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.