Back Care & Lifting
Back strain is minimized when the spine is held in its normal curves, but spinal posture has to change with pregnancy. The center of gravity moves forwards and there is a tendency to an increased lumbar curve with consequent stress on the posterior muscles and ligaments. It is important to teach the woman how to adopt positions which minimize stress and to change position regularly posture advice is given in different positions. Attention to good posture has been shown to reduce the incidence of backache in pregnancy. Standing– stretch head up out of shoulders. Feel baby sit in the pelvis, pull in abdominal muscles, tighten buttocks. Feel poised, release tension without sagging. Avoid transferring the weight through one leg for long periods of time. Lean back against a wall or chair back for support if standing is essential and try to go up and down on the toes several times to keep the circulation moving and ease muscle tension.

Sitting–Practice sitting back into the chair so that it feels as if the weight of the baby is taken on the seat, and try to have the feet well supported–on a little stool if necessary. A small cushion should be placed in the back to preserve a slight lumbar curve and reduce the stretch on the posterior spinal structures. It is also important when resting in sitting to have the legs supported in slight elevation or at least horizontal.

Sleeping positions–In pregnancy, sleeping positions may have to be altered because of the body's weight gain and altered shape (lying prone is not possible). For most women, quarter–turn from prone (recovery position) is acceptable as the weight of the baby is taken on the bed. When a pillow under the abdomen and another under the top knee the position can be very comfortable. Sleeping supine should be avoided but, if necessary, a pillow under the thighs and another under the head and shoulders will ensure flattening and support of the lumbar spine. When changing position in bed, e.g. turning, keeping the flexed knees together reduces the strain in the sacroiliac joint. While getting in and out of bed the woman should go into side–lying and avoid abdominal strain from sitting up or lying straight down.

Lifting advice–This involves lifting from a height and carrying as well as lifting from the ground level. The principles to follow are never stoop, feet should be apart to increase the base, and any object to be lifted must be held close to the body (if held at arm's length the leverage on the spine causes high loading of the spinal extensors ). When lifting from the floor, it is important to ensure that the weight is light enough to be lifted comfortably. It may be advisable to lift in stages such floor to chair and then chair to upright. Later in the pregnancy, it is inadvisable to stand on high stools or to climb step–ladders because balance is less secure with the center of gravity moved forward.

Cramp–This occurs most commonly in the calf muscles often at night or after a period of rest. It can be relieved by slow sustained stretch on the muscles pushing the foot and ankle into dorsiflexion. Some people find that it is possible to prevent cramp by performing foot exercises just after getting into bed and when turning in bed to keep the feet in dorsiflexion. Bladder control–Strong pelvic floor muscles are needed to support the ever–increasing weight. If these muscles are weak a slight dribble of urine can occur when the abdominal pressure is increased, for example in coughing, sneezing laughing or lifting. Previous pregnancies make the woman more likely to have this problem.

The Treatment is Pelvic Floor Exercises:
The woman is instructed to tighten and pull up muscles, hold for a count of 4 and rest; repeat six times. Since these muscles fatigue easily with voluntary exercise only 4–6 isometric contractions should be performed at any one time, but frequent practice throughout the day is essential. Once mastered, the exercise can be performed with the woman in any position; but to start with sitting on a hard chair with knees apart, leaning forwards so that the perineum is in contact with the chair seat.

Relaxation Techniques
Antenatal care
Neuromuscular tension control. The physiotherapist must leach the woman how to recognize tension and how to deal with it. At first it is helpful to practice relaxation in lying. The woman is taught to tighten the muscles opposing the tension position:

1. Push the legs into the supporting surface, feel the support, now stop pushing and register the comfort.
2. Stretch the hands and elbows, push the arms into the floor, feel the support and then stop pushing.
3. Push the shoulders down, feel that they are comfortable and stop pushing.
4. Push the head down into the pillow, stretch the head out of the neck (feel that this is comfortable) and then stop pushing and stretching.
5. Face and jaw. Feel smoothness over the face and up over the head. Open mouth like a yawn and rest, to release clenching of the teeth.

Physiotherapy for Antenatal Care
Teaching Positions for Labor
First stage (waiting for cervical dilatation)
Remaining upright and mobile with gravity assisting fetal descent can make contractions more effective and possibly less painful. The following may be helpful:

• Walking about, changing to leaning forwards on a support during contractions when necessary.
• Sitting comfortably, leaning on a table or using the chair back and sitting astride the chair seat or use a rocking–chair.
• Kneeling leaning forward with the forearms and trunk on a back of pillow, Big bean pillow or bed backrest.

As labor progresses fatigue sets in and rest is essential in side–lying, quarter–turn from prone or tailors position. Relaxation techniques can then be used as already described to preserve energy between contractions. It is helpful to imagine a contraction coming on and to practice breathing, rocking or touch and massage techniques already described.

Second stage (expulsive effort of giving birth)
Midwife and physiotherapist together describe the sensations of the expulsive effort and of giving birth. Most women sit supported in bed in a modified squat position, but some use side–lying and a few use kneeling or a childbirth chair. The midwife explains the various type of obstetric assistance available (episiotomies, caesarean section, forceps delivery) as well as the forms of pain relief (pethidine injection, nitrous oxide plus oxygen inhalation, spinal epidural). This enables the woman to understand the effects and implications of these procedures and to participate in the choice when the time comes. The physiotherapist may teach the woman how transcutaneous electrical nerve stimulation (TENS) may be used to relieve pain during the birth.


Physiotherapy for Postnatal Care
Aims of Physiotherapy
Pelvic floor muscles
It is important to start pelvic floor exercises within 6 hours of the delivery to regain the strength of these stretched muscles as soon as possible. The contraction may be felt only around the anus because the perineum is numb but antenatal practice helps as the mother knows what to aim for. The physiotherapist needs to encourage the mother to practice the contractions four or five times at frequent intervals throughout the day. The mother may be afraid to try because of the post delivery discharge (lochia) or because of stitches or pain. It helps, therefore, to explain that the exercises will increase the circulation, promoting healing and removing inflammatory exudates which will in turn relieve pain, because the muscles have been stretched it is important to tighten and relax slowly. As feeling returns, the mother can gauge the recovery of strength by trying to arrest urine mid–flow. The number of contractions should be increased to 50 per day in small groups of five at a time and linked to a daily activity, e.g. when washing hands, getting out of a chair, or feeding the baby. At the 6–week postnatal appointment the obstetrician will check the perineum for healing, the vaginal opening for size, the cervix for erosion and the muscles for strength. If on testing at 12–16 weeks for stress incontinence there is a problem, the mother is referred for out–patient physiotherapy. Interferential therapy is very useful in re–educating the pelvic floor muscles (see stress incontinence). Pelvic floor exercises should be continued indefinitely to reduce the likelihood of stress incontinence in later life. The suggested ultimate test for incontinence is to try jumping up and down (2–3 hours after passing urine) and coughing at the same time to raise the intra–abdominal pressure.

Strengthening the abdominal muscles
Immediately after the birth, the muscles are slack, and intra–abdominal pressure is reduced. At first the uterus remains above the pelvic rim and the woman is concerned about looking 5 months pregnant. Involution of the uterus is generally complete in about 14 days but the abdominal muscles nay take 6 weeks to return to the pre–pregnant state and it can be 6 months before full strength is returned.

Care of the back must be explained, e.g. rolling onto the side to get in and out of bed, avoiding straight sit–ups, lifting as already taught, because the normal support of the abdominals for the lumber spine is diminished and the ligamentous laxity still present renders the spinal structures more vulnerable to strain.
Suitable strengthening exercises are:

• Crook lying, pelvic tilting.
• Crook lying, back flattening, hold to count of 4 and rest–progress to holding for 10.
• Crook lying, back flattening and, keeping the back flat, slide the heels slowly down the bed and slide slowly back.
• Crook lying, tighten abdominal muscles, lift head and shoulders and lower slowly. (There may be a couple of pillows under the head to start with which are removed as the muscles become stronger).
• Half crook lying, hip hitching on the side of the straight leg.
• Sitting, trunk bending side to side.
• Crook lying. knees rolling from side to side.
• Sitting, trunk turning from side to side.
• To work the hip extensors which help to maintain the backward/forward pelvic tilt.
• Prone lying, alternate leg raising and lowering.
• Prone lying, tighten buttocks, hold for count 10 and rest.

Physiotherapy following cesarean section
First day

1. Breathing exercises.
2. Huffing with a pillow held over the wound.
3. Foot and leg exercises are performed to assist circulation.
4. Teach mother how to move about and to roll on to the side for getting in and out of bed.
5. Feeding the baby in bed–have a pillow under the thighs to prevent sliding down and an extra pillow under the knee on the side of feeding.

Second day

1. Add pelvic floor exercises.
2. Straight abdominal exercises.
3. Pelvic tilting.
4. Continue deep breathing exercises.
5. Standing, stretch tall, tighten buttocks.
6. Walk tall to prevent backache.

Subsequent days

1. Progress exercises along the same lines as for vaginal delivery.
2. Stitches are generally out by 7 days.
3. Abdominal contractions are very important to maintain mobility of the healing tissues as well as increasing circulation to promote healing.

Feeding the baby
A variety of positions can be tried:

1. Sitting in bed, back supported, bend the hip and knee on the side the baby is feeding. Side–sitting can be tried.
2. Sitting on chair back supported, support one foot on a stool–on the side the baby is feeding.
3. Sitting tailor position may be used with the back supported.
4. Side–lying in bed can be used but is not easy for first–time mothers.
5. Checking suitable heights. When bathing or changing the baby arrange an easily accessible height. Stooping must be avoided–kneel down instead.

Carrying the baby
Carrying the baby close to the body is important for security and well–being of both mother and baby. Over the shoulder is a natural position for carrying. Holding the baby on one hip for too long can cause a strain on the back. mother spending with child

Postnatal exercises from 6 weeks to 6 months
It is important that the mother can fit exercise into a busy day and that she can combine her own programs with baby play. For exercises in crook lying the baby can lie prone on the mother’s tummy and chest. During exercise in prone kneeling the baby can lie between the mother’s arms. Suitable exercises are back humping and hollowing, pelvis swinging from side to side and alternate leg stretching backwards with abdominal contractions. In standing, the baby can be held in the arms and the mother bends and stretches the knees and hips with her back against a wall. Abdominal and pelvic floor contractions and pelvic tilting can be performed during activities such as washing dishes or queuing at a supermarket.