POST- PARTUM RECOVERY: IMPROVING FUNCTION FOR …

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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.

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Physical Development: Pregnancy

Normal physiological change

Increased thoracic kyphosis

Forward rounded shoulders

Increased breast size

Increased lumbar lordosis

Knee hyperextension

Increased base of support


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


Abdominal muscles

Diastasis rectus: separation of

rectus abdominus muscle

Visible fascial thinning

Umbilicus change

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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

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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

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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


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”

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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.

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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

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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

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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

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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


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

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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


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)


VIDEO

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Patient Assessment: Abdominal strength testing:

Isometric test:


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


Dynamic endurance test:

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Oblique 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

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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.


Transverse Abdominus


TA and core progression

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TA and core progression


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”

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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

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Interventions: Body Mechanics

Breast feeding

Child care

Baby wearing

Car seat carrying


Breast Feeding Positions

Football Hold Cradle Hold



Side Lying Cross Body

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Vaginal Delivery:

Football

Ideal with newborns

Cross body

Cesarean Delivery:

Football

Side lying


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


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

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My Breast Friend

PROS:

Lumbar support

Great for small babies

CONS:

“Table” like platform; larger babies roll easily

Can be cumbersome to don



Infantino Elevate Adjustable Nursing

Pillow

PROS:

Very adjustable; position variability

Easy to use

CONS:

No back support

Can be cumbersome to arrange pillow



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

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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

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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


Wrap


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


Chinese Mei Tai : (pronounced “may tie”) Age Range: Newborn to 4 years


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

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Pouch Sling Age Range: Newborn to 3 years


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


Buckle Carriers


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


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

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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

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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

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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


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

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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

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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


Urinary incontinence:

Stress UI: leakage with increased

intra-abdominal pressure

Cough, sneeze, jumping, lifting

baby

Most common postpartum

Caused by weakened muscles!!


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

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Pelvic organ prolapse (POP)

Bladder: cystocele

Uterus: uterine prolapse

Rectum: rectocele


POP grading:


Pelvic floor muscle strengthening

Upward/inward lift of muscles

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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



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


Pelvic floor muscle strengthening progression:

Functional movement activation

Sit to stand

Lunges

Core exercise

Pilates

TRX

Viper

Incorporate with gym exercises/weights

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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

[email protected]

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POST- PARTUM RECOVERY: IMPROVING FUNCTION FOR …