# Presentation: 524510

## The Postpartum Mom

- Megan Horeis MSPT, ICCE

## Objectives

- Course Participants will be able to identify musculoskeletal pain in their patients related to pregnancy and postpartum.
- Participants will be able to evaluate and treat diastasis recti and other abdominal conditions.
- Participants will demonstrate correct technique for scar mobilization.
- Participants will be able to teach kegel exercises correctly and efficiently.

## Musculoskeletal Conditions seen in Pregnancy and Postpartum

- bony pelvic malalignment
- perineal trauma
- diastasis recti, abdominal trauma
- change in arch support, ligamentous support of feet and ankles
- malalignment of ribs
-  back pain related to poor posture, infant care, post epidural

## Pelvic Malalignment

- Symptoms: antalgic gait, pain with unilateral weight bearing, transitional pain, dyspareunia, generalized low back and buttock pain, PSIS pain
- Treatments:  postural realignment, binders, massage, ice/heat, stabilization exercises, PT referral

## Back Pain

- Posture, Posture, Posture
- Exercise
- Heat/Ice
- Ergonomic Changes (carrying and lifting, child care)
- Weight control
- Breast support

## Perineal Trauma

- Alternate Ice (frozen sanitary napkins) and heat
- Scar massage (starting 2-3 weeks after delivery)
- Ultrasound (need PT referral)
- donuts (to sit on)
- Instruct patient in kegel exercises
- Early movement (too much sitting can decrease blood supply)

## Diastasis Recti

- Separation of rectus abdominus from external obliques at linea alba.
- To Measure:  have patient in supine, lifting head and scapula off of table.
- Measure 4 cm above, at, and 4cm. below umbilicus: determine separation width using # of finger breadth.
- Measure at rest and contracted. Must have a measured width and depth to be a diastasis recti.

## Diastasis Recti

- May be observed as early as the second trimester.
- Can affect delivery by causing ineffective pushing
- Can be a cause of LBP, urinary incontinence, abdominal pain, abnormal postures

## Correction of a Diastasis Recti

- Shortening Contraction
- Binder
- Approximation: *wrap sheet around abs and pull tightly to try and approximate fibers*
- Isolated correct contraction with diaphragmatic breathing:  *breathe in, push belly out, breathe out, pull belly in*

## Post Cesarean Rehabilitation Goals/Outcomes

- Decrease Incision Pain
- Prevent respiratory and circulatory complications
- Minimize bowel gas retention
- Strengthen pelvic floor muscles
- Correct posture and body mechanics
- Mobilize scar release
- Strengthen and shorten abdominals

## Abdominals after Cesarean Birth

- Educate patient in deep breathing exercises same day post-op.
- Educate patient to attempt to tighten muscles before movement, huffing
- Scar Massage: 5-15 minutes daily. Start asap after surgery staying 1-2 in. from incision.
- Abdominal isometrics and massage left to right to minimize gas pain

## Scar Massage

- Immobile scars (abd. and pelvic) can cause chronic abdominal, pelvic, and back pain.
- Begin scar massage as soon as possible after surgery.
-  Stay 1-2” from scar until all scabs have fallen off naturally.
- Start gently and progress slowly to deeper and stronger massage
- When the scab falls off and there is no seepage you can massage scar directly.

## Variations of Scar Massage

- _Circles_:  1-2fingers deep all over abdomen
- _Bowel Stimulation_: counterclockwise motion from right hip to left hip
- _Desensitization_: helps patient feel more at ease touching scar
- _Push and Pull_: Frees up stuck scar tissue
- _Skin-Rolling_: Roll and Raise the scar
- _Plucking_: Pick up the scar from underlying tissues.

## Pelvic Floor Rehab

- 80% of all pregnant/postpartum women experience some form of incontinence during pregnancy.
- A study by Wilson et al (1996) showed a reduction  in the prevalence of UI postnatally in women who had performed pelvic floor exercises antenatally.
- The use of PFE’s is the main non-surgical treatment for UI and has been shown to be more than 80% effective.

## How to teach PFE’s (Kegels) Correctly!!!

- Verbal descriptions are only 40% effective.
- Palpate perennial tissues through clothes, should feel tissues move away from finger.
- Watch patient kegel(give pt. a mirror)
- Place finger inside patient’s vagina and pt squeeze
- Sexercises when patient is ready to resume sexual activity

## Kegels

- Make sure patient is breathing through contractions of pelvic floor muscles. (Can be difficult post-cesarean)
- Teach patient about accessory muscles (abdominals, gluteals)
- Rest hand on patient’s abdominal to make sure they are not contracting those muscles
- For patient with very weak musculature, you can teach overflow exercises using hip adductor muscles

## Benefits of PFE’s

- Exercised muscles recover better from trauma. (Cesarean deliveries, episiotomies, forceps/vacuum, prolonged second stage of labor, etc.)
- Decreased swelling and pain in perineum
- Prevention and/treatment of Urinary Incontinence
- Improved sex life

## What Physical Therapy can do for the Obstetric and Postpartum Patient

- Physical and Psychological preparation for childbirth
- Pregnancy and postpartum exercises, body mechanics
- Treatment of orthopedic problems
- Post-cesarean rehab
- Post-gynecological surgery rehabilitation
- Pelvic disorders (pain, UI, etc.)