Women's healthA.THANGAMANI RAMALINGAM PT, MSc(PSY),PGDRM, Acspss,MIAP

• B. Child-bearing phase –• a) Complications during pregnancy and its PT management

according to specific conditions/complications.• b) Antenatal Phase– specific breathing exercise, relaxation,

postural training, pelvic floor exercise and strengthening exercise.

• c) Physiotherapy during labor.• d) Postnatal Phase – complication and its physiotherapy

management. Postnatal exercise after normal labour and labour with invasive procedures like: Episiotomy, Forceps delivery, Caesarian section

Stages of pregnancy

• First trimester (week 1-week 12)• Second trimester (week 13-week 28)• Third trimester (week 29-week 40)

Complications during pregnancy

Progesterone

Estrogen

Relaxin

Reduction in tone of smooth muscles (reduced peristalsis, more water absorption, constipation, nausea, vomiting, urinary incontinence, UTI, lowered diastolic BP). Increased temperature Reduces alveolar/arterial pco2 (hyperventilation) Development of breast and glandular tissues Increases storage of fat

Growth of uterus and breast ducts Increases prolactin for lactation Assists maternal calcium metabolism Water retention (sodium retention) Increases vaginal glyCOGen

Replacement of collagen with a remodeled modified form ( increases exTENSibility + pliability) Inhibition of Myometrial activity (up to 28 weeks) Enhances uterine distention. Production of supportive connective tissue. Softening of collagenous content of the cervix Mammary growth Relaxation of pelvic floor muscles.

Stretching of abdominal muscles Decrease in ligamentous tensile strength. Hyper mobility of joints due to ligamentous laxity. Pelvic floor drops as much as 2.5 cm. COG shifts upwards & forwards posture –

*shoulder girdle becomes rounded, *scapular protraction, upper

*limb internal rotation.*increase in cervical lordosis.

*knee hyperextension.*increase in lumber lordosis

balance – pt. walks with wider BOS

Potential impairments of pregnancy • Development of faulty posture• Upper & lower extremities stress• Altered circulation, varicose vein LL edema• Pelvic floor stress• Abdominal muscle stretch & diastasis recti• Inadequate relaxation skills necessary for labour & delivery• Development of musculosketal pathologies

Antenatal Phase• To educate about the physiological changes, labor and the puerperium• To adopt coping skills• To understand labor and coping skills• To create emotional maturity• Pregnancy back care• Symphysis pubis dysfunction (SPD)• Pelvic floor/pelvic • Exercises for circulation and cramps• Stress and relaxation• Relaxation position for labor• Pain relief• Baby care• Diet in pregnancy• Medication in pregnancy• Swimming and water exercises, yoga and pilates

Antenatal exercise• Warm up• Stretches• Postural correction• Strengthening exs• Aerobic exs• Back and abdominal exercise• Ankle exercise• Relaxation exercise• Breathing exercise• Pelvic floor exercise• Cool down exs

labourThree stages of labour

Cervical dilatation

Propulsion of the foetus

Propulsion of placenta

Complications of labor Failure to progress Fetal distress Maternal distress Malpresentation Breech presentation Prolapsed or

presentation of the cord

Inco-ordinate uterine activity

Hemorrhage

Contracted pelvis Placental abruption Multiple births Perineal trauma Retained placenta Placenta accrete (life

threatening) Knots of the umbilical

cord

Postnatal Phase• Routine care by mid wife• Establishing breast feeding• milk ejection reflex oxytocin uterine contractions (after pain)• Problems: engorgement, sore or cracked nipples, blocked ducts and

mastitis.• Pain management techniques• Postnatal checking/assessment:• Mother’s BP, breast, abdominal status uterine involution, status of

the cervix, smear test and discussing contraception

Post natal exercises

• Benefits of exercise • Important information • Principles of exercise Exercise program • Core muscles • Cardiovascular fitness • Strength • Core stability • Cool down Further information

Exercise in Pregnancy

Exercise in Pregnancy

• Exercise may also reduce the risk of developing conditions associated with pregnancy, such as pregnancy-induced hypertension and gestational diabetes mellitus .

The American College of Sports Medicine (ACSM) endorses guidelines regarding exercise in pregnancy and the postpartum period set forth by the American College of Obstetricians and Gynaecologists , the Joint Committee of the Society of Obstetricians and Gynaecologists of Canada , and the Canadian Society for Exercise Physiology (CSEP).

Physiologic Responses to Acute Exercise during Pregnancy Compared with Pre pregancy

FITT for pregnant women• Frequency: At least three—and preferably

all—days of the week.• Intensity: Moderate intensity (40%–60%

[V with dot above]O2 reserve [[V with dot above]O2R]).

Because of heart rate (HR) variability during pregnancy, consider using the rating of perceivedexertion (RPE) (12–14 on a scale of 6–20) or the “ talk test” (being able to maintain a conversationduring activity) to monitor exercise intensity. HR ranges that correspond to moderate-intensityexercise have also been developed for pregnant women based on age.• Time: At least 15 min·d-1 gradually

increasing to at least 30 min · d-1 of accumulated moderate intensity physical activity to total 150 minutes per week.

• Type: Dynamic, rhythmic physical activities that use the large muscle groups, such as walking and cycling.

Age HR(beats · min-1)

<2020–2930–39 >40

140–155135–150130–145125–140

Contraindications for Exercising during Pregnancy

Relative

• Severe anemia• Unevaluated maternal cardiac

dysrhythmia• Chronic bronchitis• Poorly controlled type 1 diabetes mellitus• Extreme morbid obesity• Extreme underweight• 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

Absolute

• 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 labor during the current

pregnancy• Ruptured membranes• Preeclampsia/pregnancy-induced

hypertension

Special considerations• Pregnant women who are morbidly obese and/or have gestational diabetes mellitus or hypertension should

consult their physician before beginning an exercise program.• Pregnant women should avoid contact sports and sports/activities that may cause loss of balance or trauma to

the mother or fetus. Examples of sports/activities to avoid include soccer, basketball, ice hockey, horseback riding, and vigorous-intensity racquet sports.

• Pregnant women should avoid exercising in the supine position after the first trimester to• ensure that venous obstruction does not occur.• Pregnant women should avoid performing the Valsalva maneuver during exercise.• Pregnant women should exercise in a thermo neutral environment and be well hydrated to• avoid heat stress. • During pregnancy, the metabolic demand increases by ~300 kcal·d-1. Women should increase• caloric intake to meet the caloric costs of pregnancy and exercise.• Pregnant women may participate in a strength-training program that incorporates all major muscle groups with a

resistance that permits multiple repetitions (i.e., 12–15 repetitions) to be performed to a point of moderate fatigue. Isometric muscle actions and the Valsalva maneuver should be avoided, as should the supine position after the first trimester.

• Generally, exercise in the postpartum period may begin ~4 to 6 weeks after delivery.• Deconditioning typically occurs during the initial postpartum period, so women should gradually increase

physical activity levels until pre pregnancy physical fitness levels are achieved.• Exercise should be terminated should any of the following occur: vaginal bleeding, dyspnea before exertion,

dizziness, headache, chest pain, muscle weakness, calf pain or swelling, preterm labor, decreased fetal movement, and amniotic fluid leakage . In the case of calf

• pain and swelling, thrombophlebitis should be ruled out.