2.1.2. Pelvic floor muscles

The pelvic floor is a group of muscles often described as being shaped like a hammock or sling. The outlets of the bladder and bowel – urethra and rectum – pass through the pelvic floor.These muscles are attached to the spine's tailbone or coccyx and continue to the pubic bone at the front of the body.The pelvic floor supports the bladder and bowel in men, passing just under the prostate gland. It supports the uterus, bladder and bowel in women.We can consciously control these muscles through a system of nerves and electrical impulses sent from our brain to the muscles. When we want to tense or relax them we can.Ordinarily, the pelvic floor muscles are tense, ensuring continence by keeping the outlets closed. When we go to the toilet we relax these muscles and the urethra opens.The levator ani is a muscle group in pelvic floor group. This group is especially important for maintaining continence. The levator ani surrounds the vagina in women, and in both men and women it surrounds the anal canal and the urethra.

2.1.3. Urethral sphincters

The urethral sphincters are also important for continence and control. In fact, for men, there are two. One is located in the bladder neck and is called the internal sphincter. It's a smooth muscle, which means there's no conscious control over it. You can't voluntarily squeeze it, that happens automatically. Then there is the external sphincter, which both men and women have. It's a different type of muscle to the internal sphincter and we can voluntarily control it.In men it's located just under the prostate at the base of the penis. For women, the external sphincter extends up to the bladder and encircles both the urethra and vagina.

1.2. Male Reproductive system

For men, the external reproductive organs include: Penis: This tubular muscular organ becomes filled with blood during arousal, thus

making sexual intercourse possible. Scrotum: This pouch-like sac hangs below the penis and encases the testes, or

testicles. Testicles: These two oval shaped organs produce sperm cells and testosterone.

While all men are born with all of their sexual organs, they don’t begin to function fully until puberty. The common age of puberty is around 12. During this time, hormone changes affect a boy’s gonads and create lasting changes that have typically been viewed through history as when a boy “becomes a man.” This process affects many changes, such as growth, muscular build, hair growth on the genitals, face, and other parts of the body.

In terms of reproduction, puberty signals the time when a man has fully-functioning sexual organs and is capable of procreation.

The male testes produce spermatozoa (more commonly referred to as sperm), which is released at sexual climax. This is known as ejaculation. The sperm leaves the penis in a mixture of secretions designed to nourish and transport the cells into the female reproductive system for procreation.There are up to 750 million sperm cells in each ejaculation, but it only takes a single sperm cell to fertilize a woman’s egg.The testes also produce the hormone testosterone that is directly absorbed into the bloodstream. Along with producing sperm and maintaining sexual function, testosterone also creates common features that physically distinguish men from women, such as facial hair, deeper voice, more muscle mass, and broader shoulders.

Chapter IVAntenatal preparation programs

Antenatal preparation programmes involve several techniques and activities performed by different healthcare professionals.

1. Aims of antenatal preparation programmes

The main aims of antenatal preparation programs are: to promote healthy practices, to minimize excessive anxiety to prevent or minimize the discomforts of pregnancy and labor; to prevent post-partum complications.

2. Content of antenatal preparation programs

Such programs may include educational activities, physical exercise and psychoprophylactic techniques, among others.

The practice of regular physical exercise during pregnancy with the objective of keeping women healthy during pregnancy is recommended by the American College of Obstetricians and Gynecologists (ACOG), and can be included in antenatal programs. Moreover, daily exercises can prevent gestational diabetes and excessive gestational weight gain. There is evidence that physical exercise during pregnancy does not increase the risk of muscle injuries or changes in arterial blood pressure, and does not increase the risk of preterm labor or low fetal weight.

Studies have been conducted to evaluate whether exercise during pregnancy is able to reduce discomfort resulting from lumbar and pelvic pain and decrease the occurrence of urinary

incontinence. The practice of specific exercises was able to reduce lumbar and pelvic pain during pregnancy. As well, pelvic floor muscle exercises during pregnancy could protect against urinary incontinence both during pregnancy and in the postpartum period.

Anxiety during pregnancy has been related to adverse outcomes, such as fetal distress, premature labor, low birth weight, and problems in child development. The use of relaxation techniques (breathing exercises, massage, yoga, reflexology, visualization) during pregnancy may reduce stress and anxiety.

3. The first antenatal preparation programs: Lamaze method

One of the most known method for pre-partum sessions is the Lamaze method. The Lamaze method, developed by the French obstetrician Ferdinand Lamaze, has been used in the United States since the late '50s and remains one of the most commonly taught types of childbirth classes. In the early days, the focus was on using controlled breathing techniques to cope with labor. But the vision of Lamaze educators has expanded a lot since then.

According to Lamaze International, the goal of Lamaze classes is to "increase women's confidence in their ability to give birth." Toward that end, women learn a variety of simple coping strategies, of which breathing is only one. The classes aim to help women "learn how to respond to pain in ways that both facilitate labor and increase comfort."

The Lamaze philosophy of birth stipulates that "birth is normal, natural, and healthy" and that "women have a right to give birth free from routine medical interventions." But Lamaze also educates women so that when interventions are needed, or pain relief medication is desired, women are able to give true informed consent.

4. Sessions specificities

The sessions can be given privately, or in group.

The sessions starts in the fourth month of pregnancy;

The partner is desirably present

It is divided into 9 sessions maximum

Each session is divided into two main parts:

a theoretical part

a practical part that is divided onto exercices and sophrology

5. Objectifs of the childbirth sessions or antenatal programme

To be prepared physically and psychologically; To Better know the body and to listen to it To receive a lot of information on the course of pregnancy. To deal with the major issues facing the majority of mothers about the last weeks before

delivery , the delivery, the role and availability of the anesthesiologist , the stay at the maternity, complications, the postpartum contraception , food for the baby ...

To learn gestures and positions that will help during childbirth To practice relaxation exercises To conduct exercises for relaxing the muscles of the pelvis. To discover how to perform pelvic tilt , exercise helps mitigate the pain of the back

muscles and ligaments and the possibility the baby to pass more easily through the pelvis.

To train the body to facilitate the baby's arrival Learn to relax To discover the perineum, all muscles supporting the bladder, uterus and rectum and

between the pubis to the coccyx. During pregnancy, the perineum is distended because of the enlargement of the uterus.

o The perineum involved in urinary control and bowel movements.o It occurs during sexual intercourse.

• Better support contractions adapting its breath to better withstand the pain from contractions and knowing maneuvers to facilitate the mobility of the pelvis.

• Learn how to develop a breathing technique to recover between contractions.•To conduct a visit to the maternity to allow to become familiar with the space and

equipment present in the delivery room .

6. The practical part

Treatment plans take a comprehensive approach by working on pain’s typical triggers:

posture joint alignment muscle strength flexibility nerve involvement.

6.1. Postural rehabilitation

Additional weight, decreased posture, stress and control of the center of gravity are not independent from one another.

A change in the center of gravity of the pregnant women affects her posture which causes the muscles to work harder. Increased exertion creates fatigue which leads to decreased motivation to be active. The absence of an athletic release often results in increased stress. Though it is difficult, the domino effect can be slowed greatly with the help of physical therapy.

1.2.Low back pain

Lower back pain is an all too common reality for many expecting mothers. As the uterus and baby grow, the mother’s center of gravity moves forward. This shift increases the amount of force the muscles must generate for everyday support causing women to slump forward. Over time this poor alignment creates muscle tightness in the pectoral muscles, rolling the shoulders forward and creating increased stress on the muscles of the neck, shoulders and mid-back. If these muscular factors are not addressed, these forces will ultimately be translated down to the low back, an area which is already under a great deal of stress because it is supporting the increased center of gravity.

1.3.Muscle strength and endurance

Additionally, exercise increases physical endurance and muscle strength, especially in the hips, back and abdomen. Improving these areas can prepare the body for the physically demanding event of delivering a baby, positioning oneself for a better labor experience. Finally, therapeutic exercise during pregnancy can assist the recovery after the delivery. It tones muscle which will improve metabolism, decrease the severity of fatigue, and assist in reclaiming your pre-pregnant weight.

1.4.Contra-indiaction for exercices during pregnancy

Hemodynamically significant heart disease Restrictive lung disease Incompetent cervix/cerclage Multiple gestation at risk for premature labor Persistent second- or third-trimester bleeding Placenta previa after 26 weeks of gestation Premature labour during the current pregnancy Ruptured membranes Preeclampsia/pregnancy-induced hypertension

1.5.Precautions to be taken if the patient have any of the following

Severe anemia Unevaluated maternal cardiac arrhythmia Chronic bronchitis Poorly controlled type 1 diabetes Extreme morbid obesity

Extreme underweight (BMI < 12) History of extremely sedentary lifestyle Intrauterine growth restriction in current pregnancy Poorly controlled hypertension Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker

1.6.Symptoms that lead to stop sessions

Vaginal bleeding Dyspnea prior to exertion (Out of Breath, prior to exercise) Dizziness Headache Chest pain Muscle weakness Calf pain or swelling (DVT must be ruled out) Preterm labour Decreased fetal movement Amniotic fluid leakage

2. Exercices

Kegel (PFM contractions)

Kegel exercises are small internal contractions of the pelvic floor muscles that support the urethra, bladder, uterus, and rectum. The exercises are named after Arnold Kegel, a gynecologist who recommended them back in the 1940s to help women with urinary incontinence, or diminished bladder control, which can happen after childbirth. Strengthening the pelvic floor muscles improves circulation to the rectal and vaginal area, helping to keep hemorrhoids at bay and speeding healing after an episiotomy. There's even some evidence suggesting that strong pelvic floor muscles may shorten the pushing stage of labor.

Tighten the muscles around the vagina as if trying to interrupt the flow of urine when going to the bathroom.

Hold for a count of four, then release. Repeat ten times. Try to work up to three or four sets about three times a day.

The feeling is one of "squeeze and lift" – a closing and drawing up of the front and back passages.

The patient must make sure that she is squeezing and lifting without pulling in her tummy,

squeezing her legs together, tightening her buttocks, or holding her breath. Only the pelvic floor

muscles should be working.

Though patient may have trouble isolating these muscles at first, it gets easier with practice. It

might help to place a hand on the belly while doing Kegel’s to make sure that it stays relaxed.

At the beginning, patient starts by holding each contraction for a few seconds before releasing,

and relax for a few seconds after each one. As her muscles get stronger, she'll want to work up to

holding each Kegel for ten seconds, then relaxing for ten seconds after each one. If she’s suffering

from urinary incontinence,she should try to hold a Kegel while she’s sneezing, coughing, or lifting

something.

1. Slow contractionsPull in pelvic floor muscles. Hold for 10 seconds and release. Repeat 5 times. This may be hard to start with but try to build up to 10 seconds.

2. Medium contractionsPull in pelvic floor muscles. Hold for 2-3 second (as tight as possible) and release, do this 10 times. Repeat 3 times. This may be hard to start with but try to build up to 10 repetitions.

3. Fast contractionsPull in pelvic floor muscles. Hold for 1 second (as tight as possible) and release, do this 10 times. This is like switching a light switch on and off. Repeat 3 times.

Pelvic tilt or angry cat

This variation of the pelvic tilt, done on all fours, strengthens the abdominal muscles and eases back pain during pregnancy and labor.

Get down on hands and knees, arms shoulder-width apart and knees hip-width apart, keeping arms straight but not locking the elbows.

As breathing in, tighten the abdominal muscles and tuck the buttocks under and round the back.

Relax the back into a neutral position as breathing out. Repeat, following the rhythm of the breath.

Squat

It may not be the most elegant position, but squatting is a time-honored way of preparing for and giving birth. This exercise strengthens the thighs and helps open the pelvis.

Stand facing the back of a chair with feet slightly more than hip-width apart, toes pointed outward. Hold the back of the chair for support. Or a gymnastic ball

Contract the abdominal muscles, lift the chest, and relax the shoulders. Then lower the tailbone toward the floor as though patient were sitting down on a chair. Find the balance — most of the weight should be toward the heels.

Take a deep breath in and then exhale, pushing into the legs to rise to a standing position.

Tailor or Cobbler Pose

This position can help open the pelvis and loosen the hip joints in preparation for birth. It can also improve the posture and ease tension in the lower back.

Sit up straight against a wall with the soles of the feet touching each other (sit on a folded towel if that's more comfortable).

Gently press the knees down and away from each other, without forcing them. Stay in this position for as long as it is comfortable.

Remember to start slowly and work at patients own level for each exercise.

7.1. Lower back stretches for pregnancy and the postnatal period

1. Double/single knee hug

Lay on the back and hug both knees in.Hold for 10 seconds

Lay on your back with one leg out straight and the other hugged in to chest.Hold for 10 seconds then repeat to the other side

2. Wall stretch

Stand a large step away from the wall with both palms flat against it and your arms straight. Stick the bottom out and let the head drop right down to in between arms looking at the floor.Hold for 10 seconds

3. Knee drops

Lay on your back with your knees bent at 90 degrees, let your knees fall gently to one side with your hands to the other.Hold for 10 seconds then repeat to other side

4. Prone (not after trimester 1)

Lie on your tummy with your legs out straight behind you. Prop up on to your elbows and lift your chin. Be careful not to overextend. This will stretch your abs too.Hold for 5 to 10 seconds

5. Ab hollowing (not after trimester 1)

Lie on your back with your knees bent and feet flat on the floor. Push the small of your back down and into the floor by tightening your lower abdominal muscles.Hold for 5 to 10 seconds

6. Bridge (not after trimester 1)

Lie on your back with your knees bent and feet flat on the floor. Push down through your feet as you slowing lift your bottom up off the floor.Squeeze up and hold for 5 to 10 seconds

7. Cat stretch

On all fours, drop your head, round your spine.Hold for 5 to 10 seconds

8. Seated drop

Sit in a chair with your feet flat on the ground. Curl your neck, upper back, and low back forward until your chest is on your thighs and you can touch the ground with your hands (or as low as comfortable).Hold for 5 to 10 seconds

9. Standing reach

Stand up straight with your arms at your sides and your feet shoulder width apart. Bend your trunk sideways to the left while sliding your left hand down your thigh and reaching your right arm over your head.Hold for 10 seconds then repeat to other side

10. Standing sun salute

Begin in a standing position and exhale as you sweep the arms up and overhead. Inhale and engage the abs as you tip from the hips and lower into a forward bend, with your hands

dropping down towards the floor. Slowly roll back up, sweeping the arms overhead until palms touch again.Repeat the series 4 to 8 times

11. Standing cat stretch

Lower into a squat with the hands on the thighs, back arched. Pull the abs in and round the back up towards the ceiling. Hold for 5 to 10 seconds

12. Child’s Pose

Push back on to your knees then sit back on the heels as you stretch the arms straight out in front of you, forehead facing the floor. Breathe and relax. Hold for 5 to 10 seconds

13. butterfly pose

14. sitting in double abducted hip pose

7.2. Fit ball exercises for pregnancy

Fit/gym/swiss balls are great to exercise with during pregnancy as they work woman’s core without having to do ‘sit-up’ type exercises. This is because anything woman does on the ball is going to require her to balance and stabilise herself using her deep abdominal muscles (or TVA – Transversus abdominis). It is important to keep her core strong to support her back and pelvic floor muscles during pregnancy and to get these muscles strong for labour (and a quick recovery post-baby!) woman can do a huge variety of exercises with a gym ball (especially if you also have a set of dumbbells) to work her whole body.

Section 1: Legs and bum

1. Wall squat (hold a weight in each hand – optional)

A great exercise to work your legs. To work harder don’t completely straighten your legs between reps; keep them slightly bent staying in the muscle.

Start with your feet hip width apart and your ball between your mid to lower back and the wall. Keep your hands on your hips or by your sides if you are holding weights. Keep your shoulders back and tummy muscles pulled in throughout.

Slowly squat down, bending your knees and rolling the ball down the wall until your knees are bent at approx. 90 degrees.

Now slowly return to the starting position. Have a chair nearby for support in case you get stuck in your squat!

Repeat 15-20 times and do two sets.

2. One leg lunge (hold a weight in each hand – optional)

You could easily add a bicep/hammer curl to the upward press to bring in an upper body component.

Start by taking a big step forward with one foot. The back foot should be resting on top of your gym fall, shin down.

Keep your hands on your hips or by your sides if you are holding weights. Keep your shoulders back and tummy muscles pulled in throughout.

Slowly bend your front knee until it reaches approx. 90 degrees.

Now slowly return to the starting position. Again, have a chair/wall nearby for support in case you get stuck or find it difficult to balance without.

Repeat 15-20 times and do two sets.

3. Ballet squat

Steer clear of this one if you have any problems with your pelvis during pregnancy and keep your legs a bit narrower if it’s not comfortable.

Start with your feet double hip width apart and toes pointed outwards, holding your ball out in front of you with nearly straight arms.

Keep your shoulders back and tummy muscles pulled in throughout.

Slowly bend your knees, without pushing your bottom backwards. Hold the ball directly out in front of you and do not rest your arms until the end of the set.

Now slowly return to the starting position.

Repeat 15-20 times and do two sets.

4 - Extra: Squat and shoulder push

Remember squats are great as they work all the big muscles in your legs. This exercise brings in your upper body too!

Start with your feet hip width apart, holding your ball out in front of you with nearly straight arms.

Keep your shoulders back and tummy muscles pulled in throughout.

Slowly squat down, bending your knees and sticking your bottom back as if you were going to sit on a chair, until your knees are bent at approx. 90 degrees.

As you squat lower the ball to touch the floor.

Now slowly return to the starting position and as you do push your ball up above your head. Go directly into your next squat.

Repeat 15-20 times and do two sets.

Section 2: Arms and upper body

5. Arm work out on the ball (2 x 3kg weights)

Work your core, biceps, triceps and shoulders!

Sit upright on the ball with your feet flat on the floor about hip-width apart. Keep your shoulders back and tummy muscles pulled in throughout. In this position do:

12-15 bicep curls

12-15 tricep kick backs (arms close to your body at 90 degrees and straighten out behind you)

12-15 overhead presses

6. Arm and leg lift (2 x 3kg weights)

Work your core, shoulders and the front of your legs. You’ll need your brain in gear to co-ordinate too!

Sit upright on the ball with your feet flat on the floor about hip-width apart. Keep your shoulders back and tummy muscles pulled in throughout.

In this position slowly lift one leg off the floor, keeping it straight.

As you lift the leg, lift the opposite arm out to the side in a straight arm side raise, lifting it no higher than shoulder height.

Return both the leg and arm to the starting position and repeat with the other arm/leg.

Repeat 15-20 times (alternate sides) and do two sets.

7. Wall push up

This great exercise works your arms and chest. Less intense than a regular push up and saves getting up and down from the floor!

Stand upright facing a wall roughly a metre away. Keep your shoulders back and tummy muscles pulled in throughout. Hold the ball against the wall in front of your chest and have your hands flat on the ball in front of your shoulders.

To do the push up bend your arms and lower your chest to the ball, keeping your body straight and rolling your heels off the floor.

Hold briefly at your lowest point then return to the starting position.

Repeat 15-20 times and do two sets.

8 – Extra: Seated overhead tricep press (1 x 3kg weight)

Sit upright on the ball with your feet flat on the floor about hip-width apart. Keep your shoulders back and tummy muscles pulled in throughout.

In this position hold a dumbbell in both hands (one hand on each end) and stretch your arms straight above your head.

Keeping everything else still and your elbows close to the sides of your head, drop the weight behind your head. Be careful your elbows don’t drift outwards and focus on your triceps.

Return your arms to the starting position.

Repeat 15-20 times (alternate sides) and do two sets

Section 3: Abs and back

9. Seated upper back squeeze and ab-hold (2 x 1kg weights)

Try adding 10 normal ab squeezes at the end to make sure you have really worked your deep core muscles.

Sit upright on the ball, with your shoulders back and feet flat on the floor.

Breathe in deeply and let your chest expand. Then, as you exhale, draw your belly button in so that you feel like you are wearing a tight corset (engaging your TVA). The rest of your body should be still. Hold this position, making sure you can breathe comfortably. Hold a light weight in each hand, with your arms out in front of you at head height. Keep your shoulders back.

Slowly bring your arms in towards you, so that your shoulder blades are squeezing together and the weights come to either side of your chest.

Slowly return your arms to the starting position. Once you have completed your back squeeze repetitions release your abs.

Repeat 15–20 times and do two sets.

10. Seated pelvic tilt

Work your deep tummy muscles and keep your pelvis mobilised. Don’t be afraid of sucking your tummy in, baby won’t feel it!

Sit upright on the ball, with your shoulders back and feet flat on the floor.

Breathe in deeply and let your chest expand. Then, as you exhale, draw your belly button in so that you feel like you are wearing a tight corset (engaging your TVA).

Without moving your feet, tilt your pelvis forward and upward.

Hold for a couple seconds and return to start position. To mix it up you can also try side to side and figure of eight movements.

Repeat 15–20 times and do two sets.

11. Small bridge

In addition to working your core you need to keep your lower back strong in pregnancy. This will hit your bottom as well – fantastic!

Lie back with your head and shoulders on your ball and feet flat on the floor about hip-width apart.

Breathe in deeply and let your chest expand. Then, as you exhale, draw your belly button in so that you feel like you are wearing a tight corset (engaging your TVA).

Using a small movement, lift your pelvis upward so that your body is in a straight line.

Hold for a couple seconds and return to start position.

Repeat 15–20 times and do two sets.

12 - Extra: Roll out

Only take this move as far as is comfortable for you and keep it slow and controlled. Avoid this if you have any problems with your blood pressure.

Kneel on the floor with your arms out straight in front of you and resting on the top of the ball and your back straight. Your ball should be arms-length away.

Breathe in deeply and let your chest expand. Then, as you exhale, draw your belly button in so that you feel like you are wearing a tight corset (engaging your TVA).

Slowly roll on top of the ball until your forearms are resting on top of it (like a half plank)

Hold for a couple seconds and return to start position.

Repeat 15–20 times and do two sets.

Chapter Vpost partum complications and rehabilitation

1. COMPLICATIONS OF POSTPARTUM

1-POSTPARTAL HEMORRHAGE

Postpartal hemorrhage is the postpartum loss of blood totaling 500 ml or more within a twenty-four hour period.

After bladder distention is ruled out, the three main causes of postpartal hemorrhage are:

a. Uterine Atony. This is the inability of the myometrium to contract and constrict the blood vessels within the muscle fibers, resulting in open sinuses at the site of placental separation. Decreased muscle tone causes slow, insidious loss of blood.

b. Lacerations. Common sites. Sites of lacerations are the vaginal side wall, the cervix, the lower uterine segment, and the perineum

c. Retained Placental Fragments in the Uterus. These fragments are the major cause of late postpartum hemorrhage.

2- HEMATOMAS

Vulvar hematoma is a localized collection of blood in the connective tissue beneath the skin covering the external genitalia or vaginal mucosa. It generally forms as a result of injury to the perineal blood vessels during the delivery process.

a. Causes of Hematomas.

(1) Rapid, spontaneous delivery. (2) Perineal varicosities. (3) Episiotomy repairs. (4) Laceration of perineal tissues.

3- UTERINE SUBINVOLUTION

Uterine subinvolution is a slowing of the process of involution or shrinking of the uterus.

Causes. Endometritis, retained placental fragments, pelvic infection, and uterine fibroids may cause uterine subinvolution.

4- PUERPERAL INFECTION

Puerperal infection is a term used to describe any infection of the reproductive tract during the first six weeks of postpartum.

5-THROMBOPHLEBITIS

a. Thrombophlebitis is an inflammation/infection of pooled and clotted blood in a vein.

Types of Thrombophlebitis.

(a) Femoral- inflammation along the femoral, popliteal, or saphenous veins.

(b) Pelvic-inflammation/infection of the pelvic veins.

(c) Superficial- inflammation/infection of the superficial saphenous veins.

b. Pulmonary Embolus. This is a major complication of thrombophlebitis. It results when a clot breaksloose, travels through the circulatory system, and obstructs the pulmonary arterial bed. It is a serious, life-threatening situation.

6- MASTITIS

Mastitis is inflammation of the breast tissue, usually unilateral after the milk flow is established. It is caused by streptococcal or staphylococcal invasion of the breast tissue through cracks or fissures around the nipple. It may be obtained from the infant's nose or throat. The infant probably acquired it while in the nursery.

a. Signs and Symptoms.

(1) Erythema over the infected breast. (2) Marked breast engorgement. (3) Acute breast pain, tenderness. (4) Fever and chills. (5) Ancillary lymph gland enlargement.

7- THE CESAREAN SECTION DELIVERY

Cesarean section delivery refers to a surgical incision made into the abdomen and uterus to deliver the fetus. It requires the same postsurgical care as any other abdominal surgical patient.

8- POSTPARTAL PSYCHOSIS

Postpartal psychosis is a major psychiatric complication in three of a thousand pregnant women. Fifteen percent occurs during the prenatal period. Eighty five percent occurs during postpartal. The causes are unknown but possible precipitating factors include the birth experience itself, personality traits, hormone withdrawal following delivery, and fear of the maternal role. Postpartal psychosis usually appears the third day after

9- GRIEF-STRICKEN MOTHER

A dead, dying, or severely handicapped infant leads to the problems of grief and grief resolution for the postpartum mother. The initial task faced by the mother is the realization that her child is dead, dying, or severely handicapped. Parents feel devastated and inadequate and are mourning the loss of the fantasized perfect baby.

Postpartum depression

Postpartum depression is moderate to severe depression in a woman after she has given birth. It may occur soon after delivery or up to a year later. Most of the time, it occurs within the first 3 months after delivery.

Causes, incidence, and risk factors

The exact causes of postpartum depression are unknown. Changes in hormone levels during and after pregnancy may affect a woman’s mood. Many non-hormonal factors may also affect mood during this period:

Changes in body from pregnancy and delivery Changes in work and social relationships Having less time and freedom for yourself Lack of sleep Worries about her ability to be a good mother

A higher chance of postpartum depression if:

Under age 20 Currently abuse alcohol, take illegal substances, or smoke (these also cause serious

medical health risks for the baby) Did not plan the pregnancy, or had mixed feelings about the pregnancy Had depression, bipolar disorder or an anxiety disorder before your pregnancy, or with a

previous pregnancy Had a stressful event during the pregnancy or delivery, including personal illness, death

or illness of a loved one, a difficult or emergency delivery, premature delivery, or illness or birth defect in the baby

Have a close family member who has had depression or anxiety Have a poor relationship with your significant other or are single Have money or housing problems Have little support from family, friends, or your spouse or partner

Symptoms

Feelings of anxiety, irritation, tearfulness, and restlessness are common in the week or two after pregnancy. These feelings are often called the postpartum or "baby blues." These symptoms almost always go away soon, without the need for treatment.

Postpartum depression may occur when the baby blues do not fade away or when signs of depression start 1 or more months after childbirth.

The symptoms of postpartum depression are the same as the symptoms of depression that occurs at other times in life. Along with a sad or depressed mood, you may have some of the following symptoms:

Agitation or irritability Changes in appetite Feelings worthless or guilty Feeling withdrawn or unconnected Lack of pleasure or interest in most or all activities Loss of concentration Loss of energy Problems doing tasks at home or work Significant anxiety Thoughts of death or suicide Trouble sleeping

A mother with postpartum depression may also:

Be unable to care for herself or her baby Be afraid to be alone with her baby Have negative feelings toward the baby or even think about harming the baby (Although

these feelings are scary, they are almost never acted on. Still you should tell your doctor about them right away.)

Worry intensely about the baby, or have little interest in the baby

Signs and tests

There is no single test to diagnose postpartum depression. Diagnosis is based on the symptoms you describe to your doctor or nurse.

Women with postpartum depression should have blood tests to screen for medical causes of depression.

Treatment

A new mother who has any symptoms of postpartum depression should contact their doctor or nurse right away to get help.

Here are some other helpful tips:

Ask your partner, family, and friends for help with the baby's needs and in the home. Don't hide your feelings. Talk about them with your partner, family, and friends. Don't make any major life changes during pregnancy or right after giving birth. Don't try to do too much, or to be perfect. Make time to go out, visit friends, or spend time alone with your partner. Rest as much as you can. Sleep when the baby is sleeping. Talk with other mothers or join a support group.

The treatment for depression after birth often includes medication, therapy, or both. Whether or not you are breast-feeding will play a role in what medicine your doctor recommends. You may be recommended to a mental health specialist. Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are types of talk therapy that often help postpartum depression.

Support groups may be helpful, but they should not replace medication or talk therapy if you have postpartum depression.

Having good social support from family, friends, and coworkers may help reduce the seriousness of postpartum depression.

Expectations (prognosis)

Medication and professional talk therapy can often successfully reduce or eliminate symptoms.

Complications

If left untreated, postpartum depression can last for months or years.

The potential long-term complications are the same as in major depression. Untreated, postpartum depression may put you at risk of harming yourself or your baby.

Calling your health care provider

Call your doctor if you experience any of the following:

Your baby blues don't go away after 2 weeks Symptoms of depression get more intense Symptoms of depression begin at any time after delivery, even many months later It is hard for you to perform tasks at work or at home You cannot care for yourself or your baby You have thoughts of harming yourself or your baby You develop thoughts that are not based in reality, or you start hearing or seeing things

that other people cannot

Do not be afraid to seek help immediately if you feel overwhelmed and are afraid that you may hurt your baby.

Prevention

Having good social support from family, friends, and coworkers may help reduce the seriousness of postpartum depression, but may not prevent it.

Women who had postpartum depression after past pregnancies may be less likely to develop postpartum depression again if they start taking antidepressant medications after they deliver. Talk therapy may also be helpful in preventing it.

2. Rehabilitation post partum

For the first couple of weeks focus on those all important pelvic floor and tummy muscles – these are the ones that have taken the biggest hit through pregnancy and childbirth. Give these muscles a few minutes of attention a day with abdominal pull ins (holding your tummy in tight then releasing) and pelvic floor squeezes, 50-100 of each if you can and try and make this a permanent part of your routine for the future.If you had any a caesarean or stitches down below this can be sore for a while, so take it easy until everything feels ok. Your pelvic floor exercises will help you heal though, so do these if you can.

Try and do little and often – maybe when your baby naps, while you are feeding (ab and pelvic floor squeeze), first thing, last thing in the evening or when someone pops in to babysit. This will give you a regular burst of endorphins and believe it or not, more energy! Take everything at your own pace, everyone is different and don’t push yourself too quickly, there is no rush.

When you feel ready you can get back to regular cardiovascular exercise. For most women this will be around the time of the 6 week check.

Make sure you invest in a good sports bra and pair of trainers. Try to get a bit hot and sweaty 3 times a week for at least 30 minutes. This could be in the gym, jogging (maybe with your

pushchair), a fitness DVD, cross training, cycling, swimming or brisk walking. Couple this with active choices (e.g. stairs rather than lift) and lots of running around after baby and the extra pounds will soon melt away.

Be a bit cautious with high-impact activities if you are fairly new to exercise as a pregnancy hormone called relaxin will make your joints a little more vulnerable to injury for a few months after your baby is born. Build up and progress gradually.

What?

In addition to cardiovascular exercise try to do regular resistance training using some light weights. This will help you build lean muscle, which burns more calories at rest – how awesome is that?! It will increase your metabolism and really sculpt your body. Focus on lower body and tummy exercises, but make sure you work your whole body in the course of a week. Do this ideally 3 times a week for at least 30 minutes, bringing your total exercise in a week to 3 hours (1 and a half hours cardio and the same with weights). Fit this in, in whatever size chunks work best for you, 10 minutes here and there if you like!

You can make active choices to make exercise part of your everyday life; it doesn’t have to always be an ‘extra’.

Diastasis: very important you check this before you do the exercises in this plan!

You may have some separation of the abdominal muscles during and after pregnancy (the technical term is

‘diastasis’, which sounds scarier than it is). Around a third of women experience this. This is obvious when you think

of how much your tummy needs to expand to accommodate your little babe. When you have had your baby, you will

be able to feel whether you have this separation, or not, with your fingers. Lie on your back, with your feet on the

floor, knees bent and head and shoulders lifted. Feel above and below your belly button to see if you can find a gully

between your tummy muscles. You should avoid sit-up type exercises (like the ones in this plan) until this gap has

closed to less than two fingers width, until then you can focus on strengthening your core. Start gently and build up.

For all the exercises below remember is to always draw your belly button in so that your back doesn’t arch and is

flat on the floor at all times. For maximum flatness breath out as you curl up (or on the effort of the exercise) and

inhale as you release down and make sure there is a fist sized gap beneath your chin.

Postnatal flat tummy plan

(10-15 minutes, 10 exercises to work your core, oblique and surface abs)

Try to do every day for best results!

 1. Pulse up 3 then down

Lay back with your knees bent at 90 degrees about hip width apart and feet on the floor. Draw your belly button in so

that your lower back touches the floor at all times. Have your hands by your temples. Lift your head and shoulder

blades off of the floor, with a gap between your chin and chest. Squeeze up and pulse for 3 at your highest point then

release back to the floor.

Repeat x 20 counts of 3 (all centre)

2. Pulse across 3 then down

Lay back with your knees bent at 90 degrees about hip width apart and feet on the floor. Draw your belly button in so

that your lower back touches the floor at all times. Have your hands by your temples. Lift your head and shoulders

and reach your hand across to the outside of the opposite knee. Squeeze over and pulse for 3 at the outermost point

then release back to the floor.

Repeat x 20 counts of 3 (alternate sides)

3. Heels down, one at a time then together

Lay back with your knees about hip width apart and legs lifted up at 90 degrees (so your knees are over your chest).

Draw your belly button in so that your lower back touches the floor at all times. Have your hands by your temples. Lift

your head and shoulders off of the floor, with a gap between your chin and chest. Slowly lower one leg (keep it bent

at 90 degrees) so that your heel just touches the ground and then return to the starting position. Really pull your lower

abs in as you lower your heels to the floor and pull the legs back up.

Repeat alternate legs x 30 (each side)

Plus…..If you can touch both heels down together this is much harder!

4. Elbows to knees / cycle

Lay back with your knees about hip width apart and legs lifted up at 90 degrees (so your knees are over your chest).

Draw your belly button in so that your lower back touches the floor at all times. Have your hands by your temples,

with a gap between your chin and chest. Gradually straighten one leg and twist across your body so that you elbow

touches the knee on the bent leg. As you slowly bring the leg back in, start to straighten the other leg and twist to the

other side (a bit like cycling, but with straight legs). Try to straighten your legs close to the floor.

Repeat alternate legs x 50

5. Leg raises

Lay back with your hands part way under your bum and head and shoulders on the floor. Draw your belly button in so

that your lower back touches the floor at all times. Keeping your lower back on the floor extend legs fully straight and

maintain the extension. Move your legs up and down in a scissor action, but do not let your feet touch the floor. The

move should be slow and controlled, do not swing legs. Your lower back must stay on the floor throughout.

Repeat alternate legs x 50

6. Reverse curls

Lay back with your knees bent at 90 degrees about hip width apart and feet on the floor. Draw your belly button in so

that your lower back touches the floor at all times. Have your hands by your sides or part way under your bum. Pull

the knees to the chest and push your feet up towards the ceiling, raising the hips off the floor. Do not swing your legs

and use your lower abs to lift in a controlled way. Slowly return to starting position.

Repeat x 20

7. Balance pump and arms

Lay back on the floor with your legs straight out in front of you. Slowly lift your legs (they should be together and

straight at around 45 degrees) and lift you head and neck off the floor, with a gap between your chin and chest. Draw

your abdominals in to stabilise you and lower your legs as far as you can (this will get progressively further). You can

stay in this position and hold or hold your arms out straight in front of you and pump them up and down in tiny quick

pulsing movements.

Aim to hold for 30-60 seconds (with or without pulsing arms) and repeat twice

8. Reach to sides

Lay back with your knees bent at 90 degrees about hip width apart and feet on the floor. Draw your belly button in so

that your lower back touches the floor at all times. Have your hands by your temples. Lift your head and shoulders

and reach your hand to the outside of your calf, squeezing your waist at the side as you do. Slowly return to starting

position.

Repeat x 20 (alternate sides)

9. Touch your toes

Lay back with your legs straight (not bent at the knee) and toes pointing forwards. Draw your belly button in so that

your lower back touches the floor at all times. Keeping your lower back on the floor extend one of your legs fully

straight up to 90 degrees. At the same time lift your head and shoulders off the floor and reach both hands towards

the lifted foot. The move should be slow and controlled, do not swing the leg and ensure you are lifting your shoulder

blades off the floor. Your lower back must stay on the floor throughout. Slowly return to starting position.

Repeat x 15 (all on one leg then the other)

10. Sky sits

Lay back with your legs straight (not bent at the knee) and toes pointing forwards. Draw your belly button in so that

your lower back touches the floor at all times. Lift your head and shoulders off the floor and reach both hands towards

the sky. Your arms should be straight. The move should be slow and controlled, ensure you are lifting your shoulder

blades off the floor. Your lower back must stay on the floor throughout. Slowly return to starting position.

Repeat x 20 (all centre)

Pelvic floors

During labour and birth, your pelvic floor stretches to allow your baby’s head to come out. This may have left you with

some soreness and maybe some stitches down below.

Your pelvic floor may have been over-stretched during labour if you:

had to push your baby out for a long time

had a big old baby

had a severe tear

had a forceps birth

If your pelvic floor feels heavy, or if you feel as if you have something bulging between your legs at any time, it’s a

sign to slow down.

If you are in pain try to get some rest and don’t stay on your feet for too long. If you can, spend time lying down rather

than sitting. This will help to take some of the pressure off your perineum.

Start doing pelvic floor exercises as soon as you can – this could be the day after you have your baby.

Although pelvic floor exercises will probably be at the bottom of your to-do list, starting straight away will have lots of

benefits.

Not only will these exercises help your bladder control, they may also increase the pleasure of having sex – so get

started! If you have stitches during childbirth these exercises will also help blood flow to the area to aid the healing

process.

You may not be able to feel your pelvic floor for a while, but this will get better over time.

If, after your 6 week check, you can’t tighten your muscles well, you still have pain, or are still leaking wee, see your

doctor, who may refer you to a Physio. A Physiotherapist will be able to assess your pelvic floor and treat any

problems.

Exercise after a caesarean/c-section

A c-section, whether planned or emergency is major surgery so you will need to take it easy for the first few

weeks. The procedure is essentially the same whether planned or unplanned so my advice would apply to

any mums that have had a c-section of any kind.

You might take more time to recover mentally from an emergency procedure if your birth wasn’t straightforward; give

yourself plenty of time and headspace if you need it – exercise will eventually help with this. For the first six weeks

don’t do any intense exercise or lift anything heavy and try to get plenty of rest. Having said this, doing some simple,

gentle regular exercise may help your recovery and help your scar heal.

You should try and resume daily ab pull ins, bottom squeezes and pelvic floor plus some walking, up to 30 minutes x

3 times a week if you feel up to it. This will also prevent blood clotting. I would avoid swimming until you have had

your 6 week check up to avoid any pulling or straining of your scar or risk of infection; the time will go really quickly!

Once you have had the all-clear from your doctor at 6 weeks you can gradually step up your cardio and toning work

and think about getting stuck in to working your tummy muscles again