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1
POST- PARTUM RECOVERY: IMPROVING FUNCTION FOR MOTHERS
DR. NATALIE J. SEBBA, PT, DPT, WCS, CLT
* Slides or material not to be reproduced or used without written consent of author
Provider Disclaimer
• Allied Health Education and the presenter of this
webinar do not have any financial or other
associations with the manufacturers of any products
or suppliers of commercial services that may be
discussed or displayed in this presentation.
• There was no commercial support for this
presentation.
• The views expressed in this presentation are the
views and opinions of the presenter.
• Participants must use discretion when using the
information contained in this presentation.
Objectives:
I. Participant will understand the typical physiological changes associated with pregnancy and
childbirth.
II. The learned will identify the most important factors associated with childbirth, both vaginal and
cesarean delivery, which may impact the post-partum patient presentation.
III. Clinician will properly identify common spinal and pelvic alignment impairments of the post-
partum female.
IV. Clinician will understand how to assess diastasis rectus and effectively prescribe therapeutic
exercises associated with this presentation.
V. Following the webinar the clinician will effectively instruct the post-partum mother in proper
body mechanics associated with childcare.
VI. Learner will verbalize the importance of pelvic floor muscle function and understand the
progression of strength development in the post-partum client.
VII. Clinician will understand treatment options for scar management associated with vaginal and
cesarean delivery.
VIII. The learner will be able to properly educate women on return to general wellness and exercise
considering post-partum presentation.
IX. Participant will identify proper assessment scales to utilize with this patient population to
improve effectiveness of documentation and reimbursement.
2
Physical Development: Pregnancy
Normal physiological change
Increased thoracic kyphosis
Forward rounded shoulders
Increased breast size
Increased lumbar lordosis
Knee hyperextension
Increased base of support
Physical Development: Pregnancy
Hormonal changes
Estrogen
Levels increase 30x
Relaxin: increases ligamentous laity, softens cartilage
Significantly affects pelvic joints, sacrum, coccyx etc.
Peaks at week 14 and prior to delivery
Metabolic change
Expected gain: 25-30 lbs/ 50-60 lbs for multiples
Increased total body water and blood volume Leads to increased risk of swelling
Physical Development: Pregnancy
Abdominal muscles
Diastasis rectus: separation of
rectus abdominus muscle
Visible fascial thinning
Umbilicus change
3
Physical Development: Pregnancy
Physical Development: Pregnancy
Pelvic floor muscles
Increased weight and load
demand
Risk of urinary incontinence
Pressure on pelvic organs
Risk of pelvic organ prolapse
Pelvic floor muscles
Childbirth: Cesarean Delivery
Transversus abdominusmuscles
Weakened by incision/trauma
Leads to poor core support
Scar tissue development
Leads to scar sensitivity
Abdominal surgery
Lifting restrictions
Incision considerations
Constipation
4
Childbirth: Vaginal Delivery
Pelvic floor muscle stretch
Tissue tearing/episiotomy
Nerve injury
Pudendal nerve
Vaginal bleeding
Discomfort with bowel
function
Childbirth: Vaginal Delivery
Grades of perineal tearing:
Grade of tear: Description:
1 superficial tear vaginal tissues
2 deep perineal tear; initial pelvic floor muscles
3 partial tear through anal sphincter
4 tear into anal-rectal mucosa
Post-Partum Presentation
5
Post-Partum Presentation
Post-Partum Presentation
Day 1 Immediate weight loss of 9-12 lbs
Lochia: vaginal bleeding and sheading membranes/tissues
Low potassium: leads to fatigue
Bladder change: loss of control, reduce urge
Full body soreness/fatigue
PP 1 wk Surge of prolactin hormone: mood swings
Reducing vaginal swelling/bleeding
Reducing breast engorgement
Reducing swelling
Onset of urinary incontinence
Post-Partum Presentation
PP 4 wks Loose skin on abdomen
Full reduction of uterus
Reducing estrogen levels lead to hair thinning and loss
Cesarean scar tension and pain with healing
Risk of anemia
PP 6 mths Period returns between 4-5 mths
Return to full exercise regime
Normal bladder control
Stretch marks begin to fade
Peak of “dissatisfaction with post-pregnancy body”
6
Post-Partum Presentation
Post-Partum Presentation
Most common concerns
Upper back pain
Lower back pain
Hip pain
Abdominal weakness
Difficulty loosing weight
Post-partum body dissatisfaction
Post-Partum RED FLAGS
Breast swelling/pain
Engorgement past 3 days
Redness/pain: mastitis
Vaginal discharge
Persistent after 2 months
Difficulty with urination
Pain indicative of infection
Incomplete emptying
Mastitis is an infection in the tissue of the mammary
glands inside the breasts.
7
Post-Partum RED FLAGS
Post-Partum Depression
You feel overwhelmed.
You feel guilty.
You don’t feel bonded to your baby.
You feel irritated or angry.
You have no patience.
You feel nothing.
You can’t sleep when the baby sleeps, nor can you sleep at any other time.
You know something is wrong. You may not know you have a perinatal mood or anxiety disorder, but you know the way you are feeling is NOT right. You think you’ve “gone crazy.”
Maybe you’re doing everything right. You are exercising. You are taking your vitamins. You have a healthy spirituality. You do yoga. You’re thinking “Why can’t I just get over this?” You feel like you should be able to snap out of it, but you can’t.
Patient Assessment: Spine
Cervical
Thoracic
Lumbar
Pelvic
Patient Assessment: Cervical Spine
Likely causes:
POSTURE!
Feeding baby:
Cervical flexion and sidebending, thoracic flexion, lumbar flexion,
rounded pelvis
Weakness
8
Patient Assessment: Cervical Spine
Interventions:
Positioning!
Mobilization as indicated
Muscle tension release
Strength targets:
Cervical flexion/ thoracic extension
Stretching:
Cervical, levator scapulae, upper traps, pectoralis
Patient Assessment: Thoracic Spine
Likely causes:
Positioning!
Mid back strain from chronic positions, baby wearing and
baby care
Weakness
Enlarged breasts
Patient Assessment: Thoracic Spine
Interventions:
Mobilization as indicated
Muscle tension release
Strengthening
Postural strength
Stretching:
Pectoralis, rhomboids, latissimus dorsi, upper trap, levator scapulae
9
Patient Assessment: Lumbar Spine
Likely causes:
Positioning!
Weakness highest contributor
Sleep position
Altered gait mechanics with carrying and wearing baby
Patient Assessment: Lumbar Spine
Interventions:
Core stabilization
Proper fitting of baby wearing device
Body mechanics with all baby care
Proper sleep positioning
Body pillow
Patient Assessment: Pelvis
Likely causes:
Baby carrying positions
Chronic positioning with
carrying baby
Birthing injury
Pubic symphysis separation
Weakness
Anterior pelvic tilt most common
10
Patient Assessment: Pelvis
Interventions:
Positioning!
Strengthening
Core, gluteals, hip rotation, hamstrings, thoracic region, hip flexors
Stretching
Abdominals, IT band, quads, hip flexion, gluteals
Support
Serola SI Belt: $44
Patient Assessment: Abdominal
Diastasis Recti (DR)
3 locations:
2” above umbilicus
At umbilicus
2” below umbilicus
Patient Assessment: Abdominal
DR assessment: Fingertip
Measurement
Hook lying position
Place fingertips horizontally
across abdomen @umbilicus,
above and below
Gently curl head/shoulder
upward
Exhale throughout
Palpate for medial muscle
belly on each side of finger
(intra-rectus distance (IRD))
Determine # of finger widths
11
Patient Assessment: Abdominal
DR assessment: Caliper Measurement
Use fingertip measurement for palpation
Position inside caliper jaw between muscle belly at palpating finger
perpendicular to the surface
Adjust caliper to perceived IRD width
Condition:
Passive - Muscles at rest
Active – Partial curl-up
Patient Assessment: Abdominal
Finger width documentation:
Measure your finger widths in cm
Document actual cm distance
Research based standards:
>1.5 cm (Gilleard and Brown, 1996)
>2 cm (Lo et al.,1999)
>2.5 cm (Candido et al., 2005)
>2 finger widths during a partial sit-up (Bursch, 1987; Sheppard, 1996)
Patient Assessment: Abdominal
VIDEO
12
Patient Assessment: Abdominal strength testing:
Isometric test:
Patient Assessment: Abdominal strength testing:
Isometric test scoring:Grade MMT Score Patient Position
Normal 5 With the hands clasped
behind the neck, able to raise the upper body
until the scapulae clear
the table (20- to 30-second hold)
Good 4 With the arms crossed over the chest, able to raise the upper body until the scapulae clear
the table (15- to 20-second hold)
Fair 3 With the arms straight,
able to raise the upper body until the scapulae
clear the table (10- to 15-second hold)
Poor 2 With the arms extended toward the knees, able to raise the upper body
until the top of the
scapulae lift from the table (1- to 10-second
hold)
Trace 1 Unable to raise more
than the head off the table
Patient Assessment: Abdominal strength testing:
Dynamic endurance test:
13
Patient Assessment: Abdominal strength testing:
Oblique testing:
Patient Assessment: Abdominal strength testing:
Oblique scoring:
Grade MMT Score Patient Position
Normal 5 Flexes and rotates the lumbar spine fully with the hands behind the head (20- to 30-second hold)
Good 4 Flexes and rotates the lumbar spine fully with the hands across the chest (15- to 20-second
hold)
Fair 3 Flexes and rotates the lumbar spine fully with the arms reaching forward (10- to 15-
second hold)
Poor 2 Unable to flex and rotate fully
Trace 1 Only slight contraction of the muscle with no movement
None 0 No contraction of the muscle
Interventions: Abdominal Strengthening
Belly Hug
With manual approximation or with towel
TA activation
Exhale and curl up
14
Interventions: Abdominal Strengthening
Transverse Abdominus
Proper activation is critical
Learning to activate with ALL movement is essential
• Place fingers on the inside of your pelvic
bones.
• As you exhale, gently pull in on your lower
abdominal muscles, like trying to zip a tight
pair of pants.
• Hold contraction for 5 seconds while
counting out loud.
Interventions: Abdominal Strengthening
Transverse Abdominus
Interventions: Abdominal Strengthening
TA and core progression
15
Interventions: Abdominal Strengthening
TA and core progression
Interventions: Abdominal Strengthening
Incorporate the BABY!
Interventions: DR Taping
“Addition of KT to abdominal exercises in the postnatal physiotherapy
program provides greater benefit for the abdominal recovery in women
with cesarean section”
16
Interventions: DR Taping
Oblique activation: Rectus activation:
Interventions: Scar management
Scar massage
Manual techniques
ASTM: Graston (G6)
Recommendations:
Daily, 10-15 min
Use of lotion or skin on skin
Interventions: Scar management
Additional treatment options:
Brushing
Desensitization
Mepiform scar dressing
1 week duration
Scar massage directly on dressing
17
Interventions: Body Mechanics
Breast feeding
Child care
Baby wearing
Car seat carrying
Interventions: Body Mechanics
Breast Feeding Positions
Football Hold Cradle Hold
Interventions: Body Mechanics
Breast Feeding Positions
Side Lying Cross Body
18
Interventions: Body Mechanics
Breast Feeding Positions
Vaginal Delivery:
Football
Ideal with newborns
Cross body
Cesarean Delivery:
Football
Side lying
Interventions: Body Mechanics
Nursing Bras
Ideal components:
NO underwire
Broad lateral coverage
Padded/cushion straps
Breast pump compatible
Day and night wear
Suggestions:
Bravado!
Daytime: Bliss
Nighttime: Silk seamless
Interventions: Body Mechanics
Breast Feeding Pillows
The Boppy
PROS:
Easy to use, easy to find
Fits women of all sizes
Longevity of use as baby grows
CONS:
“Hole” with little babies Not thick enough; may lead to poor posture
No back support
19
Interventions: Body Mechanics
Breast Feeding Pillows
My Breast Friend
PROS:
Lumbar support
Great for small babies
CONS:
“Table” like platform; larger babies roll easily
Can be cumbersome to don
Interventions: Body Mechanics
Breast Feeding Pillows
Infantino Elevate Adjustable Nursing
Pillow
PROS:
Very adjustable; position variability
Easy to use
CONS:
No back support
Can be cumbersome to arrange pillow
Interventions: Body Mechanics
Breast Feeding Pillows
Leachco Natural Boost
PROS:
Head support for baby
CONS:
Can be cumbersome to use
Must adjust pillow with changing
sides
Mother’s arm is loaded; traction downward
Base pillow not thick enough; may
lead to poor posture
20
Interventions: Body Mechanics- Baby Care
Diaper station
Height of table at waist
Organization of supplies:
Diaper pail on dominant side
Minimal trunk rotation
Avoid:
Changing baby on couch, floor or on bed
Interventions: Body Mechanics- Baby Care
Bath
Newborn: baby bath
Place on counter; waist height
Avoid: placing baby tub in the bath tub
Baby/toddler:
Cushions! For elbows and knees
Face child in tub
Avoid: reaching, standing or bending over, positions of sustain trunk
rotation
Interventions: Body Mechanics- Baby Wearing
Considerations:
Postural strength
Purpose for use
Number of users
Ideal device components:
Padded straps!
Easy donn/doff
Adjustable as child grows
Compact for travel
21
Interventions: Body Mechanics- Baby Wearing
Ring Slings
Age Range: Newborn to 3 years
Weight Range: Up to 45 lbs
Pros:
Simple, quick, and easy to use
Great for nursing, even for newborns
Can be used in a variety of carrying positions and styles
Good for small babies
Cons: Will not fit both parents
Weight is centered on one shoulder
Maya Wrap
Interventions: Body Mechanics- Baby Wearing
Wrap
Age Range: Newborn to 4 years
Weight Range: Up to 55 lbs (woven & gauze) & up to 25 lbs(stretchy)
Pros:
Hands-free nursing
Versatile, with many options for carrying position, material, etc.
Very comfortable
Can use with newborns to older toddler
Cons:
Takes some practice to get the tying technique right
Can be hot and cumbersome due to the length of the material
Mobe and Boba Wrap
Interventions: Body Mechanics- Baby Wearing
Chinese Mei Tai : (pronounced “may tie”) Age Range: Newborn to 4 years
Weight Range: Up to 45 lbs
Pros:
Versatile for both parents
Many positions choices
Dual-strap design distributes weight over both shoulders
Comfortable for use with heavy children
Cons:
Not compact
Long straps which may possibly drag on the ground
Infantino Sash
22
Interventions: Body Mechanics- Baby Wearing
Pouch Sling Age Range: Newborn to 3 years
Weight Range: Up to 35 lbs
Pros:
Easy to use
Lightweight and easy to fit inside a diaper bag
Comfortable
Possible to nurse your baby
Cons:
Limited carry positions and versatility
Weight is loaded onto one side
Difficult to share between parents
No waist support
Baby K’tan
Interventions: Body Mechanics- Baby Wearing
Buckle Carriers
Age Range: Newborn to 3 years
Weight Range: Up to 25-33 lbs
Pros:
Thick padded shoulder and waist straps
Multiple position choices
Easily adjustable for multiple users
Cons:
Some have insert for newborns
More difficult to fit in diaper bag
Baby Bjorn, Ergo Baby
Interventions: Body Mechanics
Car Seat
Most common position:
Held on one side on forearm
Elbow in full extension
Concerns of load on wrist, elbows,
forearms, back and neck
Increased lumbar extension
Altered gait pattern
Bruising on legs/hip
23
Interventions: Body Mechanics
Car Seat
Ideal position:
In front with both hands on handle
Weight centered and close to the trunk
Best choice: use a baby wearing
Post-Partum Wellness
Self care strategies
“Alone” time Personal hygiene
Outdoor time
Socialization
Self forgiveness
Breathing
Balanced, healthy diet
Hydration
Sleep
Post-Partum Exercise Guidelines
ACOG Recommendations:
Exercise benefits include:
It helps strengthen and tone abdominal muscles.
It boosts energy.
It may be useful in preventing postpartum depression.
It promotes better sleep.
It relieves stress.
30 min of moderate intensity aerobic exercise 5 days weekly
Post vaginal delivery: safe to begin several days after
Post cesarean: per MD recommendation
Typically ~ 3 weeks after
24
Post-Partum Exercise Guidelines
Additional considerations:
Bra fit: supportive, minimal underwire
Hydration: increased required with nursing
½ oz to 3/4 oz per lb
“Drink when thirsty” Urine color test
Avoid sugar drinks
If nursing: feed baby before workout
Post-Partum Pelvic Health
Dyspareunia
Urinary incontinence
Pelvic organ prolapse
Post-Partum Pelvic Health: Dyspareunia
Dyspareunia: pain or discomfort with sexual intimacy
Phases of intercourse: penetration, during, post coitus
Most common causes:
Vaginal dryness
Scar tissue
Muscle tension
25
Post-Partum Pelvic Health: Dyspareunia
Vaginal dryness
The body produces less of the hormone estrogen, which can cause the
tissues in the vagina to be thinner and drier than usual
Will normalize 6 months following breast feeding
5-10% women develop postpartum thyroiditis
Inflammation of the thyroid gland
Post-Partum Pelvic Health: Dyspareunia
Vaginal dryness
Recommendations:
Daily hydration
Coconut oil
Blossom organics
Lubrication with intimacy:
Avoid parabens, proplelen gycol and glycerin
Best: blossom organics, YES
Avoid:
Perfumed soap/body wash
Non-breathable undergarments
Harsh soap: Dove sensitive skin is recommended
Vaginal douch
Post-Partum Pelvic Health: Scar Tissue
Episiotomy or tearing
Hyper-sensitive with touch
Hypomobile
Presents as pain with penetration
Recommendations:
Self scar massage
Hydrate tissue
Adequate lubrication
26
Post-Partum Pelvic Health: Scar Tissue
Perineal scar massage:
Post-Partum Pelvic Health: Muscle tension
Pelvic floor muscle tension:
Results in pelvic pain
Referred abdominal pain
Post-Partum Pelvic Health: Muscle tension
Pelvic floor muscle tension:
Pain with all phases of intercourse
Central sensitization and poor pain reactions
Breath holding
Physical tension
Emotional dissociation
Recommendations:
Pelvic health physical therapy
External pelvic muscle release
Gluteals, piriformis, adductors, abdominals, Ileopsoas/psoas
27
Post-Partum Pelvic Health: Weakness
Pelvic floor muscle weakness
Symptoms:
Stress urinary incontinence:
Pelvic organ descent:
Functional core weakness present
Bladder change:
Bladder urgency
Decreased void interval below 2 hr
norm
Post-Partum Pelvic Health: Weakness
Urinary incontinence:
Stress UI: leakage with increased
intra-abdominal pressure
Cough, sneeze, jumping, lifting
baby
Most common postpartum
Caused by weakened muscles!!
Post-Partum Pelvic Health: Weakness
Urge UI: leakage with sensation of urgency at bladder
Over activity of detrusor muscle
UI on the way to BR, can’t hold it, “key in the door”
Mixed: presentation of both stress and urge UI symptoms
28
Post-Partum Pelvic Health: Weakness
Pelvic organ prolapse (POP)
Bladder: cystocele
Uterus: uterine prolapse
Rectum: rectocele
Post-Partum Pelvic Health: Weakness
POP grading:
Post-Partum Pelvic Health: Weakness
Pelvic floor muscle strengthening
Upward/inward lift of muscles
29
Post-Partum Pelvic Health: Weakness
Pelvic floor muscle strengthening
Common mistakes with activation:
Holding breath
Tightening stomach muscles
Squeeze buttocks and adductors
Bear down or push down through the muscles
Don’t fully relax the muscles between contractions
Post-Partum Pelvic Health: Weakness
Pelvic floor muscle strengthening
Endurance activation: target slow twitch fibers
Sustained contraction, adequate rest duration
Exercise ideas:
Begin with 3 sec hold, 10 sec rest x 5
Increase reps to 10 as able
Slowly increase duration of hold, maintain 10 sec rest
Goal 10 sec hold
Quick activation: targets fast twitch fibers
Quick activation, full contract and relax
Exercise ideas:
Begin with cadence of 1 sec contract: 3 sec relax
10 quick activations at 1:3 cadence
Slowly increase speed to 1:2 cadence
Ex progression: 5 quick contractions, 10 sec rest x 3-5
Post-Partum Pelvic Health: Weakness
Pelvic floor muscle strengthening progression:
Functional movement activation
Sit to stand
Lunges
Core exercise
Pilates
TRX
Viper
Incorporate with gym exercises/weights
30
Documentation Assessment Scales
Pelvic Girdle/SIJ Pain
Pelvic Girdle Questionnaire
Low Back Pain
Oswestry Questionnaire
Arm/Shoulder Function:
Quick DASH
General Function:
SF-8
Communication
Language
Find your words of comfort
Don’t be shy!
Locate your local pelvic health PT
WCS preferred
www.womenshealthapta.org