FITNESS IN CHILD BEARING YEAR

CONTENTS

INTRODUCTION

AIMS OF PHYSIOTHERAPIST

FITNESS DURING ANTENATAL PERIOD- FIRST TRIMESTER- SECOND TRIMESTER- THIRD TRIMESTER

FITNESS DURING LABOUR

FITNESS DURING POSTNATAL PERIOD

Recent advances

INTRODUCTION

•What is child bearing year? - “ time from conception through post partum adjustments”

•Nine months of pregnancy + three months after birth of baby

•What is fitness? - physical + psycho-emotional well being

•Conception

•First trimester

•Second trimester

•Third trimester

• Labour

• Peurperium and post natal period

AIMS OF OBSTRETRIC

PHYSIOTHERAPY

1) To promote good health, poise and sense of well being during pregnancy and encourage preventive medicine

2) To give opportunity to discuss fears and expectations

3) To provide instructions in skills to conserve energy, pain tolerance level and strains of pregnancy

4) To alleviate the stress and strain

5) To rehabilitate women during puerperium and post natal life as same as pre – pregnant state

Physiological changes

Biomechanical changes

Emotional changesChild bearing year

Physiological changes

- Morning sickness

( nausea/ vomiting)

- Increased urinary frequency

- Mild enlargement of breast

- Increased vaginal secretions

- Fatigue

First trimester

Biomechanical changes

Emotional changes

- Mixed feelings

- acknowledgment

• Goals :1) To educate the pregnant woman along with

her spouse by any means like ante natal classes, pictures, videos, booklets etc.

Physiotherapy management:

• Education regarding :- Pregnancy physiology and psychology- Physical and psycho-emotional changes- Need for partner and family support- Screening examinations

- Coping with changes and minor discomforts- Small frequent meals

- Eat before rising

- Avid greasy and rich food

- Propping up the bed head

- If necessary, contact doctor

- Empty bladder often

- Take frequent fluid intake

- Eat fiber reach diet

- If necessary, contact doctor

- Warning signs:

- Fetal development- Nutrition folic acid calcium omega – 3 fatty acid iron dietary fibers

- Postural awareness

- Back care- Ergonomics at home and work place

- Relaxation techniques- Breath awareness

• Referral for specific problems

Physiological changes

- Uterus palpable above pubic bones

- Excess oil produce in skin leads to acne

- Increased perspiration

- Foetal movements felt by mother

- Increased blood volume

- Weight gain

- Supine hypotention

Second trimester

Physiological changes

- Waist thickness

- Pigmentation changes

- Stretch marks

- Heart burn

- Indigestion

- Chloasma

- Varicosities

- Braxton Hicks contractions

Biomechanical changes

Emotional changes - Stage of consolidation

• Goals:1) To educate women to cope up with certain

physiological changes2) To perform brief screening assessment

before starting actual exercise programme3) To give proper exercise guidelines4) To check contraindications5) To inform regarding precautions

Physiotherapy management:

6) To introduce proper exercise programme

- Light frequent meals

- Sleep in semi recumbent position

- Ingest proper milk

- Avoid fatty foods, coffee

Constipation &

haemorrhoids

- Increased soluble fiber and fluid intake

- Increase activity level like exercise, walking

- Change iron supplements

- analgesics, ice , padding

- Support hosiery

- Avoid prolonged standing

- Walk rather than stand

- Elevate feet when lying

- Rest frequently

• Exercise guidelines : set by the American College of Obstetricians and Gynecologists

1) Consult with medical caregiver before commencing exercises

2) Gradually increase exercises if previously sedentary

3) Women can continue to exercise during pregnancy and can experience health benefits even from mild to moderate exercise. Regular exercise at least three times per week is recommended.

4) Maximum heart rate should not exceed 140-150 beats/min or limit set in consultation with doctor.

5) Do not perform exercises that require lying on your back after the first trimester of pregnancy.

6)Prolonged periods of motionless standing should be avoided.

7) Avoid over flexing and overextending joints, quick direction changes, jumping and jarring motions. Be careful during exercises requiring balance and use outside support.

8) Modify the intensity of cardio exercise according to perceived exertion or the “talk test.” Stop exercising when fatigued and do not exercise to exhaustion. ” listen to your body.”

9) Never exercise when you have a fever or if the climate is hot and humid. Wear loose, cool clothing to stay cool.

10) Drink liquids before, during and after exercise and be particularly careful to ensure an adequate diet due to increased caloric needs.

11) Your fitness goals during pregnancy should not be exercising for weight loss, increase in flexibility or strength gain.

12) If a regular pattern of contractions, low back pain, pelvic pressure, or any other unusual symptom develops while exercising, stop and communicate with your health care provider.

13) Always include at least a 5-minute warm-up and a 5-minute cool down period.

14) Get up and down from floor carefully and keep legs moving when you first stand up. This prevents blood from pooling in the legs and causing dizziness.

15) Pain, discomfort, or shortness of breath should be avoided. Valsalva manoeuvers should be avoided.

16) Vary your exercise program. Some excellent alternatives are walking, swimming and stationary cycling.

Absolute contraindications Relative contraindicationsSevere cardiovascular, respiratory or systemic disease

History of repeated (3 or more) miscarriage or premature labor

Uncontrolled hypertension, diabetes or thyroid disease

Diabetes

Ruptured membranes or premature labor

History of rapid labor or poor fetal growth

Persistent bleeding after 1st trimester

Early pregnancy bleeding

Incompetent cervix Sedentary lifestyle with very poor fitness

Preeclampsia or toxemia Breech presentation after 28 weeks

Multiple pregnancy (triplets, etc.) Palpitations or arrhythmias

Poor fetal growth Anemia or iron deficiency

Extreme over- or underweight

Potential risk to the foetus from maternal exercisesHypothermia Hypoxia Abnormal heart rateDecreased utero placental flow Increased uterine contractionsReduced maternal glucose levelDisruption of maternal endocrine haemostasisPoor growth

• Warm up:

• Exercise programme : strengthning exercises

Pelvic tilting ex’s

• Cool down:- Mild stretching- Breathing techniques- Mental imagery techniques- Relaxation- Listening calm music- Touch of spouse

Benefits of exercise

• Maintain healthy body weight and avoid excess fat accumulation

• Maintain or improve cardiovascular fitness, muscular strength, endurance, and flexibility

• Decreased musculoskeletal complaints such as back pain

• Decreased minor discomforts of pregnancy• Improved posture and body mechanics, which

may improve coordination, balance, and body awareness

• breath awareness and relaxation• Prevention and treatment of problems

associated with gestational diabetes, hypertension, and preeclampsia

• Stress reduction and enhanced self-image• Possible easing of labour with fewer

complications of delivery faster postnatal recovery

Physiological changes

- Varicose veins

- Haemorrhoids

- Lower limb oedema

- Frequency of urination

- Breathlesness

Third trimester

Physiological changes- indigestion and constipation

- “sick of being pregnant”

- “show” in the days or hours preceding labour

Biomechanical changes

Emotional changes- Mood swings increased

- Preparation for labour

• Goals:1) To educate the woman to get relax and stress

free 2) To educate woman for dressing3) To continue exercises as much as possible of

second trimester but with mild intensity4) To educate the woman to cope up with changes5) To educate and practice for different positions

helpful in labour

Physiotherapy management:

Ex’s for circulation & cramp

• Breathing exercise: - Explain how “ slow “ , “ low ”, “ deep “ , “ calm

“ abdominal breathing

• Relaxation exercises/ techniques:- Major aim is to prevent the mother becoming

unduly tired- To help the mother in labour- To help the mother to control her thoughts

and emotions

Mitchell method Jacobson relaxation

technique

Dissociation and blocking Imagery

technique

Relaxation techniques

• Principles of teaching relaxation:- Enablement - Understanding - Beware - The ‘whole’- Flexibility - Practice - Motivation- Confidence - Safety

• Teaching different positions for labour :

• “ the process in which the foetus, placenta secundines are expelled from the uterus via the birth canal after minimum period of 20 weeks”

• Mainly 3 stages of labour

Labour

• Stage 1 – from onset of labour untill full dilation of cervix

• Changes during this stage – pain and contractions

• Stage 2 – full cervical dilation to expulsion of the foetus from vagina

• Massage to the back:

• Other approaches:- TENS- Acupuncture - Hypnosis - Water bath- Medications or injections

Post natal period

Delivery

Caesarian section

Normal / episiotomy

Immediate post natal symptoms

- Episiotomy pain

- Muscles and ligament laxity causing diastasis recti

- Oedema

- Back pain

- Breast engorgment

- Psychological state

• Goals :1) Relief of pain either of episiotomy or

caesarian2) Ergonomic advices for preventing further

complications3) Educate Exercise programme

Physiotherapy management :

• Episiotomy pain:- Icing- Water baths- Ultra sound ( 3 MHz, 0.5 W/cm for 2 min)- Pulsed electromagnetic energy(40-50 pulse

width, 10-220 repetitions)

- Advice for abdominal binder or tubigrip or supportive under wears

- Abdominal retraction exercises

- Pelvic tilting exercise

- Progression with coming up upto the hands

DRAM management

- Ultrasound to the periphery initially

- Warm compresses

- Crushed ice

- PEME

1) Jennifer Hollowell et al., did study on The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review

• 36 distinct eligible studies covering a wide range of interventions, including group antenatal care, clinic-based augmented care, teenage clinics, prenatal substance abuse programmes, home visiting programmes, maternal care coordination and nutritional programmes.

Recent advances

• Conclusions: There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing infant mortality in disadvantaged/vulnerable women.

• BMC Pregnancy and Childbirth 2011, 11:13

• Ana L Vallim et al., did study on Water exercises and quality of life during pregnancy to evaluate the effects of a physical exercise program of water aerobics on the quality of life (QOL) of sedentary pregnant women

• 35 women was given routine antenatal care, while another group of 31 women, in addition to receiving the same routine care as the first group, also participated in three classes of water aerobics per week.

• QOL was evaluated by applying the WHOQOL-BREF questionnaire in both groups at the 20th, 28th and 36th weeks of pregnancy.

• Conclusion : The great majority of the participants considered that the practice of water aerobics had benefitted them in some way. QOL scores were found to be high in both groups during follow-up. There was no association between the practice of water aerobics and QOL.

• Reproductive Health 2011, 8:14

• Po-Chun Ko, Ching-Chung Liang et al. did study on A randomized controlled trial of antenatal pelvic floor exercises to prevent and treat urinary incontinence

• to evaluate the effect of antenatal pelvic floor muscle exercise (PFME) in the prevention and treatment of urinary incontinence during pregnancy and postpartum period

• Three hundred women were randomly assigned to the PFME group and control group.

• Urogenital Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire-7 (IIQ-7), and question of self-reported urinary incontinence.

• Conclusions: PFME applied in pregnancy is effective in the treatment and prevention of urinary incontinence during pregnancy, and this effect may persist to postpartum period.

• International Urogynecology Journal January 2011, Volume 22, Issue 1, pp 17-22

• J.T. van der Spank ET AL. did study on Pain relief in labour by transcutaneous electrical nerve stimulation (TENS) by burst – conventional obstetric TENS-apparatus

• On 59 women compare to epidural analgesia • Conclusion : During TENS application the pain

scores were significantly lower (p<0.0001)• Archives of Gynecology and Obstetrics

November 2000, Volume 264, Issue 3, pp 131-136

• Keep the “WOMAN” fit and happy, always gives “SAFTEY” to “MUMMY AND

BABY”

Take Home Message

• R Sapsford et all; WOMEN’S HEALTH – a textbook for physiotherapists, part two – child bearing year

• Jil mentle, Jeanette Haslam, Sue Barton, Physiotherapy in Obstetrics and Gynaecology, pg no 93 – 244

• Elizabeth Noble, Essential Exercises for the Childbearing Year: A Guide to Health and Comfort Before and After Your Baby Is Born

REFERENCES

• Margaret Polden, Jill Mantle , Physiotherapy in Obstetrics and Gynaecology

• Exercise guidelines by The American College of Obstetricians and Gynecologists, 2001

• Ann Thomson, Alison Skinner, Joan Piercy, Tidy’s Physiotheray, twelfth edition , pg no :382-400

• Sandie Keane, Pilates for core strength• Roger L. Hammer, PhD ,Jan Perkins, MSc,Richard

Parr, EdD, FACSM, Exercise During the Childbearing Year. Journal of Perinatal Education, 9(1), 1-13; pregnancy, postpartum exercise, guidelines.

• Jennifer Hollowell et al., The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review, BMC Pregnancy and Childbirth 2011, 11:13

• Ana L Vallim et al., Water exercises and quality of life during pregnancy Reproductive Health 2011, 8:14

• Po-Chun Ko, Ching-Chung Liang et al. A randomized controlled trial of antenatal pelvic floor exercises to prevent and treat urinary incontinence. International Urogynecology Journal January 2011, Volume 22, Issue 1, pp 17-22

• J.T. van der Spank ET AL. Pain relief in labour by transcutaneous electrical nerve stimulation (TENS) Archives of Gynecology and Obstetrics November 2000, Volume 264, Issue 3, pp 131-136

Thank You…