CHAPTER-1

INTRODUCTION

1
INTRODUCTION

The influences of the pregnancy on the musculoskeletal system are the ones that
involve the physiotherapist most directly.
Pregnant women present a unique challenge for the physical therapist it a time of
tremendous musculosketal physical and emotional changes and yet is a condition of
wellness.
Pregnancy is a unique, exciting and often joyous time in a woman's life, as it
highlights the woman's amazing creative and nurturing powers while providing a
bridge to the future. Pregnancy comes with some cost, however, for a pregnant
woman needs also to be a responsible woman so as to best support the health of her
future child. The growing fetus (the term used to denote the baby-to-be during early
developmental stages) depends entirely on its mother's healthy body for all needs.
Consequently, pregnant women must take steps to remain as healthy and well
nourished as they possibly can. Pregnant women should take into account the many
health care and lifestyle considerations described in this document.

Fig-1.1
Though we have tried to present relatively comprehensive coverage of pregnancy, this
document should only be considered to be an overview. It will hopefully introduce
you to some new ideas, and help you to learn about aspects of pregnancy that you
may not have previously encountered, but it does not contain or provide all the

2
information you will need to make informed choices as you go through your own
actual pregnancy. Be sure to see your doctor when you become pregnant. Share with
him or her any questions or concerns you may have about your pregnancy. Your
doctor, and other specialized health care providers including nurses and midwives,
will be some of your more important allies during your pregnancy. They are in the
best position to guide you through the process and to make authoritative
recommendations that will best benefit your baby-to-be's development and future
health and welfare.

3
 CHAPTER-2
ANATOMY AND PHYSIOLOGY

4
THE ANATOMY AND PHYSIOLOGY OF FEMALE EPRODUCTIVE
SYSTEM:
BONE & JOINTS:

Fig-2.1

The bones of the pelvis comprising hips, sacrum and coccyx, form a cavity through
which the fetus passes during labour. The two large hip bones meet together in the
midline anteriorly, forming the symphysis pubis, and the sacrum posteriorly, Forming
two sacroiliac joints. These joints allow a small amount of movement during birth
giving the fetus an easier fit.

5
 THE UTERUS

Fig-2.2

MUSCLES
The pelvic floor muscles form a sling of elastic support for pelvic and abdonminal
contents. The pelvic floor is also known by other names: the perineum, perineal area,
urogenital diaphragm, pelvic diaphragm, or muscle names such as levatores ani, or
pubococcygenus.

Fig-2.3

6
The pelvic floor consists of a superficial and a deep layer of muscle tissue. There
openings penetrate the floor in the female, the urethra and vagina anteriorly and the
anus posteriorly.
The deep lich on contraction compress the urethra, vagina and their posterior walls,
thus maintaining continence. Each levator ani is composed of there bands of fibres:
pubococcygens, ischococcygens, names from their attachement on the hip bone and
the coccyx.

THE ABDOMINALS

The abdominal muscles form a four way stretch elastic support for the abdominal
contents. They are the:

1. Rectus abdominis.
2. Transverses abdomens.
3. Internal oblique.
4. External oblique.

Superficially, the recti abdomini stretch either side of the linea alba ligament attaching
to it in midline, running from the pubic arch below to the ribs and the xiphoid process
above. Their function is to the flex the spine, as well as gives support.

7
NERVE SUPPLY
4th & 5th sacral nerves and a branch of the Pudendal nerve.
Note: in health the muscle contract as a harmonious which is the physiotherapist
objective in treating muscle weakness?

Fig-.2.4

8
CHAPTER-3

PREGNANCY

9
PREGNANCY
It is the sequence of events that normally include fertilization, implantation,
embronoic growth and fetal growth that terminate in birth.

40 weeks from conception to delivery

PREGNANCY DIVIDED INTO THREE TRIMESTERS:-
1. Changes during the first trimester: weeks 0 to 10 days after fertilization.
a. Implantation of the fertilized ovum in the uterus occurs 7 to 10 days
after fertilization.
b. The mother may be nauseated or may vomit, is very fatigued and will
urinate more frequently because of pressure from the growing uterus.
c. The breast size may increase.
d. There is a relatively small weight gain of 0 to 1455 g (0 to 3 lb is
normal).
e. By the end of the 12th week, the fetus is 6 to 7 cm long and weights
approximately 20g (2 oz). The baby now can kick, its head, ad swallow
and has a beating heart, but these movements are not yet felt by the
mother.

10
 Fig-3.1

a) By the end or the second trimester the fetus is 19 to 23 cm (14 inches) in

length and approximately 600 g (1 to 3 lb).
b) The fetus now has eyebrows, eyelashes, and fingernails and would have a
slight chance of born prematurely.

3. Changes during the third trimester: weeks 27 to 40 of pregnancy (38 to

40 weeks is considered full term)
a. The uterus is now very large and has regular contraction, although these
may only occasionally be felt.
b. Common complaints during the third trimester are frequent urination,
back pain; leg edema and fatigue, round ligament pain, shortness of
breath, and constipation.
c. By the time of birth, the baby will be 33 to 39 cm long (16 to 19 inches)
and will weigh approximately 3400 g (7lb, although a range from 5 to 10
lb is normal)

11
CHAPTER-4
THE LABOUR

12
LABOUR
THE STAGES OF LABOUR

FIRST STAGE
Regular uterine muscle contractions establish and become progressively longer
stronger and closer together. For most women these contraction are painful and
many require- some form of analgesia. Commonly (95%) the fetus presents head
down to the cervix within the uterus, and the uterine contractions exert an
intermittent upward pull on the lower segment of the uterus and cervix, while at
the same time applying downward pressure on the fetus. The first stage is said to
be complete when the cervix has reached a dialation about 10 cm diameter- that
allows the fetal head through, so that it is able to proceed down the vagina; it is
almost the longest stage.

Fig-4.1

13
SECOND STAGE
There is often a noticeable change in the tempo of contractions; they may become
more widely spaced and even a little shorter, while still remaining intese. The
diaphragm and the abdominal muscles; brought into action to help push the fetus
out. It takes time for perineum to stretch sufficiently to allow the fetus through,
and deliv of the fetus may be accelerated by performing an episiotomy second
stage is normally much shorter than first stage and ends v the birth of the baby.

Fig-4.2

THIRD STAGE
The third stage is the passing of the placenta once it has detached from the uterine
wall. It is usually the shortest phase.

Fig-4.3

14
1. The hormonally mediated changes in collagen and involuntary
2. the increased total blood volume with increased.
3. the growth of the fetus resulting in consequent enlargement and
displacement of the uterus.
4. the increase in body weight and adaptive changes in the center of
gravity and posture.

Fig-4.4

15
 CHAPTER-5
PHYSIOLOGY OF REPRODUCTIVE SYSTEM

16
PHYSIOLOGICAL CHANGES
Pregnancy causes physiologic changes in all maternal organ systems; most return to
normal after delivery. In general, the changes are more dramatic in multifetal than in
single pregnancies.

Fig-5.1
CARDIOVASCULAR: Cardiac output (CO) increases 30 to 50%, beginning by 6
wk gestation and peaking between 16 and 28 wk (usually at about 24 wk). It remains
near peak levels until after 30 wk. Then, CO becomes sensitive to body position.
Positions that cause the enlarging uterus to obstruct the vena cava the most (eg, the
recumbent position) cause CO to decrease the most. On average, CO usually
decreases slightly from 30 wk until labor begins. During labor, CO increases another
30%. After delivery, the uterus contracts, and CO drops rapidly to about 15 to 25%
above normal, then gradually decreases (mostly over the next 3 to 4 wk) until it
reaches the prepregnancy level at about 6 wk postpartum.
The increase in CO during pregnancy is due mainly to demands of the uteroplacental
circulation; volume of the uteroplacental circulation increases markedly, and
circulation within the intervillous space acts partly as an arteriovenous shunt. As the
placenta and fetus develop, blood flow to the uterus must increase to about 1 L/min
(20% of normal CO) at term. Increased needs of the skin (to regulate temperature) and
kidneys (to excrete fetal wastes) account for some of the increased CO.

17
 Fig-5.2

To increase CO, heart rate increases from the normal 70 to as high as 90 beats/min,
and stroke volume increases. During the 2nd trimester, BP usually drops (and pulse
pressure widens), even though CO and renin and angiotensin levels increase, because
uteroplacental circulation expands (the placental intervillous space develops) and
systemic vascular resistance decreases. Resistance decreases because blood viscosity
and sensitivity to angiotensin decrease. During the 3rd trimester, BP may return to
normal. With twins, CO increases more and diastolic BP is lower at 20 wk than with a
single fetus.
Exercise increases CO, heart rate, O2 consumption, and respiratory volume/min more
during pregnancy than at other times. The hyperdynamic circulation of pregnancy
increases frequency of functional murmurs and accentuates heart sounds. X-ray or
ECG may show the heart displaced into a horizontal position, rotating to the left, with
increased transverse diameter. Premature atrial and ventricular beats are common
during pregnancy. All these changes are normal and should not be erroneously
diagnosed as a heart disorder; they can usually be managed with reassurance alone.
However, paroxysms of atrial tachycardia occur more frequently in pregnant women
and may require prophylactic digitalization or other antiarrhythmic drugs. Pregnancy
does not affect the indications for or safety of cardioversion.

18
POSTURAL CHANGES IN PREGNANCY

This diagram summarizes the effects of pregnancy on your spine. Although these
symptoms are often considered 'normal' during pregnancy, there is no reason to suffer
needlessly as chiropractic care is a safe and effective approach to keeping your spine
healthy and feeling great.

Fig-5.3

HEMATOLOGIC: Total blood volume increases proportionally with CO, but the
increase in plasma volume is greater (close to 50%, usually by about 1600 mL for a
total of 5200 mL) than that in RBC mass (about 25%); thus, Hb is lowered by
dilution, from about 13.3 to 12.1 g/dL. This dilutional anemia decreases blood
viscosity. With twins, total maternal blood volume increases more (closer to 60%).
WBC count increases slightly to 9,000 to 12,000/L. Marked leukocytosis (
20,000/L) occurs during labor and the first few days postpartum.

19
 Fig-5.4

Iron requirements increase by a total of about 1 g during the entire pregnancy and are
higher during the 2nd half of pregnancy6 to 7 mg/day. The fetus and placenta use
about 300 mg of iron, and the increased maternal RBC mass requires an additional
500 mg. Excretion accounts for 200 mg. Iron supplements are needed to prevent a
further decrease in Hb levels because the amount absorbed from the diet and recruited

20
from iron stores (average total of 300 to 500 mg) is usually insufficient to meet the
demands of pregnancy.

URINARY: Changes in renal function roughly parallel those in cardiac function.

GFR increases 30 to 50%, peaks between 16 and 24 wk gestation, and remains at that
level until nearly term, when it may decrease slightly because uterine pressure on the
vena cava often causes venous stasis in the lower extremities. Renal plasma flow
increases in proportion to GFR. As a result, BUN decreases, usually to < 10 mg/dL (<
3.6 mmol urea/L), and creatinine levels decrease proportionally to 0.5 to 0.7 mg/dL
(44 to 62 mol/L). Marked dilation of the ureters (hydroureter) is caused by hormonal
influences (predominantly progesterone) and by backup due to pressure from the
enlarged uterus on the ureters, which can also cause hydronephrosis. Postpartum, the
urinary collecting system may take as long as 12 wk to return to normal.

Fig-5.5

Postural changes affect renal function more during pregnancy than at other times; ie,
the supine position increases renal function more, and upright positions decrease renal
function more. Renal function also markedly increases in the lateral position; this
position relieves the pressure that the enlarged uterus puts on the great vessels when
pregnant women are supine. This positional increase in renal function is one reason
pregnant women need to urinate frequently when trying to sleep.

21
RESPIRATORY: Lung function changes partly because progesterone increases and
partly because the enlarging uterus interferes with lung expansion. Progesterone
signals the brain to lower CO2 levels. To lower CO2 levels, tidal and minute volume
and respiratory rate increase, thus increasing plasma pH. O2 consumption increases
by about 20% to meet the increased metabolic needs of the fetus, placenta, and several
maternal organs. Inspiratory and expiratory reserve, residual volume and capacity, and
plasma PCO2 decrease. Vital capacity and plasma PO2 do not change. Thoracic
circumference increases by about 10 cm. Considerable hyperemia and edema of the
respiratory tract occur. Occasionally, symptomatic nasopharyngeal obstruction and
nasal stuffiness occur, eustachian tubes are transiently blocked, and tone and quality
of voice change. Mild dyspnea during exertion is common, and deep respirations are
more frequent.

Fig-5.6

GI AND HEPATOBILIARY: As pregnancy progresses, pressure from the

enlarging uterus on the rectum and lower portion of the colon may cause constipation.
GI motility decreases because elevated progesterone levels relax smooth muscle.
Heartburn and belching are common, possibly resulting from delayed gastric
emptying and gastroesophageal reflux due to relaxation of the lower esophageal
sphincter and diaphragmatic hiatus. HCl production decreases; thus, peptic ulcer
disease is uncommon during pregnancy, and preexisting ulcers often become less
severe.

22
 Fig-5.7
Incidence of gallbladder disorders increases somewhat. Pregnancy subtly affects
hepatic function, especially bile transport. Routine liver function test values are
normal, except for alkaline phosphatase levels, which increase progressively during
the 3rd trimester and may be 2 to 3 times normal at term; the increase is due to
placental production of this enzyme rather than hepatic dysfunction.
Endocrine: Pregnancy alters the function of most endocrine glands, partly because the
placenta produces hormones and partly because most hormones circulate in protein-
bound forms and protein binding increases during pregnancy.
The placenta produces a hormone (similar to thyroid-stimulating hormone) that
stimulates the thyroid, causing hyperplasia, increased vascularity, and moderate
enlargement. Estrogen stimulates hepatocytes, causing increased thyroid-binding
globulin levels; thus, although total thyroxine levels may increase, levels of free
thyroid hormones remain normal. Effects of thyroid hormone tend to increase and
may resemble hyperthyroidism, with tachycardia, palpitations, excessive perspiration,
and emotional instability. However, true hyperthyroidism occurs in only 0.08% of
pregnancies.
The placenta produces corticotropin-releasing hormone (CRH), which stimulates
maternal ACTH production. Increased ACTH levels increase levels of adrenal
hormones, especially aldosterone and cortisol, and thus contribute to edema.
Increased production of corticosteroids and increased placental production of
progesterone lead to insulin resistance and an increased need for insulin, as does the

23
stress of pregnancy and possibly the increased level of human placental lactogen.
Insulinase, produced by the placenta, may also increase insulin requirements, so that
many women with gestational diabetes develop more overt forms of diabetes (see
Diabetes Mellitus and Disorders of Carbohydrate Metabolism: Diabetes Mellitus
(DM) and Pregnancy Complicated by Disease: Diabetes Mellitus in Pregnancy).
The placenta produces melanocyte-stimulating hormone (MSH), which increases skin
pigmentation late in pregnancy. The placenta also produces the subunit of human
chorionic gonadotropin (-hCG), a trophic hormone that, like follicle-stimulating and
luteinizing hormones, maintains the corpus luteum and thereby prevents ovulation.
The pituitary gland enlarges by about 135% during pregnancy. The maternal plasma
prolactin level increases by 10-fold. Increased prolactin is related to an increase in
thyrotropin-releasing hormone production, stimulated by estrogen. The primary
function of increased prolactin is to ensure lactation. The level returns to normal
postpartum, even in women who breastfeed.

DERMATOLOGIC: Increased levels of estrogens, progesterone, and MSH

contribute to pigmentary changes, although exact pathogenesis is unknown. These
changes include melasma (mask of pregnancy), which is a blotchy, brownish pigment
over the forehead and malar eminences; darkening of the mammary areolae, axilla,
and genitals; and linea nigra, a dark line that appears down the midabdomen.
Melasma due to pregnancy usually regresses within a year.
Incidence of spider angiomas, usually only above the waist, and thin-walled, dilated
capillaries, especially in the lower legs, increases.

EFFECT OF PROGESTERONE
1. Reduction in the tome of smooth muscle:
Food may stay longer in stomach, nausea, peristaltic activity reduced,
water absorption in colon increased, constipation, uterine tone reduced,
uterine activity damped down. Bladder tome reduced, tone in ureters,
uterine stasis, blood vessel tone reduced, diastolic pressure lower, dialation
of veins.
2. Increase in temperature (0.5oC).
3. Reduction in alveolar and arterial Pco2 tension, hyperventilation.

24
 4. Development of the breasts alveolar and glandular milk producing cells.
5. Increased storage of fat.

EFFECT OF OESTROGENS
1. Increase in growth of uterus and breast ducts.
2. Increasing levels of prolacting of prepare breasts for lactation; oestrogens
may assist material calcium metabolism.
3. May prime receptor sites for relaxin, e.g. pelvic joints, joint capsules
cervix.
4. Increased water retention, may cause sodium to be retained.
5. Higher levels result in increased vaginal glycogen, predisposing to thrush.

Fig-5.8
EFFECT OF RELAXIN
1. Gradual replacement of collagen in target tissues (e. g. pelvic joints, joint
capsules, cervix) with a remodeled modified form that has greater
extensibility and pliability. Collagen synthesis is greater than collagen
degradation and there is an increased water content, so there is an increase
in volume.
2. Inhibition of myometrial activity during pregnancy.

25
 3. May have a role in the remarkable ability of the uterus to distend and in
the production of the necessary additional supportive connective tissue for
the growing muscle fibres.
4. May have a role in cervical ripening.
5. May have a role in mammary growth.
Weeks Details Length Weight
(cm) (g)
3 Embryo has primitive circulation 0.2
4 Head, trunk, that, tail differentiated 0.7
6 Limb buds growing 1.5
8 Now called a fetus; has eyelids, ears, external genitalia 4
12 Fingers, toes, nails, bones, cartilage forming 9
16 Moving quite strongly 16
20 Hair erupting, vermin depositing 21 500
28 Essential development complete 35 1250
36 Greatly increasing in bulk 43 2500
40 Term 50 3500

REPRODUCTIVE SYSTEM
a. The uterus increases from a pre- pregnant size of 5 by 10 cm (2 by
4 inches) to 25 by 36 cm ( 10 by 14 inches ).
b. The uterus increases 5 to 6 time in size, 3000 to 400 times in
capacity, and 20 times in weight by the end of pregnancy.
c. By the end pregnancy, each muscle cell in the uterus has
increasesed approximately 10 times its length prior to pregnancy.

URINARY SYSTEM
a. The kidneys increase in length by cm (0. 5 inch).
b. Ureters enter the bladder at a perpendicular angle because of
uterine enlargement.
c.
MUSCULOSKELETAL SYSTEM
The influences o pregnancy on the musculoskeletal system are the ones that involve
the physiotherapist most directly; first, to attempt to prevent disorders arising and
then, when problems do arise, to treat them.

26
 a. There is generalized increase in joint laxity, and so in joint rangeg, which
is hormonally mediated. Oestrogens, progensterone, endogenous cortisols
and particularly relaxin seem to be responsible to this.
b. During pregnancy it is usually necessary for a women to adapt her posture
to compensate for her changing center of gravity.
c. How a woman does this will be individual and will depend on many
factors e.g.
1. Muscle strength, 2. Joint range, 3. Fatigue and role models
d. Physiotherapists are in no doubt that for most women the lumbar and
thoracic curves are increased. Greater Lumbar lordosis was due to an
increases in the pelvic tilt.
e. Women become clumsier and inclined to trip and fall.

Fig-5.9

These factors, together with joint laxity and fatigue, particularly in the first and third
trimster, must make pregnant women more prone to injury.
f. The changing center of gravity is chiefly made necessary by the distending
abdomen. Abdomen muscles are stretched to the point of their elastic limit
by the end of pregnancy. The Aponeurosis, fibrous sheaths and

27
 intersections and the linea alba probably undergo hormonally mediated
structural change to provide the necessary temporary extensibility.

The girth of a woman of the distance from xiphisternum to symphysis pubis can be
used as a guide to fetal growth.

The distance between the two rectus abdominis muscles can be seen to widen
throughout a pregnancy and the linea alba may even split under the strain( diastasis
recti.)
g. In the trimester there is increased water retention which may result in a
varying degree of oedema of ankles and feet in most women, result in a
varying degree of oedema of ankles and women, reducing joint range.

The oedema can also cause pressure on nerves, as in carpal tunnel syndrome where
oedema in the arms and hands causes paraesthesia and muscle weakness affecting
terminal portions of the median and ulnar nerve distributions.
MUSCLOSKELETAL SYSTEM INFLUENCE BY PREGNANCY
INDUCED PATHOLOGY
DIASTASIS RECTI
Separation of the rectus abdomens muscles in the mid line at the linea alba. The
etiology of pathology is unknown, but the continuity of the abdominal wall is
disrupted.

INCIDENCE
Any separation > 2 cm. Is considered significant.

The condition is not exclusive to childbearing women but is seen frequently in this
population.

28
 Fig-5.10

Diastasis recti possibly occurs in pregnancy as a result of hormonal effect on the

connective tissue and the biomechanical changes of pregnancy.

Uncommon in the first trimester, incidence increases in the third trimester.

It can occur above, below or at the level of the umbilicus but appears to be less
common
below the umbilicus.
Less common in women with good abdominal tone.

SIGNIFICANCE
Diastasis recti may produce musculoskeletal complaints, such as low back pain as
a result of decreased ability of the abdominal musculature to control the pelvis and
lumber spine. In severe separations, the anterior segment of the abdominal wall is
composed only of skin, fascia, fat and peritoneum. lack of abdominal support
provides less protection for the fetus. It may progress to hemiation of the abdominal
viscera through the separation in the abdominal wall.

29
JOINT LAXITY
1. SIGNIFICANCE

a. All joint structures are at increased risk of injury during pregnancy and during
the immediate postpartum period.
b. The tensile quality of the ligamentous support is decreased and, therefore,
injury can occur if women are not exercises to decrease excessive joint
protection.

2. TREATMENT OF JOINT LAXITY

a. the women is thought sage exercises to perform during the childbearing year,
including modification of exercises to decrease excessive joint stress.
b. Non- weight bearing or les stressful aerobic activities such as swimming,
walking or biking be suggested, particularly for women who were exercising
minimally before pregnancy.

30
 CHAPTER-6
HIGH RISK PREGNANCY

31
HIGH RISK PREGNANCY

A. Definition
A pregnancy that is complicated by disease or problems that put the
mother or fetus at risk for illness to death., conditions may be pre-existing, be
induced by pregnancy, or be an abnormal physiologic reason during pregnancy.
The goal of medical intervention is to prevent preterm deliver, usually trough us
of bed rest, restriction of activity, and medications, when appropriate.
B. Conditions Considered High Risk

Preterm rupture of membranes

Premature onset of labor
Incompetent cervix
Placenta previa
Pregnancy related hypertension or pre-eclampsia
Multiple gestation
Diabetes

In high-risk pregnancy problems of bed bound occurs

Impairment of bed bounded patients.
Joint stiffiness and muscles aches
Muscle weakness and atrophy
Vascular complications
Decreased proprioception is distal body parts
Constipation due to lack of exercise
Postural changes
Boredom
Emotional stress: patient may be at risk of losing the baby
Guilt from the belief that some activity caused the caused the
problem or that the patient did no lake food enough care of herself.
Anxiety about her home situation or the impending birth.

32
 CHAPTER-7
CONTRAINDICATIONS FOR EXERCISE IN PREGNANCY

33
Contraindications for Exercise in Pregnancy

Haemodynamically significant heart disease

Restrictive lung disease

Incompetent cervix/cerclage

Multiple gestation at risk for premature labor

Persistent second or third trimester bleeding

Placenta praevia after 26 weeks gestation

Premature labor during the current pregnancy

Ruptured membranes
Pregnancy induced hypertension
Severe anemia
Unevaluated maternal cardiac arrhythmia

Chronic bronchitis

Poorly controlled type I diabetes

Extreme morbid obesity

Extreme underweight (body mass index < 12)

History of extremely sedentary lifestyle

Intrauterine growth restriction in current pregnancy

Poorly controlled hypertension/pre-eclampsia

Orthopaedic limitations

Poorly controlled seizure disorder

Poorly controlled thyroid disease

34
 Heavy smoker
Vaginal bleeding
Dyspnoea before exertion

Headache

Chest pain

Muscle weakness

Calf pain or swelling (need to rule out thrombophlebitis)

Preterm labor

Decreased fetal movement

Amniotic fluid leakage

Exercise may not be safe if the pregnant woman has any of the following conditions:
preterm labor in current or past pregnancies
vaginal bleeding
cervical problems
leaking of amniotic fluid
shortness of breath
dizziness and/or fainting
decreased fetal activity or other complications
increased heart rate (tachycardia)
certain health problems such as high blood pressure or heart disease
Types of exercise to avoid during pregnancy:
horseback riding
waterskiing
scuba diving
high altitude skiing
contact sports
any exercise that can cause a serious fall

35
 exercising on your back after the first trimester (because of reduced blood
flow to the uterus)
vigorous exercise in hot, humid weather, as pregnant women are less efficient
at exchanging heat
exercise involving the Valsalva maneuver (holding one's breath during
exertion), which can cause an increased intra-abdominal pressure

36
 CHAPTER-8
MANAGEMENT

37
Physiotherapy
Exercise during pregnancy and pregnancy summarized
Potential impairments/ problems of pregnancy summarized
Development of faulty postures
Upper extremity stresses caused by the physical changes of pregnancy and the
muscular requirements of infant care
Changing body image.
Altered circulation, varicose veins, lower extremity edema
Pelvic floor stress or trauma.
Abdominal muscle stretch and trauma and diastasis recti.
Decrease in cardiovascular fitness due to lack of knowledge about adequate
and safe forms of exercise.
Lack of knowledge about physical changes in pregnancy changes in pregnancy
and childbirth, Possibly increasing the change that injury induction behaviors
will occur.
Inadequate relaxation skills, necessary for labor and delivery.
Improper body mechanics.
Improper of musculoskeletal pathogies associated with pregnancy
Lack of physical preparation (strength, enduratce, relaxtion) necessary for
labor and delivery.
Unsafe progression of postpartum exercise.

EFFECT OF AEROBIC EXERCISE

1. BLOOD FLOW
it causes a redistribution of blood flow away from the internal organs and possible the
uterus and toward the working muscle. This raises two concerns that the reduction in
blood flow may decrease the oxygen and nutrient availability to the fetus and that
uterine contraction and prater labor may be stimulator.

38
 2. RESPIRATORY RATE
the maternal respiration rate appear to adapt to mile exercise but not increase
proportionately with moderate and severe exercise when compared with a non-
pregnant state.

3. HEMATOCRIT LEVEL
The maternal hematocrit level during pregnancy is lowered: however it rise up to 10
percentage points withing15 minutes of beginning vigorous exercise.
Interior vena cava compression
Compression of the inferior vena cava by the uterus can occur after the fourth month
of pregnancy, altering venous return and cardiac output. The has been suggested as a
possible cause of abruptio placentae, or premature detachment to the placenta or the
uterus.

4. ENERGY NEEDS
Hypoglycemia occurs more readily during pregnancy: therefore, adequate
carbohydrates intake is important for the pregnant woman who exercise.
a caloric intake of an additional 500 calories per day is necessary to support the
energy needs of pregnancy and exercise, as opposed to only a 30, calorie-per-day
increase for the sedentary pregnant woman.

5. CORE TEMPERATURE
vigorous physical activity and dehydration trough perspiration can cause body core
temperature to increase. Studies report hat during pregnancy the core temperature of
physically fit women decreases during exercise.
Apparently they have increased efficiency regulating their core temperature, and thus
the thermal stress on the embryo and fetus is reduced.

6. UTERINE CONTRACTION
Nor epinephrine and epinephrine levels increase with exercise.
Nor epinephrine increases the strength and frequency of uterine contractions. This
may pose a problem for the woman at risk of developing premature labor.

39
 7. HEALTH WOMAN RESPONSE
Studies have shown that healthy women who continue to run throughout pregnancy
delivery on the average of 5 to 7 days sooner coppered with control.

FETAL RESPONSE MATERNAL AEROBIC EXERCISE

No conclusive human research has proved a detrimental fetal response to mild or

moderate-intensity maternal exercise.
A 50 percent to greater reduction of uterine blood flow is necessary before fetal well-
being is affected (based on animal research). No studies have documented such
decreases in pregnant women who exercise, even vigorously.
Brief sub maximal lmaterial exercise (up to 70 percent maternal aerobic power) does
not adversely affect fetal heart rate. The fetal heart rate (FHR) will usually increase 10
to 30 beats per minute at the onser of maternal exercise. Following mild to moderate
material exercise, the FHR usually returns to normal levels within 15 minutes.
The fetus has no mechanism such as perspiration of respiration by which to dissipate
hear. But because physically fit women are able to dissipate heat and regulate their
core temperature, this is no longer considered a reason to restrict exercise.

40
 CHAPTER-9
TREATMENT GOALS AND PLAN

41
 GENERAL TREATMENT GOALS AND PLAN OF CARE
GOAL PLAN OF CARE
1. Improve pulmonary function and Breathing instruction. Coughing and / or
decrease the risk of huffing .
pneumonia
2. Decrease incisional pain associated Postoperative TENS. Support with
incision with coughing, movement, or pillow when coughing or hand when
breast feeding. exercising. regarding incisional care and
risk injury.

3. Prevent possurgical vascular Active leg exercises. Early

complications ambulation
4. Enhance incisional circulation Gentle abdominal exercise with Support.
healing; incisional prevent adhesion Scar mobilization and f massage.
formation friction

5. Decrease post surgical discomfort Positioning instruction, massage,

from and flatulence, itching, or Supportive exercise.
catheter.

6. Correct posture Positioning instruction.

7. Protected activities of daily living Instruction in incisional splinting

(ADL) and to prevent injury. Positioning for ADL. Body instruction.
mechanics

8. Prevent pelvic floor dysfunction. Pelvic floor exercises.

9. . Develop abdominal strength. Abdominal exercises.

42
Plan:

If possible, two of three classes should be attended by the women at around 6 8

weeks pregnancy for early physiotherapy advice and instruction.

Then there is usually a course of six classes of 2 hours each, once per week during the
third trimester. The physiotherapist takes 1 hour of each class and visitor or dental
hygienist.

Time of classes it is important to have different times of the day on offer, and an
evening session should be available so that fathers may attend.

43
 CHAPTER-10
AEROBICS CRITICAL AREA OF EMPHASIS AND SELECTED
EXERCISE

44
 Critical Area of Emphasis and Selected Exercise

1. Posture Exercise
2. Abdominal muscle exercise
3. Stabilization exercise
4. Pelvic motion training
5. Pelvic floor awareness training and strengthening
6. Relaxation and breathing

Suggested Sequence of Exercise Class

1. Warm up
2. Gentle selective stretching
3. Aerobic activity for cardiovascular conditioning (15 minutes or less)
4. Upper and lower extremity strengthening
5. Cool down activates
6. Abdominal exercises
7. Pelvic floor techniques
8. Relaxation techniques
9. Educational information (as appropriate)
10. Postpartum exercise instruction (e.g. when to begin exercises, how to safety
progress, precautionas) as client may not attending a postpartum class.

45
 Fig-101
Posture Exercises

a. Stretching (with caution)

(1) Upper neck extensors and scalenes

(2) Scpular protractors, and shouler internal rotators, and levator scapulae

(3) Low back extensors

(4) Hip adductors caution do not overstretch in women with pelvic
instabilities
(5) Knee flexors Caution; do not overstretch in women with pelvic
instabilities.
(6) Ankle plantar flexors
b. Strengthening
1. Upper neck flexors, lower neck upper thoracic extensors
2. Scapular retractors and depressors
3. Shoulder external rotators

46
 4. Trunk flexors
5. Hip extensors
6. Knee extensors
7. Ankle dorsiflexors

Abdominal Muscle Exercise

As pregnancy progresses, the abdominals will not tolerate strenuous exercise:
Therefore, exercise must be adapted to meet the needs of each individual. A check for
diastasis recti must always be performed before initiating abdominal exercise. The
following exercises progress from least to most strenuous.

1. Head lift
Position of woman:
Supine hook lying with her hands crossed over midline at the diastasis to
support the area. As she exhales, she lifts only her head off the floor or until the point
just before a bulge appears. Her hands gently pull the rectus muscles toward mid
line. Then have the women lower her head slowly and relax. This exercise emphasizes
the rctus abdomens muscle and minimizes the oblique.

2. Head lift with pelvic tilt

Patient position:
Supine hook lying. If diastasis recti is present, the arms are crossed over the
diastasis and pulled toward mid- line. She lift her head of the floor while performing a
pelvic till then slowly lowers her head and relaxes. All abdominal contractions should
be performed with an exhalation so that intra- abdominal pressure is minimized. Only

47
this exercise and / or the head life should be used until the separation is corrected to 2
cm, or 2 cm finger widths.

b. Leg Sliding
(1) Patient position
hook lying with pelvis in posterior tilt. The woman halds the pelvic till as she slides
one foot along the floor until the leg is straight. She stops sliding the floor at the point
in which she can no longer, hold the pelvic tilt. Slowly she lifts the leg and brings it
back to the starting position, then repeats with the other leg. Breathing should
coordinated with the exercise so that abdominal contraction with exhalation.

(2) This exercise can be performed with both legs at the same time if abdominal
muscles can maintain the pelvic tilt through the entire exercise.

c. Quadruped pelvic tilt exercise

(1) Patient position:
all fours position on hand sand knees. Instruct her to perform a posterior
pelvic tilt. While keeping her back straight, she sucks the abdomen in and holds. Then
she releases and performs an anterior tilt through partial range.

d. Trunk curts

48
 (1) Curt downs and curl ups are classic abdominal exercises for recturs
abdominal strengthening and can be used if tolerated and no diastasis recti is present.
Protect the linea alba with crossed hands while performing trunk curls.

(2) Diagonal curls are carried out to strengthen the oblique muscles. The women
lifts one one shoulder towards the outside of the opposite knee as she curls up and
down and protects the linea alba with crossed hands.

Resisted posterior pelvic tilt

The woman is supine with the lower extremities elevated to 90 degrees. She lifts the
lower extremities upward as the pelvis comes up off the floor. When this exercise
becomes difficult to accomplish during the third trimester as the uterus enlarges and
pushes and pushes and the diaphragm,. It should not attempt. Once the woman learns
pelvic title control postpartum this exercise may be resumed.

The woman if supine with one lower extremity flexed and the other partially
extended. The lower abdominals stabilize the pelvis against the varying weight if the
lower extremities as they are flexed and extended and alternating pattern as if cycling.
The further the lower extremity extend, the greater the resistance.

Leg-lowering exercise cause excessive strain on the low back and should not be
performed during pregnancy: they may be resumed postpartum. The legs should be
lowered only through the range in which control of the posterior pelvic tilt and
flattening on the low back in maintained. It it low back strain is felt to the lumbar
spine begins to arch, this exercise should not be performed.

Stabilization exercises

These may be performed throughout the pregnancy and postpartum period.

Precautions:

49
(1) Because the trunk muscles are contraction isometric ally while stabilizing there is
a tendency to hold the breath; this is detrimental to the blood pressure and heart rate.
Caution the woman to maintain a relaxed berating pattern and exhale during the
exertion phase each exercise.

(2) If diastases recti are present, adapt the stabilization exercises to protect the line
alba as described previously.

Pelvic motion training

These exercises are used to develop proprioceptive awareness and control of pelvic
motions.

Pelvis clock
Patient position: supine hook-lying instruct the woman to imagine her pelvis as the
face of a clock. The top of the clock is the pubic symphysis and the bottom is sacrum.
She slowly rotates the pelvis in a clockwise motion. Keeping the movement smooth,
then reverses and rotates the pelvis smoothly in a counterclockwise directions.

Pelvic clock progressions

The exercise, once masters, can also be performed in the side-lying, all fours, sitting,
or standing position.

Modified upper and lower extremity strengthening:

50
As the abdomen enlarges, it becomes impossible to comfortable assume the prone
positions. Exercises that are usually performed in the prone position must be
modified.
Standing push-ups

Patient position:
Standing facing a wall, feet pointing straight forward, a shoulder- width apart, and
approximately an arm-length away form the wall. The palms are placed on the wall at
should height. Have the woman slowly bend the elbows., bringing her face close to
the wall, maintaining a stable pelvic tilt, and keeping the heels on the floor. Her
elbows should be shoulder height. She then slowly pushers with her arms, bringing
the body back to the original position.

Hip extension
(1) Supine bridging
(2) All-fours leg raising

Patient positions

On hands and knees (hands may be in fists or palms open and flat). Instruct the
woman to first perform a posterior pelvic tilt, then slowly lift on leg, extending the hip
to a level no higher than the spine while maintaining the posterior pelvic tilt. She then
slowly lowers the spine while maintaining the posterior pelvic tilt. He then slowly
lowers the leg and repeats with the opposite side. The knee may remain flexed or can
be straightened throughout the exercise.

Pelvic floor awareness training and strengthening

a. Isometric exercise
(1) patient position : supine or side lying positions are the easiest in which to
begub; progress to sitting standing.
51
(2) instruct the woman to tighter the pelvic floor as if attempting to stop urine
flow, hold for 3 to 5 seconds and relax. The bladder should be empty when
performing this execise.

(3) This training is valuable in preventing or treating incontinence and a leaky

bladder. Which may occur with coughing, sneezing, laughing or other straining
activates. Instruct the women to use this technique and practice sphincter control by
attempting to stop her flow intermittently when using the bathroom.

(4) The pelvic floor muscle are highly fatigable. Contractions should not be held
longer than 5 seconds and with a maximum of 10 repetition per session /when
fatigued, substitution of the gluteals, abdominals, or hip adductors may occur.

b. Elevator (graded isometric) exercises

(1) Instruct the women to visually imagine riding in an elevator. As the elevator
goes from one floor to the next, contract the pelvic floor muscles a little more.

(2) Relax the muscles gradually, as if the elevator were descending one floor at a
time.

c. Modified squatting

These exercise are used to strengthens the hip and knee extensors for good body
mechanics and also to help stretch the personal area for flexibility during the delivery
process.

(1) Instruct the woman stand with feet a shoulder width apart or wider, facing a
counter, chair, or wall on which she can rest her hands for support. The slowly squats
as far is comfortable, keeping knees apart and over the feet and keeping the back
straight. To protect her feet, she should wear shoes with knee problems should
perform only partial range of the squart.

52
(2) Wall slides. The women stands with her back against a wall and her feet
shoulder- width apart. She slides her back down the wall as her hips and knees flex
only as far as comfortable , then slides back up.

d. Scapular retraction

When scapular retraction exercises become difficult in the prone position the women
should continue strengthening in the sitting positions

Perineurm and adductor flexibility

In addition to the modified exercises described above, these flexibility exercises
prepare the legs and pelvis for childbirth.

a. Self - stretching
The women is positioned supine or side lying and is instructed to abduct the hip and
pull the knee toward the sides of her chest and hold the position for as long as
comfortable.

b. Sitting
Have the woman sit on a short stool with hips abducted and feet flat on the floor.

Relaxation and Breathing

a. Mental imagery

53
Use music and verbal guidance. Instruct the women to concentrate on a relaxing
mental image. Suggest that the focus on the image during the relaxation training so
that the image can be called up to the conscious when recognizing the need to relax.

b. Muscle setting
(i) Have the woman lie in a comfortable position.
(ii) Have her begin with the body. Instruct her to gently lighten and then relax first
the muscles in the feet, then tights, pelvic floor and buttocks.
(iii) Next progress to the upper extremities and trunk, then to the head .
(iv) Reinforce the importance of remaining awake and aware of the sensations of the
muscles contracting and relaxing.
(v) Add deep, slow, relaxed breathing to the routine.

c. Selective tension
Progress the training by emphasizing awareness of muscles contracting in one part of
the body while remaining relaxed in other parts. For example, while she is tensing the
fist and upper extremity, the feet and legs should be limp. Reinforce the two
sensations and ability to control the tension and relaxation.

d. Breathing
Slow, deep diaphragmatic breathing is the most efficient method for exchange of air
of use with relaxation techniques and for controlled breathing during labor.

(1) The woman is taught relax the abdomen during inspiration so that it feels as
though the abdominal cavity is filling up. During exhalation, m muscles is not
necessary with relaxed breathing.

(2) Toa void hyperventilation, avoid deep, rapid breathing. Caution the woman to
decrease the intensity of the breathing if she experiences dizziness or feels tingling in
the lips and fingers.

e. Pelvic floor relaxation

54
(i) The woman is instructed to contract pelvic floor as in the strengthening exercise,
then allow total voluntary release and relaxation of the pelvic floor.

(ii) The activity is coordinated with breathing. The woman is instructed to

concentrate on a slow, deep breathe and allow the pelvic floor to completely relax.

f. Relaxation and breathing during labor

(1) First stage.
Once labor begins, the contraction of the uterus progress relaxation during the
contraction becomes more demanding provide the women with suggested techniques
to assist in relaxation.

(a) Have moral support from the father, family member, or special friend to provide
encouragement and assist with comfort aids.

(b) Seek comfortable position including walking or lying on pillows, include gentle
motions such as pelvic rocking.

(c) Breather slowly with each contraction; use the visual imagery and relax with
each contraction. Some woman find it helpful to focus their attention on some visual
object. Other suggestions includes singing, talking or moaning during each
contraction to prevent breath holding and encourage slow breathing.

(d) During the transition (near the end of the first stage) there is often an urge to
push. Teach the woman to use quick blowing techniques, using the cheeks, not the
abdominal muscles, to overcome the desire to push.

(e) Massage or apply pressure to any areas that hurt such as the low back. Using the
hands may help distract the focus from the contraction.
(f) Apply local or cold to local symptoms; wipe off the face with a wet wash cloth.

(2) Second State:

Once active in the birth process by assisting the uterus during a contraction in
pushing the baby down the birth canal.
55
(a) While bearing down, the woman takes in breath, contracts the abdominal wall,
and slowly breathes out,. This will cause increased pressure within the abdomen along
with relaxation of the pelvic floor. Precaution: if the woman holds her breath, there
will cause increased tension and resistance in the pelvic floor. In addition, exertion
with a closed glottis, known as the Valsava maneuver,. Has adverse effects on the
cardiovascular system.
(b) For maximum efficiency the woman should maintain relaxation in the
extremities, especially the legs and perineum, keeping the face and jaw relaxed assists
with his.
(c) Between contraction, total body relaxation should be performed.
(d) As the baby is delivered, the woman should be instructed the pelvic floor as it
stretches.
Other Intervention Application of TENS and Massage
Ideally TNS should be discussed and experienced as a possible analgesic for labor
during antenatal classes. It can be describe as a pain relieving stimulator.
The intensity of labor pain experienced varies from woman to woman, and from labor
to labor in the same women. The three Ps: power (uterine contractions), pelvis (its
shape and size), and passenger (the presentation and size of the baby) will all play a
part I the length invasive analgesia. TNS may give sufficient additional analgesia
(combined with relaxation, breathing, massage, positioning mobilizing etc.) to enable
a mother to deal with her contractions without drug.

TNS gives adequate pain relief during the latent of labor this could possible influence
both the length of labor, the mode of delivery and even the condition of the new born
infant. TNS may continue to be sued it the mother opts to have additional help in the
form of poethidine or Entonox. It may be helpful to retain TNS for delivery
suturing, and it can be useful for woman experiencing serve after- pains in the early
puerperium.

Electrodes Positioning
Early reports suggested that electrodes should be positioned on the mothers back,
paravertebrally, over the dermatomes T10-L1. The innervations of the uterus and
cervix. These were used during the first stage of labor. For the second stage,

56
additional electrodes over the dermatomes S2-S4, the innervations of the birth canal
and pelvic floor, were brought into use.
MASSAGE IN LABOUR
Woman who have experienced skilful massage during labor often say, afterwards
how helpful and pain relieving it was. Although no controllers trials have as yet been
conducted to determine the exact neuropsychological mechanisms by which massage
moderates pain, it is indisputable that rubbing very often makes it better. Before the
advent of the use of anesthesia during labor in the mid-nineteenth century, midwives
and labor supports had little else to offer.
It is probable that the soothing sensory input from stroking, effleurage and kneading
activates the gate closing mechanism at spinal level age and kneading activates the
gate closing mechanism at spinal level. It may also a possible by means of tissue
manipulation to stimulate the release of endogenous opiates.
The Back
Back pain is experienced in the lumbosacral region, and it intensifies as labor
progresses. Stationary kneading, single- handed or reinforced with one hand, over the
other, applied slowly and deeply t the painful area if often helpful. Elbows should be
bent, and the masseur shoed use his or her own body weight combined with a gentle
rotary movement to apply comfortable pressure, without fatigue, for a long period.
Partners and inidwives must be warned how easy it is to increase pain by over
enthusiastic and vigorous work. Double handed kneading with loosely cleansed fists
directly over the sacroiliac joints may be necessary as the pain becomes more sever.
Effleurage from the sacrococcygeal area, up and over the iliac crests, will be even
more soothing it a little talcum powder is used to overcome the effects of sweating.
Slow rhythmical longitudinal stroking, from occiput to coccyx, single or double
handed, can relive tension and facilitate relaxation. The strokes may be applied.

Exercise That Are Not Safe During Pregnancy

1. Bilateral straight leg raising

57
The exercise typically place more stress on the abdominal muscles and low back than
they can tolerate. It can causes back injury or diastases recti and there fore should not
be attempted.
2. Fire hydrant exercise
This exercise is perfumed on hands and knees. With the hip and knee flexed, the hip is
abducted. If the leg elevated too high, compression of the SI joint can occur. The
exercise can be performed safely if hip abduction remains with in the physiologic
range. It should be avoided by any woman who has pre- existing SI joint symptoms.
3. All fours hip extension
This exercise can be performed safely. It becomes unsafe and can cause low- back
pain when the leg is elevated beyond the physiologic range of hip extension, coursing
the to anteriority and the lumber spine to hyperextend.
4. Unilateral weight bearing activities
Weight bearing on one leg (which includes slouched standing with the majority of
weight shifted to one leg and the pelvis titled down on the opposite side) during
pregnancy can cause SI joint irritation and should be avoided by women with pre-
existing SI joint symptoms. Unilateral weight bearing also can cause balance
problems due to the increasing body weight and shifting of the center of gravity. This
posture becomes a significant problem postpartum when the woman carries her
growing child on one hip. Any asymmetries becomes accentuated symptoms develop.
Significance To Physical Therapists
Woman who have had cesarean deliveries still require pelvic floor rehabilitation.
Many women experience a lengthy labor and trial pushing before a cesarean section is
deemed necessary. Therefore, the pelvic floor musculature and tissue are not spared
the stress of labor. Also pregnancy itself creates significant stress on the pelvic floor
musculature and tissues.
Rehabilitation of the patient who has had cesarean delivery is essentially the same as
that of the patient who has a vaginal delivery. However, a cesarean section is major
abdominal surgery with all the risks and complication of such surgeries. The patient
with a cesarean section will also require general post surgical rehabilitation.

Many childbirth preparation classes do not adequately educate and prepare couples
ples for the experience of a cesarean delivery. As a result, the patient with a cesarean

58
section frequently feels as if her body has failed her, causing her to have more
emotional changes than has experienced a more traditional delivery.

Suggested Activities for the Patient with a Caesarean Section

1. Exercises
a. The woman should during be instructed to begin preventive exercises as soon
as possible during the recovery period.
1. Initiate ankle pumping, active lower, extremity range of motion, and
walking to promote circulation and venous stasis.
2. Initialed pelvic floor exercises to regain tone and control of the
muscles of the perineum.
3. Deep breathing and coughing or huffing is used to prevent pulmonary
complications.
2. Coughing ad huffing
59
 a. Coughing is difficult because of pain. An alternative is huffing. A huff is a
forceful outward breath using the diaphragm rather than the ab dominals to
push air out of the lungs. The abdominal are pulled up and in, rather than
pushed out, cousing decreases pressure in the abdominal cavity and less
strain on the incision.
b. Huffing must be done quickly to generate sufficient force to expel mucus.
c. Patient instructions
(1) Support the incision with a pillow or the hands.
(2) Say ha forcefully while pulling in the abdominal muscles.

3. Exercise to relive intestinal gas

a. Abdominal massage or kneading while lying on the left side.
b. Pelvic titling and / or bridging (can done in conjunction with massage).
c. Bridge and twist.
d. Partial abdominal curl- up.

4. Scar mobilization
Cross-friction massage should be initiated as soon as sufficient healing has
occurred. The will minimize adhesions that may contributed to postural problems and
back pain.
Physiotherapy in High Risk Pregnancies
Goal Plan of care
1. Decrease stiffness. 1. Positioning instruction.
2. Maintain muscle length and bulk 2. Stretching and strengthening
exercises
and improve circulation. Within limits imposed by the
physician.
3. Improve proprioception. 3. Movement activities for as many
body
part as possible.
4. Improve posture within available limits. 4. Posture instruction, modified as
necessary
based on allowed activity level.

60
 Bed mobility and transfer
techniques if able.
5. Relieve boredom. 5. Vary activities and positioning for
exercises.
6. Stress management and enhanced relaxation. 6. Relaxation techniques
7. Prepare for delivery. 7. Childbirth education, breathing
training, and
exercise to assist and prepare for
labor.
8. Enhance postpartum recovery. 8. Exercise instruction and home
program for
postpartum period. Body mechanics
instruction.

Suggestions for Exercise Programs with high Risk pregnancy

1. Positioning instructions
a. Left side lying to prevent vena cava compression, enhance cardiac
output, decrease lower extremity edema.
b. Pillows to support body parts and enhance relaxation.
c. Supine positioning for short period, with a wedge placed under the right
tip to decease inferior vena cava compression.
d. Modified prone positionoining( side lying, partially rolled prone, with
pillow under abdomen ) to decrease low-back discomfort and pressure.
2. Range of motion instructions
a. Active range of motion (ROM) of all should be included.
b. Motion should be slow, no stressful, and through the full range if possible.
c. Teach in a gravity neutral position if antigravity ROM is too stressful.
d. The number of repetitions and frequency needs to be individualized to the
womans condition.
3. Suggested exercises
a. Lying
(1) supine or side lying with alternate knee to chest.
61
 (2) ankle pumping
(3) shoulder, elbow, and finger, flexion and extension; reach to ceiling;
arm circles
(4) unilateral straight le raise in supine or side lying position.
(5) bilateral active ROM in diagonal patterns for the upper and lower
extremities.
(6) lower extremity abduction and adduction.
(7) pelvic tilt. bridging, gluteal setting.
(8) abdominal exercises (check for diastasis); these should be very mild
and closely moneitored
(9) pelvic floor exercises.
b. Sitting (may not be allowed)
(1) Feet dangling over edge of bed.
(2) hip adductor and internal rotator stretch; tailor sitting
(3) upper extremities
(4) active ROM through diagonal patterns for upper and lower
extremities
(5) ankle pumping exercises
(6) alternate active ROM knee flexion and extension
(7) knee extension with ankle dorsifelxed to stretch hamstrings and
heel cords.
(8) arms reaching towards ceiling, then out to the side arm circle
added
(9) scapular retraction with hands behind the head.
(10)cervical ROM emphadizing flexion and lateral bening
c. Ambulation (almost always contraindicated when allowed usally will be only
to use bathroom)
(1) Good posture in ambulation
(2) tip toe o heel walking
(3) gentle partial range squatting to stretch quadriceps
(4) lower extermity rotation
4. Relexation techniques
5. bed mobility and transfer activities
a. moving up down side to side in bed
62
 b. rolling incorporate neck and upper and lower extremities to aid movement.
c. supine to sitting, assisted by arms.
6. preparatoion for labor.
a. relaxation technique
b. modified squatting supine sitting or side lying with knees to chest
c. pelvic floor relaxaion
d. breathing exercises
7. postpartum exercise instruction
exercise for postpartum period
Type Of Exercise

aerobics
this types of exercise increases the key benefits
heart rate and the supply of oxygen to invreases the heart rate
the muscles it will make you breathe increase the supply of oxygen
harder to the muscles
Boots the metabolism
Builds stamina
help reduce weight by
burning fat over a sustained
period.
produces endorphins in the
brain which create the feel good
factor.
aerobic activites
jogging, skipping, runing cycle walking rebounded, step most sport

63
64
 Pilates Key benefits;

pilates key benefits;

this is modetrn system of body
maintenace that soordinates body
mind and spirit. it works on the
theory of naturally correct alignment.
lengthens short muscles.
strengthens weak muscles
improves the quality of the
movement.
focses on the core postural
muscle to stabilize the body.
works to place the breath
correctly
aids mental relaxation

alexander technique key benefit

this is ktherapy basses upon the posture Corrects posture.
of the body in particular the back it Improves quality of
teaches you how to realign your body movement.
and make subtle changes to your daily Lengthens muscles.
positions such as sitting, standing and Improves energy flow
bending down. Aids mental relaxiation

yoga key benefit

yoga is a form of exercise that works Increase mobility in the
on developing muscle and buliding joints and muscles.
stength and stamina throrgh strecthes. Develops the cordination
the performance of these body it can be of muscles.
a very tough form of exerices that place Increases mind body
great demand on the muscles. awareness .
Increases steaming.
Increases strength.
Aids relaxation.

65
For Rectus Muscle Distension
1. lie on your back with the knees bent or sit or stand
2. pull in your abdominal and hold for a count of five. lnhale as you
pull the muscles in and hold them.
3. release the muscles while exhaling

This excises can be performed standing

1. pull in the abdominals and hold for a count of 5.
2. Release the muscles.

oblique curl ups

1. Lie on your back with knees bent hip width apart and the lower back pushed
into the floor.
2. Breathe out and lift your shoulders head and neck but keep your chin tucked
towards your chest.

ankle Rotation
1. Lie on the bed or on the floor with the legs extended
2. Lift and circle the right ankle five times anticlockwise then five times
anticlockwise then five times clockwise.
3. Return the leg to the floor
4. Lift and orate the lift ankle five times in each direction

Breast-feeding techniques
be aware of your posture during breast feeding. sitting with the back unsupported and
unsupported and allowing the shoulders to roll forwards will cause your to slouch
restricting the blood supply. the baby necks to be supported on a pillow or cushion a d
your back should also be supported.

Breathing techmique
66
1. with feet hip whdth apart and arms loose by your side check your posture.
your back should be straight. shoulders relaxed but feeling streched downwards and
chest open.
2. inhale through your noise and feel the air travel down to your lungs. allow the
fungs to open and expand sideways. feel the tension in the fungs as you increase the
amount of oxygen to them.
3. hold the breath for a count of five
4. release the breath and as you axhale let the jaw drop forward and down. allow
the jaw to stretch and push the air out of the lungs until you feel that there is
absolutely no more left. your will be amazed how much air is exhaled. the mouth
should be open and relaxed and you will hear the breath as your exhale.
5. relax for a moment before your repeat the whole process again.
6. try this breathing for five breaths and then rest you should relaxed and
restored.

67