The Postpartum Mom

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The Postpartum Mom

• Megan Horeis MSPT, ICCE

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Objectives

• Course Participants will be able to identify
  musculoskeletal pain in their patients related to
  pregnancy and postpartum.
• Participants will be able to evaluate and treat
  diastasis recti and other abdominal conditions.
• Participants will demonstrate correct technique
  for scar mobilization.
• Participants will be able to teach kegel
  exercises correctly and efficiently.

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Musculoskeletal Conditions seen in Pregnancy and
Postpartum

• bony pelvic malalignment
• perineal trauma
• diastasis recti, abdominal trauma
• change in arch support, ligamentous support of
  feet and ankles
• malalignment of ribs
• back pain related to poor posture, infant care,
  post epidural

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Pelvic Malalignment

• Symptoms antalgic gait, pain with unilateral
  weight bearing, transitional pain, dyspareunia,
  generalized low back and buttock pain, PSIS pain
• Treatments postural realignment, binders,
  massage, ice/heat, stabilization exercises, PT
  referral

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Back Pain

• Posture, Posture, Posture
• Exercise
• Heat/Ice
• Ergonomic Changes (carrying and lifting, child
  care)
• Weight control
• Breast support

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Perineal Trauma

• Alternate Ice (frozen sanitary napkins) and heat
• Scar massage (starting 2-3 weeks after delivery)
• Ultrasound (need PT referral)
• donuts (to sit on)
• Instruct patient in kegel exercises
• Early movement (too much sitting can decrease
  blood supply)

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Diastasis Recti

• Separation of rectus abdominus from external
  obliques at linea alba.
• To Measure have patient in supine, lifting head
  and scapula off of table.
• Measure 4 cm above, at, and 4cm. below umbilicus
  determine separation width using of finger
  breadth.
• Measure at rest and contracted. Must have a
  measured width and depth to be a diastasis recti.

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Diastasis Recti

• May be observed as early as the second trimester.
• Can affect delivery by causing ineffective
  pushing
• Can be a cause of LBP, urinary incontinence,
  abdominal pain, abnormal postures

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Correction of a Diastasis Recti

• Shortening Contraction
• Binder
• Approximation wrap sheet around abs and pull
  tightly to try and approximate fibers
• Isolated correct contraction with diaphragmatic
  breathing breathe in, push belly out, breathe
  out, pull belly in

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Post Cesarean Rehabilitation Goals/Outcomes

• Decrease Incision Pain
• Prevent respiratory and circulatory complications
• Minimize bowel gas retention
• Strengthen pelvic floor muscles
• Correct posture and body mechanics
• Mobilize scar release
• Strengthen and shorten abdominals

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Abdominals after Cesarean Birth

• Educate patient in deep breathing exercises same
  day post-op.
• Educate patient to attempt to tighten muscles
  before movement, huffing
• Scar Massage 5-15 minutes daily. Start asap
  after surgery staying 1-2 in. from incision.
• Abdominal isometrics and massage left to right to
  minimize gas pain

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Scar Massage

• Immobile scars (abd. and pelvic) can cause
  chronic abdominal, pelvic, and back pain.
• Begin scar massage as soon as possible after
  surgery.
• Stay 1-2 from scar until all scabs have fallen
  off naturally.
• Start gently and progress slowly to deeper and
  stronger massage
• When the scab falls off and there is no seepage
  you can massage scar directly.

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Variations of Scar Massage

• Circles 1-2fingers deep all over abdomen
• Bowel Stimulation counterclockwise motion from
  right hip to left hip
• Desensitization helps patient feel more at ease
  touching scar
• Push and Pull Frees up stuck scar tissue
• Skin-Rolling Roll and Raise the scar
• Plucking Pick up the scar from underlying
  tissues.

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Pelvic Floor Rehab

• 80 of all pregnant/postpartum women experience
  some form of incontinence during pregnancy.
• A study by Wilson et al (1996) showed a reduction
  in the prevalence of UI postnatally in women who
  had performed pelvic floor exercises antenatally.
  
• The use of PFEs is the main non-surgical
  treatment for UI and has been shown to be more
  than 80 effective.

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How to teach PFEs (Kegels) Correctly!!!

• Verbal descriptions are only 40 effective.
• Palpate perennial tissues through clothes, should
  feel tissues move away from finger.
• Watch patient kegel(give pt. a mirror)
• Place finger inside patients vagina and pt
  squeeze
• Sexercises when patient is ready to resume sexual
  activity

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Kegels

• Make sure patient is breathing through
  contractions of pelvic floor muscles. (Can be
  difficult post-cesarean)
• Teach patient about accessory muscles
  (abdominals, gluteals)
• Rest hand on patients abdominal to make sure
  they are not contracting those muscles
• For patient with very weak musculature, you can
  teach overflow exercises using hip adductor
  muscles

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Benefits of PFEs

• Exercised muscles recover better from trauma.
  (Cesarean deliveries, episiotomies,
  forceps/vacuum, prolonged second stage of labor,
  etc.)
• Decreased swelling and pain in perineum
• Prevention and/treatment of Urinary Incontinence
• Improved sex life

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What Physical Therapy can do for the Obstetric
and Postpartum Patient

• Physical and Psychological preparation for
  childbirth
• Pregnancy and postpartum exercises, body
  mechanics
• Treatment of orthopedic problems
• Post-cesarean rehab
• Post-gynecological surgery rehabilitation
• Pelvic disorders (pain, UI, etc.)