kidneys increase in length by 1 cm (0.5 in.).

Ureters. The ureters enter the bladder at a perpendicular angle because of uterine enlargement. This may result in a reflux of urine out of the bladder and back into the ureter; therefore, during pregnancy, there is an increased chance of developing urinary tract infections because of urinary stasis.

Pulmonary System

Hormonal influences. Hormone changes affect pulmonary secretions and rib cage position.

• Edema and tissue congestion of the upper respiratory tract begin early in pregnancy because of hormonal changes. Hormonally stimulated upper respiratory hypersecretion also occurs.

• Changes in rib position are hormonally stimulated and occur prior to uterine enlargement. The subcostal angle progressively increases; the ribs flare up and out. The anteroposterior and transverse chest diameters each increase by 2 cm (1 in.). Total chest circumference increases by 5 to 7 cm (2 to 3 in.) and does not always return to the prepregnant state.

• The diaphragm is elevated by 4 cm (1.5 in.); this is a passive change caused by the change in rib position.

Respiration. Respiration rate is unchanged, but depth of respiration increases.⁷⁸

• Tidal volume and minute ventilation increase, but total lung capacity is unchanged or slightly decreased.^78,91

• There is a 15% to 20% increase in oxygen consumption; a natural state of hyperventilation exists throughout pregnancy to meet the oxygen demands of pregnancy.^78,91

• The work of breathing increases because of hyperventilation; dyspnea is present with mild exercise as early as 20 weeks into the pregnancy.^78,91

Cardiovascular System

Blood volume and pressure. Blood volume progressively increases 35% to 50% (1.5 to 2 L) throughout pregnancy and returns to normal by 6 to 8 weeks after delivery.

• Plasma increase is greater than red blood cell increase, leading to the "physiologic anemia" of pregnancy, which is not a true anemia but is representative of the greater increase of plasma volume. The increase in plasma volume occurs as a result of hormonal stimulation to meet the oxygen demands of pregnancy.

• Venous pressure in the lower extremities increases during standing as a result of increased uterine size and increased venous distensibility.

• Pressure in the inferior vena cava rises in late pregnancy, especially in the supine position, because of compression by the uterus just below the diaphragm. In some women, the decline in venous return and resulting decrease in cardiac output may lead to symptomatic supine hypotensive syndrome. The aorta is partially occluded in the supine position.

• Blood pressure decreases early in the first trimester. There is a slight decrease of systolic pressure and a greater decrease of diastolic pressure. Blood pressure reaches its lowest level approximately midway through pregnancy and then rises gradually from mid-pregnancy to reach the prepregnant level approximately 6 weeks after delivery. Although cardiac output increases, blood pressure decreases because of venous distensibility.

Heart. Heart size increases, and the heart is elevated because of the movement of the diaphragm.

• Heart rhythm disturbances are more common during pregnancy.

• Heart rate usually increases 10 to 20 beats per minute by full term and returns to normal levels within 6 weeks after delivery.

• Cardiac output increases 30% to 60% during pregnancy and is most significantly increased when a woman is in the left side-lying position, in which the uterus places the least pressure on the aorta.

Musculoskeletal System

Abdominal muscles. The abdominal muscles, particularly both sides of the rectus, as well as the linea alba, are all subjected to significant biomechanical changes and become stretched to the point of their elastic limit by the end of pregnancy. This greatly decreases the muscles' ability to generate a strong contraction and thus decreases their efficiency of contraction. The shift in the center of gravity also decreases the mechanical advantage of the abdominal muscles.^54,91

Pelvic floor muscles. The pelvic floor muscles, in their antigravity position, must withstand the total change in weight; the pelvic floor drops as much as 2.5 cm (1 in.) as a result of pregnancy.⁸⁶

Connective tissues and joints. The hormonal influence on the ligaments is profound, producing a systemic decrease in ligamentous tensile strength. Joint laxity has been measured in multiple joints during pregnancy and postpartum. The evidence is inconclusive in terms of indentifying which specific hormones are responsible. These changes in joint stability have been noted as many as 4 months postpartum.⁵³

• The thoracolumbar fascia is lengthened via its connection to the abdominal wall, which diminishes its ability to support and stabilize the trunk effectively.²⁸

• Joint hypermobility occurs as a result of ligamentous laxity and may predispose the patient to injury, especially in the weight-bearing joints of the back, pelvis, and lower extremities.

Thermoregulatory System

Metabolic rate. During pregnancy, basal metabolic rate and heat production increase.³

• An additional intake of 300 calories per day is needed to meet the basic metabolic needs of pregnancy.

• In pregnant women, normal fasting blood glucose levels are lower than in nonpregnant women.³

Changes in Posture and Balance

Center of Gravity

The center of gravity shifts upward and forward because of the enlargement of the uterus and breasts. This requires postural compensations to maintain balance and stability.^54,74,91

• The lumbar and cervical lordoses increase to compensate for the shift in the center of gravity.

• The shoulder girdle and upper back become rounded with scapular protraction and upper extremity internal rotation because of breast enlargement; this postural tendency persists in the postpartum period due to infant care demands. Tightness of the pectoralis muscles and weakness of the scapular stabilizers may be preexisting to or induced by the pregnancy postural changes.

• The suboccipital muscles respond in an effort to maintain appropriate eye level (optical righting reflex), and to moderate forward head posture along with the change in shoulder alignment.

• A tendency toward genu recurvatum will shift weight toward the heels in an attempt to counteract the anterior pull of the growing fetus.

• Changes in posture do not automatically correct after childbirth, and the pregnant posture may become habitual. In addition, many child care activities contribute to persistent postural faults and asymmetry.

Balance

With the increased weight and redistribution of body mass, there are compensations to maintain balance.^74,91

• The pregnant woman usually walks with a wider base of support and increased external rotation at the hips.

• This change in stance, along with growth of the baby, makes some activities such as walking, stooping, stair climbing, lifting, reaching, and other activities of daily living (ADLs) progressively more challenging.

• Activities requiring fine balance and rapid changes in direction, such as aerobic dancing and bicycle riding, may become inadvisable, especially during the third trimester.

Overview of Pelvic Floor Anatomy, Function, and Dysfunction

Treatment of pelvic floor impairment has become more visible and accepted in the physical therapy community over the past 10 to 15 years. In 2010, the specialty area of Women's Health was recognized on a national level at Combined Sections Meeting of the American Physical Therapy Association (APTA), at which 60 newly certified Women's Health Clinical Specialists (WCS) were acknowledged for their achievements. Advanced and in-depth study of anatomy, including internal muscle assessment, physiology, evaluation, and treatment continues to be highly recommended for therapists who specialize in this area.^*

Pelvic Floor Musculature

The pelvic floor musculature is composed of three layers in a funnel-shaped orientation, with boney attachments to the pubic bone and the coccyx. Laterally, the tissues blend into a fascial layer overlying the obturator internus. The prime mover of the pelvic floor is the levator ani. The levator ani, in combination with the coccygeus, forms the pelvic diaphragm. The most superficial muscles of the pelvic floor include the superficial transverse perineal muscles, the ischiocavernosus, the bulbocavernosus, and the external anal sphincter. Both the right and left sides of the pelvic floor complex contribute fibers to the perineal body located superficially between the vagina and rectum (Fig. 24.3). The structure and action of the muscles of each layer are summarized in Table 24.1. The combined action of these muscles creates a superior force toward the heart and a puckering or drawstring motion around the sphincters.

Female Pelvic Floor

The female pelvic floor allows for passage of the urethra, vagina, and rectum. This automatically results in less intrinsic stability and pelvic organ support when compared to the male anatomy.

Innervation

Recent cadaveric studies have uncovered many variations in configuration of the nerves to the pelvic floor complex.^8,42,90 The nerve supply to the perineal tissues includes the pudendal nerve (with its three terminal branches, the dorsal, perineal and rectal), the levator ani nerve, and direct branches from the sacral nerve roots, with conflicting findings as to sacral levels. This dual and apparently inconsistent innervation provides a safeguard against damage during labor and vaginal delivery, which would be more likely with a single-nerve arrangement.

Function

The pelvic floor musculature has the following essential roles:

• Provide support for the pelvic organs and their contents

• Withstand increases in intra-abdominal pressure

• Contribute to stabilization of the spine/pelvis

• Maintain continence at the urethral and anal sphincters

• Sexual response and reproductive function

Effect of Childbirth on the Pelvic Floor

Neurological Compromise

Stretch and compression of the pudendal and levator ani nerves occur during labor as the baby's head travels through the birth canal; this stretch can be as much as 20% of the total length of the nerve.^9,83 This compromise to the nerve tissue is most intense during pushing (the second stage of labor), through the completion of vaginal delivery.

Muscular Impairment

Extreme stretching of the pelvic floor tissues is inherent in the process of labor and vaginal delivery. Recent research simulations specific to the biomechanics of childbirth are adding to the understanding of these impairments. Muscle injury during vaginal birth diminishes the maximal closure pressure of the pelvic floor complex, which makes the muscle complex more vulnerable to increased intra-abdominal pressure and changes force transmission to the distal vagina, possibly leading to prolapse.⁶

The pelvic floor musculature may also be torn or incised during the birth process. Additional soft tissue trauma can occur as a result of forceps use, necessitating suturing throughout the musculature and into the vaginal vault.

Episiotomy

An episiotomy is an incision made in the perineal body (see Fig. 24.3). It is automatically considered a second-degree laceration according to the following classification of perineal lacerations.⁷⁸

• First degree—only skin

• Second degree—includes underlying superficial muscle layer (see Fig. 24.3 B)

• Third degree—extends to anal sphincter

• Fourth degree—tears through the sphincter and into the rectum, possibly into the deeper muscular layer of the pelvic floor (see Fig. 24.3 A)

Although episiotomy is common, occurring in 33% to 54% of vaginal deliveries, there is no strong medical evidence supporting its use. In fact, outcomes with episiotomy are worse in some cases, including pain with intercourse and extension of the episiotomy into the sphincter or rectum. Anal sphincter defects were linked with fecal incontinence in the postpartum period as many as 6 months after delivery in a study done by the Pelvic Floor Disorders Network.¹⁴ There is consistent agreement in the literature that episiotomy is closely associated with forceps-assisted delivery; additionally, if epidural anesthesia, forceps, and episiotomy are all utilized during labor and delivery, the risk of anal sphincter tear is even greater.^{1,14,35,45,58} Pregnant women have many questions about labor in general and episiotomy in particular; the clinician is able to provide education and support for the patient as she explores her options with her physician.

Classification of Pelvic Floor Dysfunction

This is a very broad category that encompasses bladder, bowel and sexual symptoms in a variety of combinations. Some patients with pelvic floor disuse atrophy, weakness, or nerve damage; others will have hypertonic pelvic floor musculature. Pelvic pain is another far-reaching diagnosis; many of these patients will be seen by multiple doctors prior to physical therapy being considered.

Prolapse

A prolapse is a supportive impairment. It refers to the descent of any of the pelvic viscera out of their normal alignment because of muscular, fascial, and/or ligamentous deficits and because of increased abdominal pressure (Fig. 24.4). A prolapse often worsens over time and with subsequent pregnancies and can be aggravated by constipation and/or straining with elimination.

• A cross-sectional study found stage I prolapse in 33% of the subjects and stage II descent in 62.9%. The sample included 270 women with a mean age of 68.3 years and median parity of three vaginal births.⁷⁰ This is critically important information for all clinicians prescribing trunk stabilization programs for female patients, regardless of diagnosis.

• From a biomechanical aspect, activation of the pelvic floor is necessary in coordination with deep segmental muscle activation and trunk strengthening activities to prevent excessive downward forces. Otherwise, trunk strengthening will likely increase a previously undetected prolapse or aggravate an existing condition.

• As prolapse progresses, functional changes occur as a result of perineal pressure and heaviness, low back pain, abdominal pressure or pain, and difficulties with defecation.¹⁷ These symptoms can interfere with exercise, recreation, household responsibilities, including yard work, and occasionally the ability to work outside the home.⁶⁸ Currently, there is very limited evidence regarding prevention or physical therapy treatment of pelvic organ prolapse.

Urinary or Fecal Incontinence

Involuntary loss of bladder or bowel contents, frequently a result of both neuromuscular and musculoskeletal impairments, often occurs in combination with prolapse. A conservative estimate of people affected with urinary incontinence is 15 million in the United States alone (approximately 1 in 20 people); women are twice as likely to have these symptoms as men.³⁰ These patients often have significant social discomfort and anxiety regarding leakage and hygiene concerns.

• Strength training of the pelvic floor (using principles of exercise physiology) improves structural support of the organs and connective tissue in addition to facilitating more effective recruitment of motor units and more consistent, proficient contractions.

• Counterbracing of the pelvic floor musculature done intentionally and habitually prior to increases in intra-abdominal pressure becomes a form of behavioral modification with "trigger" activities.

Pain and Hypertonus

Pain and hypertonus may be related to delayed healing of perineal lacerations, trauma to the soft tissues or the sacrococcygeal joint during delivery, pelvic obliquity, multiple gynecologic/visceral diagnoses, cauda equina involvement, scar tissue restrictions, as well as high incidence clinically of protective muscle spasm, guarding, and anxiety regarding movement in general.

• One study described "nonmenstrual" pelvic pain as being most commonly caused by endometriosis, adhesions, interstitial cystitis, or irritable bowel syndrome, occurring in as much as 20% of women aged 15 to 50.¹² In another study with a total sample of 581 women (aged 18 to 45), the following prevalence was found: pelvic pain, 39%; dyspareunia (pain with intercourse), 46%; and dysmenorrhea, 90%.⁵⁵

• Functional impairments may include pain with ADLs, decreased sitting tolerance, dyspareunia, and difficulty with elimination of bladder and bowel contents. In patients with pelvic pain impairments, often referred to as chronic pelvic pain (CPP), persistent tightness of the lumbar paraspinals and hip flexors is typically present.⁷

• Because of the breadth of this topic, treatment recommendations are conflicting. More attention is being given to the correlation of pelvic pain with a history of sexual abuse, which highlights the need for multidisciplinary assessment in order to address all potential causative factors. Sexual abuse continues to be underreported, yet recent studies cite rates of 20% to 25% of women who report childhood sexual trauma.^56,72,76

Risk Factors for Dysfunction

Childbirth

Childbirth is clearly the most significant risk factor for pelvic floor impairments. The process of labor, particularly with vaginal delivery and current medical management, can produce significant trauma to the structures of the pelvic floor.

• A longitudinal cohort study with follow-up 15 years after delivery (n=55) showed that stress incontinence during the first pregnancy doubled the risk of reoccurrence 15 years later.²⁹ With respect to risk of future pelvic organ prolapse (POP), in a cohort study of over 17,000 women, those with one delivery were four times more likely and those with two children were over eight times more likely to have a subsequent hospital admission for POP. However, this study did not distinguish mode of delivery.⁶¹

• Other potential obstetric risk factors include mothers older than 30 years of age, multiple deliveries, prolonged second stage of labor, forced pushing, use of forceps, vacuum extraction or oxytocin, third-degree perineal tears, and birth weight greater than 8 lb.^54,69,83,89

Other Causes

Women who have never been pregnant may also present with pelvic floor dysfunction. Excessive straining because of chronic constipation, smoking, chronic cough, obesity, and hysterectomy can contribute to these impairments in any woman.^9,30,47,89 The role of estrogen in the development of incontinence is still unclear, with some studies citing estrogen depletion as a risk factor³⁰ and others finding a connection between incontinence and estrogen replacement therapy.^47,89 High caffeine intake (more than 400 mg/day) is a specific risk factor for urge incontinence.⁴⁷

Interventions for Pelvic Floor Impairments

Patient Education

Teach the patient about pelvic floor anatomy and function. Emphasis should be placed on appreciating all three dimensions of the muscle complex: the sling/hammock fibers, the figure-eight orientation of the musculature, and the "funnel" configuration extending inferiorly to the outlet (see Fig. 24.3). Use visual aids to help the patient visualize the fibers that run anterior-posterior as well as superior-inferior (to create a "lifting" motion toward the heart), as well as the circumferential fibers (which produce a drawstring or "pucker" effect).

Provide individual instruction in exercise performance. Detailed, individual instruction is linked to significant proprioceptive improvements and certainly meets the criteria for skilled care. Successful strengthening is unlikely without this individualized educational component along with later confirmation of correct exercise performance; instructing women in pelvic floor exercises by verbal instruction alone was not beneficial in 50% of women and, in fact, caused increased downward pressures to the bladder in 25% of women, rather than producing an appropriate superiorly directed force.¹⁹

Neuromuscular Reeducation

Facilitate pelvic floor muscular activation. Neuromuscular reeducation is essential, because many women have significant disuse atrophy and proprioceptive deficits of the pelvic floor muscles. Internal techniques of assessment and treatment are often indicated for optimal patient outcomes. For example, manual stretch facilitation (a proprioceptive neuromuscular facilitation technique) to the levator ani can be an effective treatment option. Initially, emphasis on isolated contractions of the pelvic floor is needed¹¹ because many patients exhibit excessive accessory muscle recruitment such as the gluteals, hip adductors, and abdominals. Once coordination has improved, the patient progresses to integration of pelvic floor activity with ADLs, lumbar stabilization, and other functional exercises.

Biofeedback

Use biofeedback with instrumentation. The definition of biofeedback is "the technique of using monitoring devices to furnish information regarding … bodily function … in an attempt to gain some voluntary control over that function" (www.thefreedictionary.com). This can be accomplished by a creative physical therapist in a number of ways. There are multiple types of instruments that can be used to provide sensory feedback as the pelvic floor muscles contract around the device. Some are pressurized objects, which allow for isotonic strengthening; traditional surface electromyography (SEMG) sensors are solid and provide isometric resistance to the muscular contraction. SEMG can also be applied through peri-anal electrodes for patients who are not candidates for internal assessment or treatment. Motor learning, which occurs due to the "real-time" capabilities of the equipment, is greatly enhanced when compared to exercise without this intervention.

Combine biofeedback with exercises. Specific exercises to address pelvic floor impairments are listed in the exercise section of the chapter. The use of exercise and biofeedback, including SEMG for treatment of pelvic floor dysfunction in a female population, has been studied with mixed results,^20,30,73,92 and the need for further research is great. SEMG provides immediate visual and/or auditory feedback regarding pelvic floor activity, which improves patient comprehension, appropriate recruitment patterns, and proprioceptive awareness. It is particularly invaluable for pelvic floor reeducation owing to generalized lack of knowledge of the muscles' existence, let alone their function and importance.

Manual Treatment and Modalities

Manual treatment and modalities, including intravaginal and intrarectal techniques, also play a role in the treatment of all pelvic floor disorders. Advanced training is necessary for true expertise with internal techniques.

Pregnancy-Induced Pathology

The combined influence of hormones, weight gain, and postural changes of pregnancy contributes to a variety of impairments (in addition to pelvic floor dysfunction that was described in the previous section) that can be addressed with physical therapy.

Diastasis Recti

Diastasis recti is separation of the rectus abdominis muscles in the midline at the linea alba. The etiology of this separation is unknown; however, the continuity and integrity of the abdominal musculature are disrupted (Fig. 24.5). Any separation larger than two finger widths is considered significant.^13,21,65

Incidence

The condition is not exclusive to childbearing women but is seen frequently in this population. In one study, Boissonnault and Blaschak tested 89 women for separation of the rectus abdominis muscles.¹³ The sample included one group of women who were not pregnant, one group for each trimester of pregnancy, and two postpartum groups. The incidence in this study ranged from none in the nonpregnant and first trimester women to 27% in the second trimester to a high of 66% in the third trimester. Also of interest is that 36% of the women between 5 weeks and 3 months postpartum continued to display a separation. A second study, done by Bursch, found a significant diastasis in 62.5% of postpartum women tested within 92 hours of delivery.¹⁹ More recently, in a population of 547 women seen in a urogynecology practice, 52% of these women had persistent diastasis recti; 66% of those women also had various combinations of stress or fecal incontinence and pelvic organ prolapse.⁸⁵

• Diastasis recti may occur in pregnancy as a result of hormonal effects on the connective tissue and the biomechanical changes of pregnancy; it may also develop during labor, especially with excessive breath-holding during the second stage.⁸⁶ It causes no discomfort.

• It can occur above, below, or at the level of the umbilicus but appears to be less common below the umbilicus.

• It appears to be less common in women with good abdominal tone before pregnancy.¹³

• Clinically, a diastasis may be found in women well past their childbearing years and also in men. Routine assessment for this condition is highly recommended and can easily be done in conjunction with abdominal strength testing.

Significance

The condition of diastasis recti may produce musculoskeletal complaints, such as low back pain, possibly as a result of decreased ability of the abdominal musculature and thoracolumbar fascia to stabilize the pelvis and lumbar spine.

Activity limitations. Activity limitations can also occur, such as inability to perform independent supine-to-sitting transitions because of extreme loss of the mechanical alignment and function of the rectus muscle. Again, this finding is not exclusive to childbearing patients.

Decreased fetal protection. In severe separations, the remaining midline layers of abdominal wall tissue are skin, fascia, subcutaneous fat, and peritoneum.^13,21,86 The lack of muscular support provides less protection for the fetus.

Potential for herniation. Severe cases of diastasis recti may progress to herniation of the abdominal viscera through the separation at the linea alba. This degree of separation requires surgical repair. Rehabilitation following this type of repair may include components of C-section rehabilitation, with specific precautions and input from the referring surgeon. There may be a need for very slow progression depending on the severity of the diastasis and how it was repaired.

Examination for Diastasis Recti

Test all pregnant patients for the presence of diastasis recti before performing any abdominal exercises. This test should be repeated throughout the pregnancy, and appropriate modifications should be made to existing exercises.

Instruct patients to perform a self-test on or after the third postpartum day for optimal accuracy. Until 3 days after delivery, the abdominal musculature has inadequate tone for valid test results.^65,86

Patient position and procedure: Hook-lying. Have the patient slowly raise her head and shoulders off the floor, reaching her hands toward the knees, until the spines of the scapulae leave the floor. Place the fingers of one hand horizontally across the midline of the abdomen at the umbilicus (Fig. 24.6). If a separation exists, the fingers will sink into the gap between the rectus muscles, or a visible bulge between the rectus bellies may be appreciated. The number of fingers that can be placed between the muscle bellies is then documented. Because this condition can occur above, below, or at the level of the umbilicus, test for it at all three areas.

Intervention for Diastasis Recti

Teach the patient to perform the corrective exercise for diastasis recti (see Fig. 24.8 and accompanying text later in this chapter) until the separation is decreased to 2 cm or less prior to resuming more strenuous abdominal strengthening that increases intra-abdominal pressure.^65,86 Transverse abdominis exercises may be incorporated with the caution against breath-holding. Once the correction has been obtained, strengthening of the obliques and more advanced abdominal work can be resumed.⁵³

Posture-Related Back Pain

Back pain commonly occurs because of the postural changes of pregnancy, increased ligamentous laxity, hormonal influences, and decreased abdominal muscle function.^{5,28,54,65,71,74,77,91}

Incidence

Back pain is reported by 50% to 80% of pregnant women at some point during pregnancy^39,64; this condition contributes to lost work days, decreased functional ability, and quality of life scores. In addition, symptoms may continue in the postpartum period, with prevalence in as many as 68% of women, for as long as 12 months after delivery.^64,70

Characteristics

The symptoms of low back pain usually worsen with muscle fatigue from static postures or as the day progresses; symptoms are usually relieved with rest or change of position. Women who are physically fit generally have less back pain during pregnancy.⁷³

Interventions

Low back pain symptoms can be treated effectively with many traditional low back exercises, proper body mechanics, posture instructions, improvement in work techniques, along with superficial modality application.^65,86 The use of deep heating agents, electrical stimulation, and traction is generally contraindicated during pregnancy.

Sacroiliac/Pelvic Girdle Pain

Characteristics

Sacroiliac pain is localized to the posterior pelvis and is described as stabbing deep into the buttocks distal and lateral to L5/S1. Pain may radiate into the posterior thigh or knee but not into the foot. Symptoms include pain with prolonged sitting, standing or walking, climbing stairs, turning in bed, unilateral standing, or torsion activities. Symptoms may not be relieved by rest and frequently worsen with activity. Pubic symphysis dysfunction may occur alone or in combination with sacroiliac symptoms and includes significant tenderness to palpation at the symphysis, radiating pain into the groin and medial thigh, and pain with weight bearing. In addition, excessive separation and translation at the joint may occur.^28,86 One study reported a four times greater incidence of posterior pelvic pain than low back pain in pregnant women.⁷¹

Interventions

Pelvic girdle and sacroiliac symptoms are treated via modification or elimination of activities that may further aggravate sensitive tissue, stabilization exercises, and the use of belts and corsets to provide external support to the pelvis.

Activity modification. Daily activities should be adapted to minimize asymmetrical forces acting on the trunk and pelvis. For example, getting into a car is done by sitting down first, then pivoting both legs and the trunk into the car, keeping the knees together; side-lying is made more symmetrical by placing a pillow between the knees and under the abdomen; and sexual positions are altered to avoid full range of hip abduction. Single-leg weight bearing, excessive abduction, and sitting on very soft surfaces should be avoided. In addition, caution patients to avoid climbing more than one step at a time, swinging one leg out of bed at a time when getting up, or crossing the legs when sitting.^28,86

Exercise modification. Exercise must be modified so as not to aggravate the condition. Avoid exercises that require single-leg weight bearing and excessive hip abduction or hyperextension. Teach the patient to activate the pelvic floor and transverse abdominals when transitioning from one position to another and with any lifting in order to stabilize the pelvis.

External stabilization. Use of external stabilization such as belts or corsets designed for use during pregnancy helps reduce posterior pelvic pain, especially when walking.

Varicose Veins

Varicosities are aggravated in pregnancy by the increased uterine weight, venous stasis in the legs, and increased venous distensibility.

Characteristics

Varicosities can present in the first trimester and are more prevalent with repeated pregnancies. They can occur in the lower extremities, the rectum (hemorrhoids), or vulva. Symptoms usually include heaviness or aching discomfort, especially with dependent leg positions; intensity may become severe as the pregnancy progresses. In addition, pregnant women are more susceptible to deep vein thrombosis.⁸⁶

Interventions

Exercise modification. If there is discomfort, exercises may need to be modified so that minimal dependent positioning of the legs occurs.

External support. Elastic support stockings should be worn to provide an external pressure gradient against the distended veins, and the woman should be encouraged to perform lower extremity exercises and to elevate the lower extremities as often as possible. Vulvar varicosities may benefit from use of a perineal pad or belt that provides counter-pressure and support to the tissues.⁶⁵

Joint Laxity

Significance

All joint structures are at increased risk of injury during pregnancy and during the immediate postpartum period. The tensile quality of the ligamentous support is decreased, and therefore injury can occur if women are not educated regarding joint protection. There is much controversy regarding the impact of postpartum hormone levels; however, elevated levels have been found 3 to 5 months after delivery.⁸⁶ This elevation may persist even longer if the woman is nursing. Many patients are aware of persistent symptoms in conjunction with the menstrual cycle.

Interventions

Exercise modification. Teach the woman safe exercises to perform during the childbearing year, including modification of exercises to decrease excessive joint stress (see exercises described in the management section of this chapter).

Aerobic exercise. Suggest nonweight-bearing or less stressful aerobic activities such as swimming, walking, or biking, particularly for women who were relatively sedentary before pregnancy.

Nerve Compression Syndromes

Causes

Impairments from conditions such as thoracic outlet syndrome (TOS) or carpal tunnel syndrome (CTS) may be caused by one or more of the following in pregnancy: postural changes in the neck and upper quarter, fluid retention, hormonal changes, or circulatory compromise. Overall, women are three times as likely as men to experience carpal tunnel syndrome. Occurrence in pregnancy can be as high as 41%.⁷³ (See Chapter 13 for discussion of CTS and TOS and Chapter 14 for discussion of posture.)

Nerve compression syndromes (for example, of the lateral femoral cutaneous nerve) may also occur in the lower extremities because of the weight of the fetus, fluid retention, hormonal changes, or circulatory compromise.

Interventions

Typical protocols include postural correction exercises, manual techniques, ergonomic assessment, and modalities (see Chapter 13 for management of nerve compression syndromes). Splints may be used in the treatment of carpal tunnel syndrome. Carpal tunnel surgery in the pregnant population is rare, because symptoms generally resolve soon after delivery; a longer course of the problem has been noted in women who breastfeed.⁸⁶

Physiological Effects of Aerobic Exercise During Pregnancy

Many women who have been doing aerobic exercises choose to continue exercising during pregnancy to maintain their cardiopulmonary fitness. Maternal^{5,23,25,57,91} and fetal^{3,23,24,26,38,57,84,91} responses have been well studied; therefore, this information is used to guide both the therapist and the patient in determining necessary modifications to an existing exercise program.

Maternal Response to Aerobic Exercise

Blood Flow

Aerobic exercise does not reduce blood flow to the brain and heart. It does, however, cause a redistribution of blood flow away from the internal organs (and possibly the uterus) and toward the working muscles. This raises two concerns: that the reduction in blood flow may decrease the oxygen and nutrient availability to the fetus and that uterine contractions and preterm labor may be stimulated.²³ Stroke volume and cardiac output both increase with steady-state exercise. This, coupled with increased blood volume and reduction in systemic vascular resistance during pregnancy, may help offset the effects of the vascular shunting.

Respiratory Rate

The maternal respiration rate appears to adapt to mild exercise but does not increase proportionately with moderate and severe exercise when compared with a nonpregnant state. The pregnant woman reaches a maximum exercise capacity at a lower work level than a nonpregnant woman because of the increased oxygen requirements of exercise.

Hematocrit Level

The maternal hematocrit level during pregnancy is lowered; however, it rises as many as 10 percentage points within 15 minutes of beginning vigorous exercise. This condition continues for as many as 4 weeks postpartum. As a result, cardiac reserve is decreased during exercise.

Inferior Vena Cava Compression

Compression of the inferior vena cava by the uterus can occur after the fourth month of pregnancy, with relative obstruction of venous return. This leads to decreased cardiac output and orthostatic hypotension. It occurs most often in supine or static standing positions, and therefore prolonged time in these positions should be avoided.³

Energy Needs

Hypoglycemia occurs more readily during pregnancy; therefore, adequate carbohydrate intake is important for the pregnant woman who exercises.²⁴ A caloric intake of an additional 500 calories per day is suggested to support the energy needs of pregnancy and exercise, dependent on the intensity and duration of the exercise. In comparison, a sedentary pregnant woman requires a 300 calorie per day increase.⁵

Core Temperature

Vigorous physical activity and dehydration through perspiration leads to increased core temperature in anyone who exercises. Concern has been expressed over this occurring in the pregnant woman because of the relationship of elevated core temperature to neural tube defects of the fetus. Studies report that during pregnancy the core temperature of physically fit women actually decreases during exercise. These women appeared to be more efficient in regulating their core temperature, and thus the thermal stress on the embryo and fetus is reduced.^24,25

Uterine Contractions

Norepinephrine and epinephrine levels increase with exercise. Norepinephrine increases the strength and frequency of uterine contractions. This may pose a problem for the woman at risk of premature labor.

Responses of Healthy Women

Studies have shown that healthy women who continue to run throughout pregnancy deliver an average of 5 to 7 days sooner compared with controls.^23,24 Clapp^23,24,25 found that exercise, including weight bearing (even with ballistic motions such as during aerobic dancing), can be performed in mid- and late pregnancy without risk of preterm labor or premature rupture of the membranes. Women who wish to continue strenuous or competitive exercise or participate in specific athletic training require close supervision by a specialist during pregnancy.^3,84

Fetal Response to Maternal Aerobic Exercise

No human research has conclusively proven a detrimental fetal response to mild- or moderate-intensity maternal exercise. Recent studies suggest that even vigorous exercise does not have the detrimental effects on the fetus that once were feared, and therefore restrictions on exercise because of concerns for the effects on the embryo and fetus have been lessened. In fact, fit women who maintained their volume of exercise after 20 weeks' gestation delivered babies with lower fat mass than those who decreased exercise intensity midway through the pregnancy.^23,24,25 Given the epidemic of obesity in the United States, the need for future research to define further the connections between fetal nutrition and adult disease is imperative.²⁶

Blood Flow

A 50% or greater reduction of uterine blood flow is necessary before fetal well-being is affected (based on animal research). No studies have documented such decreases in pregnant women who exercise, even vigorously. It is suggested that the cardiovascular adaptations in exercising women offset any redistribution of blood to muscles during exercise.²³

Fetal Heart Rate

Brief submaximal maternal exercise (as much as 70% maternal aerobic power) does not adversely affect fetal heart rate (FHR).³ The FHR usually increases 10 to 30 beats/minute at the onset of maternal exercise. After mild to moderate maternal exercise, the FHR usually returns to normal levels within 15 minutes, but in some cases of strenuous maternal exercise, the FHR may remain elevated as long as 30 min. Fetal bradycardia (indicating fetal asphyxia) during maternal exercise has been reported in the literature with the return to preexercise FHR levels within 3 min after maternal exercise, followed by a brief period of fetal tachycardia.³⁸ The healthy fetus appears to be able to tolerate brief episodes of asphyxia with no detrimental results.

Heat Dissipation

The fetus has no mechanism such as perspiration or respiration by which to dissipate heat. However, physically fit women are able to dissipate heat and regulate their core temperature more efficiently, thus reducing risk.²³

Newborn Status

Newborn children of women who continue endurance exercises into the third trimester of pregnancy are reported to have an average decrease in birth weight of 310 g There is no change in head circumference or heel-crown length. Further study of these children (as old as 5 years of age) has shown slightly better neurodevelopmental status in addition to higher percentage of lean body mass.²⁵

Exercise for the Uncomplicated Pregnancy and Postpartum

Exercise classes during pregnancy and after childbirth are designed to minimize impairments and help the woman maintain or regain function while she is preparing for the arrival of the baby and then caring for the infant.^* The potential structural and functional impairments and the management guidelines related to uncomplicated pregnancies are summarized in Box 24.2, and a suggested sequence for teaching an exercise class is listed in Box 24.3.^5,74,86,91

Guidelines and techniques for exercise class instruction are included in this section.^{3,5,31,54,65,74,84,86,91} In addition, interventions for women receiving individualized care for specific impairments are noted throughout this section. Interventions for special situations such as cesarean childbirth and high-risk pregnancy are described in the following sections.

Guidelines for Managing the Pregnant Woman

Suggest that your patients discuss with their physicians any guidelines or restrictions to exercise before engaging in an exercise program, either in a class or on a one-to-one basis. As always, follow your state practice act for physical therapy regarding referral, evaluation, and treatment.

Examination. Individually examine each woman before participation to screen for preexisting musculoskeletal problems, posture, and fitness level.

Education. Educate your patients that increased uterine cramping may occur with moderate activity; this is acceptable as long as the cramping stops when the activity is completed. Teach your patient all exercise guidelines and precautions so that exercises may be carried out safely at home. Include the following:

• Do not exceed 5 minutes of supine positioning at any one time after the first trimester of pregnancy to avoid vena cava compression by the uterus. Educate your patients that compression of the vena cava also occurs with motionless standing. For supine exercise, place a small wedge or rolled towel under the right hip to lessen the effects of uterine compression on abdominal vessels and to improve cardiac output. The wedge turns the patient slightly toward the left (Fig. 24.7).⁵ This modification is also helpful during physical therapy evaluation and treatment when the patient is positioned supine.

• To avoid the effects of orthostatic hypotension, instruct the woman to always rise slowly when moving from lying down or sitting to standing positions.

• Discourage breath-holding, and avoid activities that tend to elicit Valsalva's maneuver because this may lead to undesirable downward forces on the uterus and pelvic floor. In addition, breath-holding causes stress to the cardiovascular system in terms of blood pressure and heart rate.

• Break frequently for fluid replenishment. The risk of dehydration during exercise is increased in pregnancy. Avoid exercising in high temperature or humidity. Increase water intake in proportion to time spent exercising and as environmental temperature increases.

• Encourage complete bladder emptying before exercise. A full bladder places increased stress on an already weakened pelvic floor.

• Include appropriate warm-up and cool-down activities.

• Modify or discontinue any exercise that causes pain.

• Limit activities in which single-leg weight bearing is required, such as standing leg kicks. In addition to possible loss of balance, these activities can promote sacroiliac or pubic symphysis discomfort.

Stretching/flexibility. Choose stretching exercises that are specific to a single muscle or muscle group; do not involve several groups at once. Asymmetrical stretching or stretching multiple muscle groups can promote joint instability.

• Avoid ballistic movements.

• Do not allow any joint to be taken beyond its normal physiological range.

• Use caution with hamstring and adductor stretches. Overstretching of these muscle groups can increase pelvic instability or hypermobility.

Muscle performance and aerobic fitness. Recommendations and adaptations for pelvic floor training, general strengthening, and cardiopulmonary conditioning during pregnancy and postpartum are described in the exercise section of this chapter. Exercises to prepare for labor and delivery are also described in the exercise section.

PRECAUTIONS: Observe participants closely for signs of overexertion or complications. The following signs are reasons to discontinue exercise and contact a physician^3,84:

• Persistent pain, especially in the chest, pelvic girdle, or low back

• Leakage of amniotic fluid

• Uterine contractions that persist beyond the exercise session

• Vaginal bleeding

• Decreased fetal movements

• Persistent shortness of breath

• Irregular heartbeat

• Tachycardia

• Dizziness/faintness

• Swelling/pain in the calf (rule out phlebitis)

• Difficulty in walking

Recommendations for Fitness Exercise

NOTE: These recommendations are for pregnant women with no maternal or fetal risk factors.^*

• It is strongly recommended for all women to participate in mild to moderate exercise, for both strength and cardiopulmonary benefits, 15 to 30 minutes/session, most days of the week. Individualized programs, based on prepregnancy fitness level, are preferable.^3,84

• Currently, there are no data in humans suggesting that pregnant women need to decrease their intensity of exercise or lower their target heart rates, but because of decreased oxygen supply, they should modify exercise intensity according to their tolerance.

  • Conventional (age-based) target heart rate zones may be too aggressive for the average pregnant patient.

  • Use of the Borg scale of perceived exertion (Box 24.4) is more appropriate in this population, with exertion between 12 and 14 suggested during uncomplicated pregnancy.^15,84

  • When fatigued, a woman should stop exercising, and she should never exercise to exhaustion.

• Activities to avoid include contact sports, anything with a high risk of abdominal trauma or falling, high-altitude activities (greater than 6,000 ft), and scuba diving. The fetus is at increased risk of decompression sickness during scuba diving.⁸⁴

• Nonweight-bearing aerobic exercises, such as stationary cycling, swimming, or water aerobics, will minimize the risk of injury throughout pregnancy and the postpartum period.

• If the woman cannot safely maintain balance because of the shifting and increasing weight, have her modify exercises that could result in falling and injuring herself or the fetus.

• Adequate caloric intake for nutrition, adequate fluid intake, and appropriate clothing for heat dissipation are critical.

• Resumption of prepregnancy exercise routines during the postpartum period should be gradual. Initiation of pelvic floor exercises immediately postpartum may reduce symptoms and duration of incontinence.^62,63,64

• Physiological and morphological changes of pregnancy continue for a minimum of 4 to 6 weeks postpartum—longer if the woman is breastfeeding. Encourage continued joint protection.

• Breastfeeding women can be reassured that moderate exercise does not impair quantity or quality of breast milk or infant growth.

  • Lactating women will have slower weight loss in the postpartum period; an additional 500 calories/day are needed to support production of breast milk.

  • Water intake continues to be important; 12 or more glasses per day are recommended.

  • There may be a short-term increase in lactic acid secreted in breast milk after high-intensity exercise; if the baby appears to eat less after an exercise session, this can easily be remedied by nursing before exercise.^3,54,84

Precautions and Contraindications to Exercise

There are some circumstances in which exercise is contraindicated or requires very specific restrictions and precautions.^{3,4,5,18,39,40,48,52,65,66,67,73,74,82,84,86,91} Discussion of interventions for patients with high-risk pregnancy are described later in this chapter.

Absolute Contraindications

• Incompetent cervix: early dilation of the cervix before the pregnancy is full term

• Vaginal bleeding, especially second or third trimester

• Placenta previa: placenta is located on the uterus in a position in which it may detach before the baby is delivered

• Multiple gestation with risk of premature labor^3,54,66

• Preeclampsia: pregnancy-induced hypertension

• Rupture of membranes: loss of amniotic fluid before the onset of labor

• Premature labor: labor beginning before the 37th week of pregnancy

• Maternal heart disease, thyroid disease, or serious respiratory disorder

• Maternal type 1 diabetes

• Intrauterine growth retardation

Precautions to Exercise

The woman with one or more of the following conditions may participate in an exercise program under close observation by a physician^{4,5,18,49,54,65} and a therapist as long as no further complications arise. Exercises may require modification.^3,84

• Gestational diabetes

• Severe anemia

• Systemic infection

• Extreme fatigue

• Musculoskeletal complaints and/or pain

• Overheating

• Extreme obesity or extreme underweight/eating disorder

• Diastasis recti

Critical Areas of Emphasis and Selected Exercise Techniques

Posture Exercises

The growing fetus places added stress on postural muscles as the center of gravity shifts forward and upward and the spine shifts to compensate and maintain stability. In addition, after delivery, activities involving holding and caring for the baby stress postural muscles. Muscles that require emphasis are listed in Box 24.5. General exercise descriptions are listed in respective chapters. Subsequent sections describe adaptations of exercises specific for the pregnant woman.

Flexibility and stretching exercises are implemented with caution. Remember that connective tissues and supporting joint structures are at increased risk of injury from forceful stresses during pregnancy and the immediate postpartum period because of hormonal changes. Resistance exercises are performed at a low intensity.

Corrective Exercises for Diastasis Recti

A check for diastasis recti must always be performed before initiating abdominal exercise. Only the corrective exercises (head lift or head lift with pelvic tilt) should be used until the separation is corrected to 2 cm (two finger widths) or less.⁶⁵

Head Lift

Patient position and procedure: Hook-lying with her hands crossed over midline at the level of the diastasis for support. Have the woman exhale and lift only her head off the floor. At the same time, her hands should gently approximate the rectus muscles toward midline (Fig. 24.8). Then have the woman lower her head slowly and relax. This exercise emphasizes the rectus abdominis muscle and minimizes the obliques. Some women may not be able to successfully reach over their abdomens. In this case, the use of a sheet wrapped around the trunk at the level of the separation can be used to provide support and approximation.⁶⁵

Head Lift with Pelvic Tilt

Patient position and procedure: Hook-lying. The arms are crossed over the diastasis for support as before. Have the patient slowly lift only her head off the floor while approximating the rectus muscles and performing a posterior pelvic tilt, then slowly lower her head and relax. All abdominal contractions should be performed with an exhalation so that intra-abdominal pressure is minimized.

Stabilization Exercises

Exercises for activating the abdominal and low back muscles and developing control of their stabilizing function in the lumbar spine and pelvis are described in Chapter 16 (see Table 16.5, Fig. 16.47, and 16.48 [Level 3 A–C]; see also Table 16.6 and Fig. 16.49 A–D). The exercises should be initiated and progressed at the intensity that the woman is able to safely control. Slow, controlled breathing is emphasized while developing the stabilizing function of the muscles. As pregnancy progresses, the abdominals will undergo extreme overstretching. Therefore, exercise must be adapted to meet the needs of each individual, and periodic reassessment must be done (approximately every 4 weeks during pregnancy).

PRECAUTIONS:

• Because the trunk muscles are contracting isometrically in many of the stabilization exercises, there is a tendency to hold the breath; this is detrimental to the blood pressure and heart rate. Caution the woman to maintain a relaxed breathing pattern and exhale during the exertion phase of each exercise.

• If diastasis recti is present, adapt the stabilization exercises to protect the linea alba as described in the Corrective Exercises for Diastasis Recti section. Any progression of postpartum abdominal strengthening exercises should be postponed until the diastasis has been corrected to two finger widths or less.

• Keep in mind the 5-minute time limit for supine positioning when prescribing abdominal exercises after 13 weeks' gestation.

Dynamic Trunk Exercises

Pelvic Motion Training

These exercises are helpful in cases of posture-related back pain; they are beneficial for improving proprioceptive awareness, as well as lumbar, pelvic, and hip mobility.³²

Pelvic tilt exercises. Begin in quadruped (on hands and knees). Instruct the patient to perform a posterior pelvic tilt. While the patient keeps her back straight, have her isometrically tighten (imagine drawing in) the lower abdominals and hold, then release and perform an anterior tilt through very small range.

• For additional exercise, while holding the abdominals in and the back straight, have the woman laterally flex the trunk to the right (side-bend to the right), looking at the right hip, then reverse to the left.

• Have the woman practice pelvic tilt exercises in a variety of positions, including side-lying and standing.

Pelvic clock. With the woman hook-lying, ask her to visualize the face of a clock on her lower abdomen. The umbilicus is 12 o'clock and the pubic symphysis is 6 o'clock. The patient's legs may move slightly while performing this exercise.

• Have her begin with gentle movements back and forth between 12 and 6 o'clock (the basic pelvic tilt exercise).

• Then ask her to move back and forth between 3 o'clock (weight shifted to left hip) and 9 o'clock (weight shifted to the right hip).

• Then move in a clockwise manner from 12 to 3 to 6 to 9 and then back to 12 o'clock, then reverse.

With practice, these will become very smooth and rhythmical movements and will not require such concentration on each number of the clock. Continue relaxed breathing throughout the exercise, and do not force any part of the movement. If the patient has difficulty with the motion, make the clock "smaller" until coordination improves.³²

Pelvic clock progressions. Use the visual imagery of cutting the face of the clock in half so that there is a right side and a left side or a top half and a bottom half. Have the woman move her pelvis through the arc on the one side and back through the middle of the clock, and then move the pelvis through the opposite side and back through the middle. Initially, the woman may notice asymmetry when comparing the halves; this will improve with time.

• Once the patient understands and is able to perform the clockwise pattern, have her do counterclockwise motions with all of the activities mentioned previously, and then progress the exercises to the sitting position.³²

Trunk Curls

• Curl-ups and curl-downs are classic abdominal exercises and can be used in the early stages of pregnancy if tolerated and if no diastasis recti is present. Have a pregnant patient protect the linea alba with crossed hands (see Fig. 24.8) while performing trunk curls.

• Diagonal curls are carried out to emphasize the oblique muscles. Have the woman lift one shoulder toward the outside of the opposite knee as she curls up and down and protects the linea alba with crossed hands.

Modified Upper and Lower Extremity Strengthening

As the abdomen enlarges, it becomes impossible to comfortably assume the prone position. Exercises that are usually performed in the prone position must be modified.

Standing Push-Ups

Patient position and procedure: Standing, facing a wall, feet pointing straight forward, shoulder-width apart, and approximately an arm-length away from the wall. The palms are placed on the wall at shoulder height. Have the woman slowly bend the elbows, bringing her upper body close to the wall, maintaining a stable trunk and pelvic position, and keeping the heels on the floor. Her elbows should be shoulder height. She then slowly pushes with her arms, bringing the body back to the original position.

Supine Bridging

Patient position and procedure: Supine in the hook-lying position. Have the woman perform a posterior pelvic tilt and then lift her pelvis off the floor. She can do repetitive bridges or hold the bridge position and alternately flex and extend her upper extremities to emphasize the stabilization function of the hip extensors and trunk musculature (see Fig. 20.21).

Quadruped Leg Raising

Patient position and procedure: On hands and knees (hands may be in fists or palms may be open and flat). Instruct the woman to first perform a posterior pelvic tilt and then slowly lift one leg, extending the hip to a level no higher than the pelvis while maintaining the posterior pelvic tilt (Fig. 24.9). She then slowly lowers the leg and repeats with the opposite side. The knee may remain flexed or can be straightened throughout the exercise. Monitor this exercise, and discontinue if there is stress on the sacroiliac joints or ligaments. If the woman cannot stabilize the pelvis while lifting the leg, have her just slide one leg posteriorly along the floor and return (see Fig. 16.50 A).

Modified Squatting

Wall slides and supported squatting exercises are used to strengthen the hip and knee extensors for good body mechanics and also to help stretch the perineal area for flexibility during the delivery process. In addition, if the woman wishes to use squatting for labor and delivery, the muscles must be strengthened and endurance trained in advance.

• Patient position and procedure: Standing with back against a wall and her feet shoulder-width apart. Have the woman slide her back down the wall as her hips and knees flex only as far as is comfortable, then slide back up (see Fig. 20.24).

• Patient position and procedure: Standing with feet shoulder-width apart or wider, facing a counter, chair, or wall on which the woman can rest her hands and/or forearms for support. Have the woman slowly squat as far as is comfortable, keeping knees apart and over the feet and keeping the back straight. To protect her feet, she should wear shoes with good arch support. A woman with knee problems should perform only partial range of the squat. For optimal success with squatting during stage 2 of labor (pushing), increase the duration of the squat gradually to 60 to 90 seconds as tolerated.

Scapular Retraction

When scapular retraction exercises become difficult in the prone position, the woman should continue strengthening in the sitting or standing position (see Figs. 17.46 and 17.47.)

Perineum and Adductor Flexibility

In addition to the modified squatting exercises described in the preceding text, these flexibility exercises prepare the legs and pelvis for childbirth.^65,74,86

Self-Stretching

• Patient position and procedure: Supine or side-lying. Instruct the woman to abduct the hips and pull the knees toward the sides of her chest and hold the position for as long as is comfortable (at least to the count of 10).

• Patient position and procedure: Sitting on a short stool with the hips abducted as far as possible and feet flat on the floor. Have her flex forward slightly at the hips (keeping the back straight), or have her gently press her knees outward with her hands for an additional stretch.

Pelvic Floor Awareness, Training, and Strengthening

Pelvic floor muscle training is a valuable modality regardless of a patient's presentation or cause of symptoms.^* The majority of women are unfamiliar with the presence of the pelvic floor muscles and are even less aware of their function and role in daily activities. Intervention is slowly becoming more common during the childbearing years owing to the stress of pregnancy, labor, and delivery on the pelvic floor. Pelvic floor anatomy, function, and dysfunction are described in the first section of this chapter.

Begin pelvic floor exercise training with an empty bladder. Gravity-assisted positioning (hips higher than the heart, such as supported bridge or elbows/knees position) may be indicated initially for some women with extreme weakness and proprioceptive deficits. Varied positions may need to be explored initially to maximize patient awareness and motor learning with progression into more challenging activities/positions as functional application becomes feasible.

Contract-Relax

Instruct the woman to tighten the pelvic floor as if attempting to stop urine flow or hold back gas. Hold for 3 to 5 seconds, and relax for at least the same length of time. Repeat as many as 10 times (if performed with proper technique). With significant coordination dysfunction or fatigue, substitution with the gluteals, abdominals, or hip adductors may occur. To maximize proprioception and motor learning, it is important initially to emphasize isolation of the pelvic floor and avoid the substitute muscle actions. In addition, watch for Valsalva's maneuver; if necessary, have the woman count out loud to encourage normal breathing patterns.

Quick Contractions

Have the woman perform quick, repeated contractions of the pelvic floor muscles while maintaining a normal breathing rate and keeping accessory muscles relaxed. Try for 15 to 20 repetitions per set. This type II-fiber response is important to develop in order to withstand pressure from above, especially with coughing or sneezing.

"Elevator" Exercise

Instruct the woman to imagine riding in an elevator. As the elevator goes up from one floor to the next, she contracts the pelvic floor muscles a little more. As strength and awareness improve, add more "floors" to the sequence of the contraction. Another way to increase difficulty is to ask the woman to relax the muscles gradually, as if the elevator were descending one floor at a time. This component requires an eccentric contraction and is very challenging.

Pelvic Floor Relaxation

• Instruct the woman to contract the pelvic floor as in the strengthening exercise, then allow total voluntary release and relaxation of the pelvic floor. Use of the "elevator" imagery should also be emphasized, with particular attention to taking the elevator to the "basement."

• Pelvic floor relaxation is closely linked with effective breathing and relaxation of the facial muscles. Instruct the woman to concentrate on a slow, deep breath and allow the pelvic floor to completely relax. Relaxation of the pelvic floor is extremely important during stage 2 of labor and vaginal delivery.^37,65,86

• Chronic inability to relax the pelvic floor muscles may lead to impairments such as hypertonus, pain with intercourse, or voiding dysfunction. Please refer to the earlier information on pelvic pain syndromes. If the patient presents with these symptoms, increase the rest time between pelvic floor contractions and sets; also use submaximal contractions to improve awareness of tension versus relaxation. Use of surface EMG for down-training and muscle reeducation is invaluable with these impairments for increasing awareness of holding patterns, pain inhibition, and resting tone.

Relaxation and Breathing Exercises for Use During Labor

Developing the ability to relax requires awareness of stress and muscle tension. Techniques of conscious relaxation allow the individual to control and cope with a variety of imposed stresses by being mentally alert to the task at hand while relaxing tense muscles that are superfluous to the activity (see Chapter 4). This is particularly important during labor and delivery when there are times that the woman should relax and allow the physiologic processes to occur without excessive tension in unrelated muscles.⁶⁵ Additional relaxation techniques for managing stress are described in Chapter 14. The following guidelines are most effective for the pregnant woman if consistently practiced in preparation for labor and delivery.

Visual Imagery

Use instrumental music and verbal guidance. Instruct the woman to concentrate on a relaxing image such as the beach, mountains, or a favorite vacation spot. Suggest that she focus on the same image throughout the pregnancy so that the image can be called up to the conscious level when recognizing the need to relax during labor.

Muscle Setting

• Have the woman lie in a comfortable position.

• Have her begin with the lower body. Instruct her to gently contract and then relax first the muscles in the feet, then legs, thighs, pelvic floor, and buttocks.

• Next, progress to the upper extremities and trunk, then to the neck and facial muscles.

• Reinforce the importance of remaining awake and aware of the contrasting sensations of the muscles. Emphasize "softening" of the muscles as the session continues.

• Add deep, slow, relaxed breathing to the routine.

Selective Tension

Progress the training by emphasizing awareness of muscles contracting in one part of the body while remaining relaxed in other parts. For example, while she is tensing the fist and upper extremity, the feet and legs should be limp. Reinforce the comparison between the two sensations and the ability to control both tension and relaxation.

Breathing

• Slow, deep breathing (with relaxation of the upper thorax) is the most efficient method for exchange of air to use with relaxation techniques and for controlled breathing during labor.

• Teach the woman to relax the abdomen during inspiration so that it feels as though the abdominal cavity is "filling up" and the ribs are expanding laterally. During exhalation, the abdominal cavity becomes smaller; active contraction of the abdominal muscles is not necessary with relaxed breathing.

• To prevent hyperventilation, emphasize a slow rate of breathing. Caution the woman to decrease the intensity of the breathing if she experiences dizziness or feels tingling in the lips and fingers.

Relaxation and Breathing During Labor

First Stage

As labor progresses, the contractions of the uterus become stronger, longer, and closer together. Relaxation during the contractions becomes more difficult. Provide the woman with suggested techniques to assist in relaxation.⁶⁵

• Ensure the woman has emotional support from the father, family member, or special friend to provide encouragement and assist with overall comfort.

• Seek comfortable positions including walking, hands and knees (Fig. 24.10), lying on pillows, or sitting on a Swiss ball; include gentle repeated motions such as pelvic rocking.

• Breathe slowly with each contraction; use the visual imagery, and relax with each contraction. Some women find it helpful to focus their attention on a specific visual object. Other suggestions include singing, talking, or moaning during each contraction to prevent breath-holding and encourage slow breathing.

• During transition (near the end of the first stage), there is often an urge to push. Teach the woman to use quick blowing techniques, using the cheeks, not the abdominal muscles, to overcome the desire to push until the appropriate time.

• Massage or apply pressure to any areas that hurt, such as the low back. Using the hands may help distract the focus from the contractions.

• Apply heat or cold for local symptoms; wipe the face with a wet washcloth.

Second Stage

Once dilation of the cervix has occurred, the woman may become active in the birth process by assisting the uterus during a contraction in pushing the baby down the birth canal.⁶⁵ Teach her the following techniques:

• While bearing down, take in a breath, contract the abdominal wall, and slowly breathe out. This will cause increased pressure within the abdomen along with relaxation of the pelvic floor.

PRECAUTION: Tell the woman that if she holds her breath, there will be increased tension and resistance in the pelvic floor. In addition, exertion with a closed glottis, known as Valsalva's maneuver, has adverse effects on the cardiovascular system.

• For maximum efficiency, maintain relaxation in the extremities, especially the legs and perineum. Keeping the face and jaw relaxed assists with this.

• Between contractions, perform total body relaxation.

• As the baby is delivered, just "let go," and breathe with light pants or groans to relax the pelvic floor as it stretches.

Unsafe Postures and Exercises During Pregnancy

Bilateral straight-leg raising. This exercise typically places more stress on the abdominal muscles and low back than they can tolerate. It can cause back injury or diastasis recti and therefore should not be attempted.

"Fire hydrant" exercise. This exercise is performed on hands and knees, and one hip is abducted and externally rotated at a time (the "image" of a dog at a fire hydrant). If the leg is elevated too high, the sacroiliac joint and lumbar vertebrae can be stressed. It should be avoided by any woman who has preexisting sacroiliac joint symptoms or women in whom symptoms develop.

All-fours (quadruped) hip extension. This exercise can be performed safely only as explained earlier in this chapter (see Fig. 24.9). It becomes unsafe and can cause low back pain when the leg is elevated beyond the physiologic range of hip extension, causing the pelvis to tilt anteriorly and the lumbar spine to hyperextend.

Unilateral weight-bearing activities. Weight bearing on one leg (which includes slouched standing with the majority of weight shifted to one leg and the pelvis tilted down on the opposite side) during pregnancy can cause sacroiliac joint irritation and should be avoided by women with preexisting sacroiliac joint symptoms. Unilateral weight bearing also can cause balance problems because of the increasing body weight and shifting of the center of gravity. This posture becomes a significant problem postpartum when the woman carries her growing child on one hip. Any asymmetries become accentuated, and painful symptoms may develop.

Exercise Critical to the Postpartum Period

After an uncomplicated vaginal delivery, exercise can be started as soon as the woman feels able to exercise and has been cleared by her physician or midwife.^{3,5, 54,62,63,65,79,84}

Pelvic floor strengthening. Exercises should be resumed as soon after the birth as possible. These exercises may increase circulation and aid healing of lacerations or episiotomy. Combining pelvic floor contractions with feeding or changing the baby may help them become integrated into the daily routine. When treating a postpartum client in the clinic, emphasize life-long need for pelvic floor exercise, especially when lifting or with significant exertion, to allow the pelvic floor muscles to provide additional trunk support.

Diastasis recti correction. The testing procedure for diastasis recti was described earlier in this chapter. The mother should be taught this test and encouraged to perform it on the third postpartum day. Corrective exercises (see Fig. 24.8) should continue until the separation is two finger widths or less. At that time, more vigorous abdominal exercise can be resumed.

Aerobic and strengthening exercises. As soon as the woman feels able, cardiopulmonary exercise and light resistance training can be resumed with gradually increasing intensity. A physical examination is suggested before the onset of vigorous exercise or sport-specific training.

PRECAUTIONS: Because the woman may not be seen for exercise instruction after the delivery, inform her of the following precautions:

• If bleeding increases or turns bright red, exercise should be postponed. Tell her to rest more and allow a longer recovery time.

• Joint laxity may be present for some time after delivery, especially if breastfeeding. Precautions should be taken to protect the joints as described previously.^74,86,91 Adequate warm-up and cool-down time is important.

Cesarean Childbirth

A cesarean section is the delivery of a baby through an incision in the abdominal wall and uterus rather than through the pelvis and vagina.^{2,40,43,54,67} General, spinal, or epidural anesthesia may be used.

Significance to Physical Therapists

Surgical Risks

Cesarean section (C-section) delivery is now at an all-time high and is the most commonly performed surgical procedure in the United States. In 2007, the total number of C-sections was almost 1.5 million, for a record high rate of 31.8%⁵⁰ This statistic has fluctuated in the past three to four decades, in part depending on the type of hospital and the population it served. Since the early 1990s, the American College of Obstetricians and Gynecologists (ACOG) has discouraged repeat C-sections as routine practice, and the Healthy People 2010 goal was to reduce the primary rate to 15%, with a target rate for repeat cesareans at 63%.⁵¹ The Vaginal Birth After Cesarean (VBAC) movement was a factor in reducing C-sections from 1990 to 1996; however, since then, the rates have continued to climb. The medical community is continuing to discuss the short- and long-term benefits and harms to both mother and baby of a trial of labor following a previous C-section. Pregnant clients will have many questions regarding this evidence. Al-Zirqi and colleagues² identified specific risk factors for uterine rupture with a VBAC and determined that absolute risk was low (5.0/1,000 births; n=18,794). However, the use of prostaglandin induction significantly increased the odds for rupture when compared to spontaneous labor.

Recently, the perceived "convenience" of a C-section is becoming a factor, leading to increases in not only repeat but also elective C-sections. In addition to the appeal of scheduling a delivery date, there is some evidence that cesarean delivery may aid in prevention of future pelvic floor dysfunction.^6,43,83 These risks and benefits will continue to be discussed as maternal and fetal outcomes are detailed in the literature.

Pregnant women need to be informed of the risks and benefits of each choice in order to make informed decisions. Because these statistics continue to fluctuate and more changes will be inevitable as our healthcare system evolves, physical therapists must stay informed in order to address these issues with all pregnant patients.^{2,6,35,40,43,58,61,67,69,83,86,89}

Interventions

Pelvic floor rehabilitation. Women who have had a cesarean delivery may still require pelvic floor rehabilitation. Many women experience a lengthy labor, including prolonged second stage (pushing), before a C-section is deemed necessary. Therefore, the pelvic floor musculature and the pudendal and levator ani nerves may still be compromised. Also, pregnancy itself creates significant strain on the pelvic floor musculature and other soft tissues.

Postsurgical rehabilitation. Postpartum intervention for the woman who has had a cesarean delivery is similar to that of the woman who has had a vaginal delivery. However, a C-section is a major abdominal surgery with all the risks and complications of such surgeries, and therefore the woman may also require general postsurgical rehabilitation.^40,43,67,86, Impairments and management guidelines are summarized in Box 24.6.

Emotional support. All childbirth preparation classes do not adequately educate and prepare couples for the experience of a cesarean delivery. As a result, the woman with an unplanned C-section frequently feels as if her body has failed her, causing her to have more conflicting emotions than a woman who has experienced a vaginal delivery.

Suggested Activities for the Patient Following a Cesarean Section

Exercises

• Instruct the woman during her pregnancy in all appropriate exercises, with indicated precautions.

• Instruct the woman to begin preventive exercises as soon as possible during the recovery period.^40,65,66

  • Ankle pumping, active lower extremity ROM, and walking are used to promote circulation and prevent venous stasis.

  • Pelvic floor exercises are used to regain tone and control of the muscles of the perineum.

  • Deep breathing and coughing or huffing are used to prevent pulmonary complications (see instructions that follow).

• Progress abdominal exercises slowly. Check for diastasis recti, and protect the area of the incision to improve comfort. Initiate nonstressful muscle-setting techniques and progress as tolerated, based on the degree of separation.^40,65,66,86

• Teach posture correction as necessary. Retrain postural awareness and help realign posture with indicated therapeutic exercise. Develop control of the shoulder girdle muscles as they respond to the increased stress of caring for the new baby.

• Reinforce the value of deep diaphragmatic breathing techniques for pulmonary ventilation, especially when exercising, and relaxed breathing techniques to relieve stress and promote relaxation.

• Inform the woman that she should wait at least 6 to 8 weeks before resuming vigorous exercise. Emphasize the importance of progressing at a safe and controlled pace and not expecting to begin at her prepregnancy level.

Coughing or Huffing

Coughing is difficult following a C-section because of incisional pain. An alternative is huffing.⁶⁵ A huff is an outward breath caused by the upper abdominals contracting up and in against the diaphragm to push air out of the lungs. The abdominals are pulled up and in, rather than pushed out, causing decreased pressure in the abdominal cavity and less strain on the incision. Huffing must be done quickly to generate sufficient force to expel mucus. Instruct the patient to support the incision with a pillow or the hands and say "ha" forcefully and repetitively while contracting the abdominal muscles.

Interventions to Relieve Intestinal Gas Pains

Abdominal massage or kneading. Have the patient lie supine or on the left side. This is very effective and typically done with either long or circular strokes. Begin on the right side at the ascending colon, stroking upward, then stroke across the transverse colon from right to left and down the descending colon, then finish with an "S" stroke along the sigmoid colon. This can also be particularly effective for stimulating peristalsis and improving constipation.⁴⁴

Pelvic tilting and/or bridging. These can be done in conjunction with massage.

Bridge and twist. Have the patient maintain a position of bridging while twisting her hips to the right and left.

Scar Mobilization

Cross-friction massage should be initiated around the incision site as soon as sufficient healing has occurred. This will minimize adhesions that may contribute to postural problems and back pain.

High-Risk Pregnancy

A high-risk pregnancy is one that is complicated by disease or problems that put the mother or fetus at risk for illness or death before, during, or after delivery. Conditions may be preexisting, induced by pregnancy, or caused by an abnormal physiologic reaction during pregnancy.^41,54 The goal of medical intervention is to prevent preterm delivery, usually through use of bed rest, restriction of activity, and medications, when appropriate. Prolonged bed rest can impact not just the musculoskeletal system but also pulmonary, cardiovascular, and metabolic functions. Although these women may initially be seen in the home, the deconditioning present continues to create functional restrictions for the postpartum client in terms of strength and endurance, making this scenario ideal for physical therapy intervention. Here again, as with pelvic floor dysfunction, advanced education for the therapist and specialized care is required for successful outcomes.^{41,53,54,73,74,77,86}

High-Risk Conditions

Premature onset of labor. If cervical dilation, effacement, and/or uterine contractions begin before 37 weeks' gestation, this is considered preterm labor. Clearly, the health of the baby is of primary concern if these signs are present. The mechanism for this condition is still unclear.⁵⁴

Preterm rupture of membranes. The amniotic sac breaks, and amniotic fluid is lost before onset of labor. This can be dangerous to the fetus if it occurs before fetal development is complete. Labor may begin spontaneously after the membranes rupture. The chance for fetal infection also increases when the protection of the amniotic sac is lost. Leakage of amniotic fluid is an indication for immediate medical attention.

Incompetent cervix. An incompetent cervix is the painless dilation of the cervix that occurs in the second trimester (after 16 weeks' gestation) or early in the third trimester of pregnancy. This may lead to premature membrane rupture and delivery of a fetus too small to survive.

Placenta previa. The placenta attaches too low on the uterus, near the cervix. As the cervix dilates, the placenta begins to separate from the uterus and may present before the fetus, thus endangering fetal life. The primary symptom is intermittent, recurrent, or painless bleeding that increases in intensity.

Pregnancy-related hypertension or preeclampsia. Characterized by hypertension, protein in the urine, and severe fluid retention, preeclampsia can progress to maternal convulsions, coma, and death if it becomes severe (eclampsia). It usually occurs in the third trimester and disappears after birth. The cause is not understood.

Multiple gestation. More than one fetus develops. Complications of multiple gestations include premature onset of labor and birth, increased incidence of perinatal mortality, lower birth weight infants, and increased incidence of maternal complications (e.g., hypertension).

Diabetes. Diabetes can be present before pregnancy or may occur as a result of the physiological stress of pregnancy. Gestational diabetes, which presents or is first recognized in pregnancy, affects 7% of pregnant women and usually disappears after pregnancy; however, as many as 50% of these women may develop type 2 diabetes within 10 years.⁴⁹

Unlike many of the previously discussed high-risk conditions, women with gestational diabetes may be appropriate candidates for more traditional physical therapy interventions. Supervised, individualized exercise programs are excellent options. Parameters for exercise in pregnancy for women with gestational diabetes were published by the American Diabetes Association in 2006.⁴ They support aerobic exercise with limited duration and at 50% maximum aerobic capacity; alternatively, the Borg scale may be used with a range of 11 to 13 rate of perceived exertion (RPE) as maximal activity level (see Box 24.4). With appropriate monitoring of fetal/uterine activity, maternal heart rate, and blood glucose levels, exercise duration of 15 to 30 minutes appears to be safe.⁵⁴ Instruct patients to monitor for any postexercise uterine activity; contractions need to be fewer than one every 15 minutes.^4,54

Exercise may actually prevent gestational diabetes in obese pregnant women.³ In particular, recumbent bicycling or arm ergometer exercises have been shown to stabilize and lower glucose levels.⁷³

Management Guidelines and Precautions for High-Risk Pregnancies

All exercise programs for high-risk populations should be individually established based on diagnosis, limitations, physical therapy examination and evaluation, and consultation with the physician. Activities must address patient needs but should not further complicate the condition.^74,86 Management guidelines for the woman who is confined to bed because of her high-risk status are summarized in Box 24.7.

Develop good rapport with the patient and instill trust. Closely monitor the patient during all activities; reevaluate her after each treatment, and note any changes. It is also important to teach the patient self-monitoring techniques so that she will be alert to adverse reactions and respond appropriately.

• Prolonged static positioning is a primary concern. The position of choice for the high-risk patient is left side-lying, which is optimal for reducing pressure on the inferior vena cava and for maximizing cardiac output, thereby enhancing maternal and fetal circulation.

• Some exercises, especially abdominal exercises, may stimulate uterine contractions. If this occurs, modify or discontinue them.

• Monitor and report any uterine contractions, bleeding, or amniotic fluid loss.

• Do not allow use of Valsalva's maneuver. Avoid any activities that increase intra-abdominal pressure. Body mechanics and postural instruction may stimulate abdominal contractions, so be sure the patient does not strain and closely monitor for adverse symptoms.

• Keep the exercises simple. Have the patient do them slowly, smoothly, and with minimal exertion.

• Many high-risk pregnancies result in cesarean deliveries, so educate the woman about cesarean delivery rehabilitation.

• Incorporate maximum muscle efficiency into each movement.

• Teach the patient self-monitoring techniques.

Exercise Suggestions with High-Risk Pregnancies

Exercise suggestions are adaptations of interventions that have already been described that should be considered for the bedbound patient with a high-risk pregnancy.^73,74,86 Exercises to include are summarized in Box 24.8.

Positioning

• Left side-lying to prevent vena cava compression, enhance cardiac output, and decrease lower extremity edema

• Pillows between the knees and under the abdomen when side-lying

• Supine positioning for short periods, with a wedge placed under the right hip to decrease inferior vena cava compression (see Fig. 24.7)

• Modified prone positioning (side-lying, partially rolled toward prone, with pillow under abdomen) to decrease low back discomfort and pressure

Range of Motion (ROM)

• Active ROM of all joints.

• Motions should be slow, nonstressful, and through the full range if possible.

• Teach in a gravity-neutral position if antigravity ROM is too much exertion.

• Individualize the number of repetitions and frequency to the woman's condition.

Ambulation/Standing

Getting out of bed is almost always contraindicated; when allowed, it usually will be only to use the bathroom or to shower

• Encourage good posture in ambulation

• Tip-toe or heel walking to emphasize calf muscles

• Gentle, partial-range squatting to emphasize hip and thigh muscles

Relaxation Techniques, Bed Mobility, and Transfer Activities

• Relaxation as in the uncomplicated pregnancy

• Moving up, down, and side-to-side in bed

• Log rolling: incorporate neck and upper and lower extremities to aid movement

• Supine-to-sitting: use log-roll technique, assisted by arms

Preparation for Labor

• Relaxation techniques

• Substitutions for squatting: supine, sitting, or side-lying, bringing flexed knees toward chest (hips will have to be abducted)

• Pelvic floor relaxation

• Breathing exercises: minimize forced abdominal exhalations

Postpartum Exercise Instruction

Instructions are the same as previously described in the uncomplicated pregnancy section.

Critical Thinking and Discussion

1. Describe three normal changes of pregnancy that will affect exercise tolerance.

2. Explain the clinical significance of diastasis recti, the testing procedure, and the corrective exercise.

3. Differentiate between postural and sacroiliac back pain in the pregnant patient.

4. Name five risk factors for pelvic floor dysfunction.

5. What exercise guidelines are most helpful for a woman who has not exercised prior to becoming pregnant?

6. Discuss optimal positioning for an uncomplicated labor and delivery in terms of biomechanics, gravity, and energy conservation.

7. Vaginal delivery places great stretch and compression on which nerves?

Laboratory Practice

1. Practice giving instructions to a lab partner on how to perform the following exercises. Observe that they are being done correctly. Reverse the experience and provide feedback.

   • Diastasis recti exercises

   • Pelvic clock exercises

   • Breathing and relaxation for the different stages of labor and delivery

2. Practice giving instructions, and get verbal feedback as to the success of instructions for the pelvic floor awareness training and strengthening exercises.

3. Observe an exercise class for pregnant women. Critique the effectiveness and inclusiveness of the instruction.

Case Studies

1. Ms. V is a 32-year-old pregnant woman referred with a diagnosis of "low back pain," that became severe at 24 weeks' gestation. She reports (L) lumbar/thoracic, (R) anterior rib/pectoral, and cervical symptoms, which are worsening as the pregnancy progresses. Before her pregnancy, she wore a custom-made bra (32-MM), which is now much too small and provides inadequate support. Wearing this bra greatly increases her cervical and upper trapezius symptoms. Wearing a sports bra or standing more than 10 to 15 minutes causes increased low back symptoms. Pain is severely limiting her daily activities both at home and in the community. She has difficulty climbing stairs, grocery shopping, doing laundry, and other household chores. She is wakened at night by pain and also reports numbness in her lower extremities at night. She is a single mother of a 6-year-old son. Pertinent medical history includes: weight gain of 100 lb with her previous pregnancy, C-section delivery, removal of fibrocystic breast tissue three times. No systemic medical conditions or medications other than prenatal vitamins. Current weight: 238 lb, height: 5′4″.

Clinical Findings

Postural assessment reveals marked forward head/shoulders with internal rotation at both shoulder joints, significant lordosis (cervical and lumbar), recurvatum bilaterally, decreased longitudinal arches, increased base of support with excessive external rotation (ER) at both hips. All dynamic movements are pain inhibited: frequent weight shift and asymmetrical transitions, antalgic gait pattern with increased ER of hips. Lumbar extension and (L) cervical rotation most limited by pain and spasm.

Diastasis recti of 9 cm noted above umbilicus; abdominal strength 3–/5. Pelvic landmarks difficult to assess due to adipose tissue; leg lengths appear equal. Slight tenderness over pubic symphysis with palpation.

• Identify the impairments and functional limitations.

• Identify goals that deal with impairments and functional limitations.

• Develop a treatment plan to meet the goals; identify specific interventions and parameters, number of times she will be seen, and any follow-up or referrals that you believe will be necessary.

2. Mrs. W is a 71-year-old woman with an 11-year history of urinary incontinence and urgency. She experiences frequent, large-volume accidents, using 8 to 10 large incontinence pads and 8 panty liners per day for garment protection. Voiding frequency is 13 to 16 times every 24 hours. She also reports constipation and straining for evacuation, which improves with increased fiber intake. Caffeine intake is two servings per day. Mrs. W is a nonsmoker. She is much less active with social and community activities as a result of this problem. Urodynamic testing revealed diminished bladder capacity at 150 cc and confirmed the diagnosis of detrusor instability.

Pertinent medical history includes nine pregnancies and seven live births (G9, P7) with one breech presentation. reported with lumbar fusion done when she was 44 and 48 years of age. Other surgical history includes rectocele/cystocele repair when she was 36 and partial hysterectomy when she was 37. Hypertension and asthma are both well controlled with medication.

Clinical Findings

Pelvic floor muscle assessment reveals poor sensory awareness, decreased resting tone, and an MMT of 2/5. Patient able to hold a contraction 4 seconds and repeat 10 "quick flicks" in 10 seconds. Accessory recruitment of the abdominals noted. Pressure perineometry confirms muscle weakness with 6.35 cm of water pressure generated. Levator ani contraction is enhanced with stretch facilitation to the pelvic floor (R > L).

Abdominal strength is 3/5. Diastasis recti noted above the umbilicus of 4.5 cm. Diaphragmatic breathing pattern present; no Valsalva's with exertion. All dynamic movements of the trunk are mildly restricted because of lumbar fusion.

The patient underwent physical therapy treatments approximately 18 months ago and is independent with her low back (LB) program. (Because of insurance limitations of 10 visits, the patient requested primary attention to pelvic floor dysfunction and incontinence.)

• Identify the impairments and functional limitations.

• Identify goals that deal with the impairments and functional limitations.

• Design a treatment plan to meet the goals; identify specific interventions and parameters, number of times she will be seen, and any follow-up or referrals that you believe will be necessary.

• http://www.womenshealthapta.org (Section on Women's Health, APTA)

• http://sis.nlm.nih.gov/outreach/whrhome.html (Women's Health Resources)

• http://www.healthywomen.org

• http://www.pfdn.org (Pelvic Floor Disorders Network)

• http://www.nafc.org (National Association for Continence)

• http://www.pelvicpain.org (International Pelvic Pain Society)