Mums shape up. Lisa westlake Ba app sci physiotherapy

Transcription

1 Mums shape up Lisa westlake Ba app sci physiotherapy It is well recognised that exercising during pregnancy requires extra care and consideration. Postnatal woman however, frequently return to exercise after the birth of their baby with little or no guidance. A sound approach is to consider the childbearing year as a period for special consideration. Many circumstances and conditions necessitate exercise modification in the early weeks and months after delivering a baby. To safely design programs and include new mums into exercise classes it is important to understand the postnatal needs and the risks of inappropriate exercise. Physically they need to recover from pregnancy and labour, as well as adjust to breast feeding, broken sleep patterns and a new, busy routine. Psychological considerations are also significant. New mothers are often very keen to return to exercise. They are frequently in a hurry to lose weight, tone up, and get rid of the jelly belly. Appropriate exercise at appropriate time frames will be extremely beneficial, but guidance and understanding of limitations is crucial, as is rest and tlc. How does a new mum feel? 0 48 hours 1 week later Life in those first few weeks at home? Postnatal exercise considerations Pre existing fitness Pregnancy Labour Baby s health and situation Home situation Pregnancy Relaxin: softened various tissues ~> joint laxity and vulnerability Muscles: stretched, especially pelvic floor and abdominals Postural changes may have created spinal discomfort Loss of general fitness and muscle tone / strength Weight gain Enlarged breasts

2 Pregnancy related problems that do not resolve immediately Pubic symphysis or sacroiliac joint: pain or instability Back pain Carpel tunnel syndrome Rectus diastasis Labour Level of fatigue and health prior to labor Type and length of labor: 1st stage (endurance / exhaustion) o 2nd stage (pelvic floor / continence) Delivery Vaginal delivery Forceps Vacuum extraction Episiotomy Perineal tear Caesarean: emergency vs planned Retained products Baby s health at delivery Recovery Early days Commencing breast feeding First weeks Lifestyle Changes Timetabling exercise / needing to be flexible Energy levels Sleep / Fatigue Emotional Systemic recovery Breast feeding Whether easy or difficult breast-feeding applies physical demands on the new mother: Time of feeding, metabolic demands, extra requirements of hydration, tiring Some problems that can occur with breast-feeding include: cracked nipples, engorgement, blocked ducts, mastitis, conflicting advice. Breast support, but avoid underwire bras Do not exercise in the presence of infection Feed prior to exercise if possible Prone position may be uncomfortable Attention to calories and hydration

3 Pelvic floor The pelvic floor is stretched and weakened following pregnancy and delivery. Pelvic sphincters may be less effective and muscular innervation may be compromised. Many factors influence the likelihood of further continence problems postnatally including: Type of labour (v vs c) Length of second stage Use of forceps Number of pregnancies Mother being overweight Other stress to the pelvic floor ( impact, lifting, straining) Back pain Long term problems may include urinary or faecal incontinence or prolapse. Risks are increased by straining, jolting or early return to inappropriate exercise High impact or heavily resisted exercise for 12 weeks or longer. Stress or strain on the pelvic floor Prolonged standing. Include PF early, little and often. Progress to more and longer contractions Do not progress to weight work or impact if unable to control bladder or bowel. Seek advice where necessary. Train to contract the pelvic floor, with ta prior to lifting, activity and exercise. Abdominals The abdominal muscles are stretched and weakened as a result of pregnancy. Commence with simple abdominal indrawing. Progress to curls when able to maintain deep contraction throughout whole ab curl. Overloading the spine Abdominal exercises that are intense and / or cause poor technique, Breath holding or inability to spinal stabilise.

4 Diastasis of rectus abdominis A result of widening of the linea alba, down the midline of the abdomen, which will mechanically interfere with the supportive function of the abdominal wall. Larger diastasis will be visible, during sitting or attempting a curl, as a bulge. Include Core / PF rcruitment in all positions and during all activities. Progress to upright oblique exercise without then with resistance Do not progress to abdominal curls until core control is significant and diastasis is narrowed Abdominal curls or oblique curls until function is resolved. Pubic symphysis and sacroiliac pain / instability Pain or instability of the pelvic joints may occurs during pregnancy, and occasionally as a result of labour /delivery. Aggravating activities Prolonged standing Asymmetrical stance Wide stance Stairs Weight transfer side to side Impact activity Wide stance/stepping Asymmetrical exercise (eg stepping) and ADL Include Rest Non weight bearing / narrow exercise live life like you re in a mini skirt. Seek professional advice. Pelvic sling and stability exercise

5 Neck and Back pain Low back pain is often a consequence of postural changes during pregnancy. Neck and mid thoracic back pain is a more common consequence of early mother hood. Sustained poor postures such as thoracic flexion, lumbar lordosis Jarring and jolting Overloading the spine, shoulder girdle or pelvic girdle. Include Postural exercises: core stabilisation, rhomboid strengthening. Flexibility and mobility of neck, shoulders and thoracic spine Education and advice for positioning during adl. Refer Carpel tunnel syndrome Results from tissue swelling at the wrist, due to fluid retention during pregnancy. Symptoms include pain, numbness or pins and needles +/- muscle weakness. weight bearing through upper limb (hands and knees or push up position) Heavy weight work, or prolonged gripping. May require treatment. Caesarean section % deliveries. Epidural vs general anaesthetic Planned elective vs emergency. Recovery will depend on previous health, labour before caesar, type of caesarean. Allow 12 weeks or more for healing to occur. Prior to this walking within limits of comfort, progressed to gentle forms of exercise only. all lifting where possible and straining of abdominals. Abdominal exercises can recommence when comfortable and ta retraining is particularly beneficial. Remember a caesarean is a major operation and healing requires rest.

6 Post natal emotional and psychological issues A variety of emotional issues play a role in the new mothers progress. First baby, fatigue, hormones, life changes, responsibility, conflicting advice, time management and difficulty coping are just a few common considerations. Women often feel they must return to exercise quickly. This is further encouraged by the desire to regain their pre pregnancy shape and size. Wanting to get out to exercise early and quickly may conflict with organisational difficulties as well as fatigue and the need to adjust to and accept mother hood. Assisting postnatal women to undertake appropriate exercise whilst enabling her to enjoy motherhood is challenging but rewarding. Her inner figure and health are equally important to her outer appearance. Encourage and assist her to take time, to rest, develop realistic goals and most importantly, to enjoy her new status... Motherhood, and her new little miracle. Post natal exercise guidelines Allow recovery Pf and deep abdominals must come first Gradual progression: core, low load, low impact Increase slowly and carefully always training for weakest link Early days Recovery, bonding, adjustment, establishing breast-feeding, adjustment Rice Ta and pelvic floor Relaxation and walking within comfort. Early weeks Ongoing adjustment and recovery. Elation may be replaced with fatigue and concerns. Walking, pelvic floor and abdominals are recommended. All exercise should still be modified. Ensure adequate breast support and hydration. Months The safe time frame for return to impact exercise and weight training is around 12 weeks post natally but individual assessment is imperative. This is quite a lot longer than might have been expected. The reason for this is it is vital to allow repair of abdominals and pelvic floor before re stressing those muscles. Remember incontinence may develop later. Focus on health and fitness not weight loss

7 References Allen re, hosker gl, smith arb, warrell dw. Pelvic floor damage and childbirth: a neurophysiological study. Br. J. Obst gynecol sept 90, vol 97, Brown s, lumley j. Maternal health after childbirth: results of an australian population based survey. Br. J. Obst and gynecol. Feb 1998, vol Bullock saxton j. Musculoskeletal changes in the prenatal period. Women s health, a text book for physiotherapists. Wb saunders Bump rc, mattiasson a, bo k, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am j obst gynecol 1998 vol 175 Dimpfl th, hesse u, schussler b. Incidence and cause of post partum urinary stress incontinence. Eur j obst gynecol 43, Millard r. Risk factors for urinary incontinence in women. Aust continence journal, dec Physiotherapy in obstetrics and gynaecology. Ch 7, the post natal period. Sapsford, bullock-saxton and markwell womens health, a text book for physiotherapists. Wb saunders co Snooks sj, swash m, mathers se and henry mm. Effect of vaginal delivery on the pelvic floor: a 5 year follow up. Br.j.surg. 1990, vol 77 dec, Snooks j, swash m, henry mm and setchell m. Risk factors in childbirth causing damage to the pelvic floor innervation. Br j surg. Vol 72, sept 1985 s15 - s17 Westlake,L Mums Shape Up, Hachette 2012 Wilson pd, herbison gp a randomized controlled trial of pelvic floor muscle exercises to treat post natal urinary incontinence. Int urogynecol :

8