+++
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. Maternal5,23,25,57,91 and fetal3,23,24,26,38,57,84,91 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
++
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.
++
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.
++
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
++
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
++
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
++
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 Clapp23,24,25 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
++
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
++
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.
++
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 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
++
BOX 24.2 MANAGEMENT GUIDELINES—Pregnancy and Postpartum Potential Structural and Functional Impairments
Musculoskeletal pain and muscle imbalances from faulty postures
Poor body mechanics related to lack of knowledge, changing body size, and physical demands of child care
Lower extremity edema and discomfort from altered circulation and varicose veins
Pelvic floor dysfunction, including:
Abdominal muscle stretch, trauma, and diastasis recti
Potential decrease in cardiovascular fitness
Lack of knowledge of body changes and safe exercises to use during and after pregnancy
Changing body image
Lack of physical preparation (strength, endurance, relaxation) necessary for labor and delivery
Lack of knowledge of appropriate positioning for optimal comfort in labor and delivery
Lack of adequate postpartum rehabilitation
++
BOX 24.3 Suggested Sequence for Exercises Classes
General rhythmic activities to "warm-up"
Gentle selective stretching for postural alignment and for perineum and adductor flexibility
Aerobic activity for cardiovascular conditioning (duration/intensity may need to be individualized)
Postural exercises; upper/lower extremity strengthening and individualized abdominal exercises
Cool-down activities
Pelvic floor exercises
Relaxation techniques
Labor and delivery techniques
Educational information
Postpartum exercise instruction (e.g., when to begin exercises, how to safely progress, precautions) because the patient may not be attending a postpartum class. Include education regarding body mechanics relative to child care.
++
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.
++
CLINICAL TIP
Consider use of muscle energy techniques using light resistance for a client with pelvic instability and one whose pelvic boney landmarks are out of alignment. (See Chapter 15 for description of techniques.)
++
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 physician3,84:
++
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
++
CLINICAL TIP
Keep in mind when developing intervention programs, whether providing advice to a class or providing individual therapy, that most physical agents are contraindicated in pregnancy. Superficial heat or ice may be beneficial to relieve pain/spasm and improve circulation.
Electric stimulation may be added postpartum to modulate pain and to stimulate muscle contractions, respectively.
Ultrasound may be helpful in cases of poor episiotomy healing and painful scar tissue.
+++
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
++
BOX 24.4 Borg Rating Scale for Perceived Exertion (RPE)15
6—Very, very light
7
8
9—Very light
10
11—Fairly light
12
13—Moderately hard
14
15—Hard
16
17—Very hard
18
19—Very, very hard
20—Exhaustion
+++
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 labor3,54,66
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 physician4,5,18,49,54,65 and a therapist as long as no further complications arise. Exercises may require modification.3,84
++
+++
Critical Areas of Emphasis and Selected Exercise Techniques
++
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.
++
BOX 24.5 Selected Stretching and Resistance Exercises During Pregnancy Stretching (with Caution)
Upper neck extensors and scalenes (Chapter 16)
Scapular protractors, shoulder internal rotators, and levator scapulae (Chapter 17)
Low back extensors (Chapter 16)
Hip flexors, adductors, and hamstrings (Chapter 20). CAUTION: women with pelvic instabilities should not overstretch these muscles.
Ankle plantarflexors (Chapter 22)
Strengthening (Low Intensity with Modifications Described in This Chapter) Upper neck flexors and lower neck and upper thoracic extensors (Chapter 16)
Scapular retractors and depressors (Chapter 17)
Shoulder external rotators (Chapter 17)
Trunk flexors (Chapter 16), particularly lower abdominals; use corrective exercises for diastasis recti if present
Hip extensors (Chapter 20)
Knee extensors (Chapter 21)
Ankle dorsiflexors (Chapter 22)
++
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
++
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).
++
++
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
++
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.
++
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.
++
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).
++
++
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.
++
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
++
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.
++
FOCUS ON EVIDENCE
A Cochrane review of 43 randomized trials concluded that pelvic floor muscle training is an effective treatment for stress or mixed urinary incontinence and is better than no treatment or placebo.46 Functional improvements (decreased urinary incontinence and improved pelvic floor strength) have been noted in late pregnancy and from 3 to 12 months postpartum in a number of studies.62,63,79 For optimal outcomes, pelvic floor contractions should be incorporated into routine ADLs, particularly activities that are "triggers" for leakage due to increased intra-abdominal pressure; used for stabilization prior to coughing or sneezing; and continued for life-long health benefits.10,46
++
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.
++
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.
++
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.
++
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.
++
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.
++
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.
++
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.
++
CLINICAL TIP
While practicing selective tension, have your client work with a partner who gently shakes the extremity that is "relaxed" to make sure there is no tension in it.
++
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
++
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.
++
++
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.
++
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
++
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
++
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.
++
BOX 24.6 MANAGEMENT GUIDELINES—Postcesarean Section Potential Structural and Functional Impairments
Risk of pulmonary, gastrointestinal, or vascular complications
Postsurgical pain and discomfort
Development of adhesions at incision site
Faulty posture
Pelvic floor dysfunction
Abdominal weakness, diastasis recti
General functional restrictions of post delivery
++
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
++
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 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.
++
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.
++
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
++
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
++
FOCUS ON EVIDENCE
In a randomized study of overweight women with gestational diabetes (n=32), the control group was treated with diet alone, while the remaining women also participated in circuit resistance training. The diet-plus-exercise group was able to postpone the use of insulin therapy until later in the pregnancy (p <0.05) and was also prescribed less insulin overall (p<0.05) than the diet-alone group.18
+++
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.
++
BOX 24.7 MANAGEMENT GUIDELINES—High-Risk Pregnancy Potential Structural and Functional Impairments, Activity Limitations, (Functional Limitation)
Primary activity limitations are inability to be out of bed and move about, prolonged static positioning, contributing to the following impairments:
Joint stiffness and muscle aches
Muscle weakness and disuse atrophy
Vascular complications including risk of thrombosis and decreased uterine blood flow
Decreased proprioception in distal body parts
Constipation caused by lack of exercise
Postural changes
Boredom
Emotional stress; patient may be at risk of losing the baby
Guilt from the belief that some activity caused the problem or that the patient did not take good enough care of herself
Anxiety about her home situation, older children, finances, or the impending birth
++
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.
++
BOX 24.8 Bed Exercises for High-Risk Pregnancy
Patient supine (with wedge under the right hip), semireclined or side-lying
Cervical active ROM and chin tucks
Backward shoulder circles (scapular retraction); reach to ceiling (protraction)
Unilateral upper extremity diagonal patterns
Shoulder, elbow flexion/extension; arm circles in side-lying
Forearm pronation/supination; wrist flexion/extension, hand open/close
Pelvic tilts
Abdominal exercises (per physician consultation)
Pelvic floor exercises (per physician consultation)
Quad and gluteal isometric sets
Unilateral hip abduction and adduction, internal/external rotation
Unilateral hip and knee flexion/extension in side-lying
Ankle pumping, ankle circles, ankle "alphabet"
Toe flexion/extension
++
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.
++
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.
+
++
++
++