special exercises for pregnancy &the puerperium

SPECIAL EXERCISES FOR PREGNANCY &THE PUERPERIUM

Prepared by : Hanaa Behar Shoroq edaliy Khetam elkhafarna Hadeel abo quse Sabren salama Wesam khatab Somya abo omra

SAFE EXERCISE IN THE CHILDBEARING YEAR

The exercise in the childbearing year The exercise needs of the disabled

woman during the childbearing year that specific .

should be assessed individually ,so advice and

information can be given.

Exercising during the childbearing year is not harmful to either .

mother or baby if the pregnancy is normal and the mother healthy .

and can be positively beneficial if at a mild to moderate level.

The aims of exercising in pregnancy should be to maintain, or slightly

improve, the woman's level of fitness.

Provided there are no specific obstetric or medical contraindications, fit women can safely maintain the same level of fitness during pregnancy.

Pregnant women should not undertake new, vigorous exercise, which could make them too warm, tired or breathless and regular exercisers should reduce the intensity and duration of their training as the pregnancy progresses .

Pregnant women should not undertake new, vigorous exercise, which could make them too warm, tired or breathless and regular exercisers should reduce the intensity and duration of their training as the pregnancy progresses .

All women should be encouraged to exercise at a moderate level to derive the associated health benefits.

A moderate level is that intensity which can be maintained while able to carry on a conversation.

The Borg Scale of Perceived Exertion or the Talk Test can be used, preferably at level 3–5.

This should be used in preference to a heart rate monitor, which is less reliable due to the pregnancy-induced increase in heart rate.

There are benefits to exercising in the childbearing year. The benefits according to the ACPWH may include:

maintenance of cardiovascular fitness, respiratory and musculoskeletal .status

maintenance of healthy weight

range for mother

improvement of body awareness,

balance, coordination and

posture

improvement in circulation and lowered diastolic pressure .

an increase in both endurance and stamina

increased feelings of social and

emotional well-being, when exercise is

combined with social interaction.

a possible reduction in problems during labour

and delivery. Labour may also be shorter and there may be

fewer interventions (forceps, caesarean

section)

evidence of neurological benefits to the baby and developing child

a reduction in common disorders of pregnancy

suggestion of a more rapid postnatal recovery as the woman is likely to be fitter

better glucose utilization by increasing insulin sensitivity ,

suggested improved placental growth, increased fetal growth

•However, further research on the benefits of exercise in pregnancy is needed and health professionals should remain up to date with current literature.

•Most women will fall into one of the following four types of exerciser. Using the Borg Scale of Perceived Exertion is appropriate for all women, whatever their level of fitnessor ability.

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The occasional exerciser These women may recognize the benefit of exercising when pregnant and may wish to increase the level of intensity, duration and regularity .

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The regular exerciser Guidelines for exercise in pregnancy (ACOG 2002) suggest that the woman who exercises regularly should:

discuss her exercise programme with the obstetrician, GP, physiotherapist or midwife before continuing

• exercise at least three times per week for 20–30 min to improve aerobic capacity but discontinue contact or dangerous sports

self-regulate both the level of intensity and duration of exercise as the pregnancy progresses. This will help to keep core temperature below 38 °C.

•

always aim for low impact activity to reduce musculoskeletal stresses and wear supportive footwear

prevent dehydration by maintaining an adequate fluid intake and should avoid exercising during hot and humid weather or with

pyrexia

ensure that they warm up and cool down for at least

5 minutes

not overstretch because of the hormonal effects on the ligaments

consult the relevant professional for advice on specific exercises, e.g. for the pelvic floor and abdominal muscles

avoid certain movements like low squats, cross-over steps, rapid changes of direction and ballistic exercise

avoid aortocaval compression by not exercising in the supine position (supine hypotension syndrome ,

aim to pursue a variety of exercise activities in order to avoid overtraining

not exercise to the point of fatigue nor become breathless.

The athlete These women are often the most difficult to advise as they are often highly motivated and competitive. They should follow the advice of regular exercisers.

A safe level of aerobic exercise for the athlete will depend on the chosen sport and degree of fitness attained .

The athlete will inevitably need to lower the intensity and length of her training sessions and they should be aware that the same warnings and contraindications apply as for the regular exerciser .

Advisors of pregnant women athletes regarding safe exercise should remember that research into strenuous activity during pregnancy is limited, so should Endeavour to keep updated of new information.

ANTENATAL EXERCISE

It is best to continue with familiar activities rather than begin new types of exercise and the woman should listen to her body when exercising and stop if she feels uncomfortable, fatigued or unwell

BASIC EXERCISE

Brisk walking during which the Borg Scale/Talk Test is correctly observed is an easy and accessible method of exercising for all.

NOTI. Swimming is excellent exercise if

aerobic changes are induced.II. Exercising in water also raises the

plasma beta endorphin levels significantly and has a beneficial effect on the respiratory cardiovascular and musculoskeletal systems.

CONTRAINDICATIONS TO EXERCISE IN PREGNANCY

1. serious cardiovascular, respiratory, renal or thyroid disease

2. 3. poorly controlled type 1 diabetes4. • risk of, or current, premature labor5. • cervical incompetence6. • history or risk of IUGR and premature labor –

reduce activity after 12 weeks7. • hypertension – should be discussed with the

woman's doctor8. • placenta praevia after 26 weeks' gestation –

should be discussed with the woman's doctor9. • sudden swelling of ankles, hands or face10. • acute infectious disease11. • severe rhesus isoimmunization.

PRECAUTIONS TO EXERCISE IN PREGNANCY

1. • asthma2. • diabetes type 1. If insulin regimes are well controlled

and exercise is moderate (Arena and Manfully 2002), discuss with diabetic consultant, GP or specialist nurse

3. • history of miscarriage4. • pre-pregnancy hypertension5. • placenta praevia6. • vaginal bleeding7. • reduced fetal movement8. • anemia9. • breech presentation10.• extreme obesity11.• extreme underweight BMI<1212.• heavy smoking

.13thyroid disease

WARNINGS1) • abdominal pain2) • leakage of amniotic fluid3) • pelvic girdle pain4) • pelvic girdle pain which may lead

to difficulty in walking5) • vaginal bleeding6) • shortness of breath, dizziness,

faintness, palpitations or tachycardia7) • persistent severe headache8) • calf pain9) absence of or reduced fetal

movements

For each port of the body where tension manifests itself there is a there –fold

instruction*** *an order to the reciprocal muscle group

to work strongly**a command to that muscle group to stop

working*

*a direction to the brain to recognize the new position of ease and to remember it*

lie down comfortably on your side or sit in a chair with back and hand supported *

Breathe in expanding above the waist and lower ribs then sigh out easily and continue to breathe gently keeping the movement fairly low down in the chest*

The shoulders arms and hands are usually the first areas to stress so begin with these parts*

*shoulders –pull your shoulders to wards your –feet –stop pulling –can cent rate on this new

position of ease –your shoulders so begin with these parts*

*arms push your elbows slightly our from your body as though straightening the elbows –stop pushing think about this position –your

arms are relaxed and comfortably supported* *hands let them rest on your tummy or thighs

or the supporting surface –open out the fingers and thumbs keeping the wrists on the

support*

Stretch the fingers and thumbs –stop moving feel the new

position –comfortable supported and relaxed*

The teacher moves on to the remainder of the body the hips knees head and face giving clear precise instructions

which can be found in full in the ACPWH leaflet*

Your body should end up in apposition of ease and as relaxed as possible

breathing is at your normal resting rate relaxation can be adapted as labour

Progresses by adopting the most comfort able position for your with easy breathing in

the lower part of

thechest**********

:COPING SKILLS FOR LABOUR IS

Relaxation .breathing techniques . encouragement to move and adopt an

upright or forward leaning .posture during labor will help women to cope with discomfort and pain of contraction .

RELAXATION

This is fight or flight (preparing the body for action )

however if cause is not an enemy that can be fought with the

tension persists become exhausting and causes physical changes in heart . Lungs and other body part.

Relaxation can be particularly useful during pregnancy & labour and early postnatal days .

This technique involves aseries of instruction & movements that help the body to move away from the posture .

POSITION OF LABOUR

woman in Early first stage of labour use upright position who :

Have more efficient contraction . Have shorter labours. are less likely to use pethidine or an

epidural for pain relief. Are less likely to have their labour

accelerated artificially than women who were lying down.

COPING WITH EARLY STAGE OF LABOUR :

Position that help during the early stage of labour : Sitting against a table &relaxation forwards so that

shoulders .arms and head are supported. Standing .learning backwards against the wall

of the room . Kneeling on all fours . Kneeling on the floor & learning forwards onto

chair . Learning forwards against a partner . Sitting astride an armless chair with arms

supported on the chair back . The birthing room may have additional aids.

Later first stage of labour

When labour progresses it increase difficult to find comfortable position.

many women are content to sit back against pillows on the bed at this stage and contraction on relaxation &breathing .

Second stage of labour Women in this stage use deferent

position . Who remained up right or lay on their

sides to give birth . Mid wives encourage women to

choose the most comfortable position &discourage from lying on their backs .

COPING WITH SECOND STAGE OF :LABOUR

In this stage position depend on: individual choice Pain relief &obstetric factors .

If there is pain in the pelvic girdle .particularly over the symphysis pubis or sacroiliac joints then undue abduction of the hips should be avoided during labour .vaginal examination & birth the symphysis pubis joint may be protected from further disruption by limiting hip abduction and maintaining symmetry of hip positions .prone kneeling or side –lying are the optimum position for birth .

The symphysis pubis joint may be protected from further disruption by limiting hip abduction and maintaining symmetry of hip position .

Prone kneeling or side lying are the optimum position for birth .

As the contraction starts the mother is reminded to breath in & out gently .

Breathing control Respiration is affected by stress & adapted breathing

is one of the easiest ways of assisting relaxation. speed .slower breathing lead to deeper relaxation . natural rhythmic breathing mustn't Be confused with

specific unnatural rates of breathing its harmful to fetus &mother.

Women in labour breath very rapidly at the peak of contraction but should not encouraged it.

very Slow deep breathing cause hyperventilation Rapid shallow breathing cause hypoventilation.

ANTENATAL AND POSTNATAL EXERCISES AND ADVICE

ANTENATAL AND POSTNATAL EXERCISES AND ADVICE Preventing and alleviating the early

physical stresses of pregnancy and childbirth, should be taught as a priority. Common consequences of pregnancy and childbirth are the physical problems of pelvic girdle and low back pain or incontinence.

The main aim in the postnatal period is to address healthcare needs and give advice and exercises to reduce the risk of future pelvic floor dysfunction or the possibility of long-term back problems, so that the woman may recover normal function free of both pain and symptoms.Women whose pain or continence problems do not resolve with simple advice and exercises should be referred to a women's health physiotherapist

PAIN

Some 45% of all pregnant women suffer pregnancy-related pelvic girdle pain (PGP) and/or pregnancy-related low back pain (PLBP). Serious pain occurs in 25% of pregnant women and severe disability in 8% of pregnant women (Wu et al 2004).

Pelvic floor dysfunction (PFD) occurs in 52% of all pregnancy-related PGP/PLBP (Pool-Goudzwaard et al 2005).

PELVIC FLOOR DYSFUNCTION

Pelvic floor disorders are very common and strongly associated with the female gender, ageing, pregnancy, parity and instrumental birth (MacLennan 2000).

• 31–47% report antenatal stress incontinence • up to 34% report postnatal incontinence

(Reilly et al 2002) • 11.5% report faecal incontinence after a 3rd

degree tear • 25% report faecal incontinence after a 4th

degree tear (Sangalli et al 2001). For best compliance with the following advice and

exercises, explain, demonstrate, supervise and practice at every opportunity.

ANTENATAL

Postural awareness and care of the back Women should be advised that the

weight of her baby, her altered centre of gravity and tiredness may alter her posture and place strain on her body, putting her at risk of low back and pelvic girdle pain. Her sustained posture when standing, sitting or lying

plus repetitive movements may influence that risk and correction may prevent or reduce pain. Back-care advice should be developed relating to comfortable positions in sitting, standing, lying, general mobility and correct lifting

STANDING

For good standing posture, the centre of the head, shoulders and hips should fall in a line when viewed from the side. Standing tall, with shoulders relaxed, tummy gently drawn in and bottom tucked under, knees straight but not locked, and weight evenly distributed on both feet is advised .

SITTING

The pregnant woman should choose a comfortable chair, which supports both her back and thighs . She should sit well back and if necessary place a small cushion or folded towel behind the lumbar spine for additional comfort. Equal weight should be placed on each of her buttocks to prevent strain on the pelvic ligaments. The seat height should allow the feet to rest on the floor, or a small footstool or cushion may be placed under the feet to raise them slightly

SITTING Her workstation should be at the correct

height such that she does not need to bend forwards. If relaxing in an easy chair, the head can be supported and the legs elevated slightly on a stool. Legs should not be crossed.

Sleep is a very valuable commodity during pregnancy and health professionals can advise and help women to find a comfortable position. Lying flat

on the back should be discouraged because of the risk of supine hypotension due to pressure from the gravid uterus on the inferior vena cava. However, if she wakes having been lying on her back she should be advised to lie on her side for a few moments before rising slowly.

lying

WORK ACTIVITIES Women should be encouraged to make

sure their seating and workstation is suitable, particularly if sitting for any length of time

. Regular changes of task and alteration of positions is beneficial

IF the woman's work involves constant standing she should ensure she sits at regular break times and be very careful

WORK ACTIVITIESif her work involves lifting or great physical effort. Many workplaces offer pregnancy risk assessments to employees

LIFTING AND CARRYING

Lifting heavy or awkward objects should be avoided during pregnancy

Twisting or bending while lifting is a particularly high-risk activity. If lifting is unavoidable

, the thigh muscles, not those of the back, should take the strain.

The abdominal and pelvic floor muscles should be drawn in for support and protection of the back and pelvis before bending the knees, holding the object or toddler close to the body, then lifting with the back straight (Fig. 16.9).

Toddlers should not be carried on one hip, or, at least, advise to alternate the hip. A rucksack carried on the back is much better for the back than a heavy shopping bag.

PELVIC FLOOR EXERCISES There is evidence that pelvic floor muscle

training used during a first pregnancy reduces the prevalence

of urinary incontinence at 3 months following birth).

The recommendation for preventive use of physical therapies is that pelvic floor muscle training should be offered to women in their first pregnancy as a preventive strategy for urinary incontinence

TEACHING THE PELVIC FLOOR MUSCLE EXERCISE1. • Sit, stand or lie down on your side.

Imagine that you are trying to stop yourself passing wind and at the same time trying to stop the flow of urine

2. • The feeling should be of squeeze and lift, closing and drawing up the back and front passages

3. • Hold for as long as possible, up to 10 s, breathing normally, and then relax

4. • Repeat up to 10 times

The muscles should also be able to react to and maintain continence during sudden rises in intra-abdominal pressure as during a sneeze, cough or laugh; practicing a few short, fast squeezes will help maintain this control

• Try to draw up the pelvic floor muscle gently when lifting.

TEACHING THE PELVIC FLOOR MUSCLE EXERCISE

Try to practice this set of up to 10, 10-s squeezes at least 3 times a day This regime will help to build up, or maintain the endurance in the pelvic floor muscle during pregnancy

• You should feel that your low tummy support muscle is working at the same time; this is good

Abdominal exercisesto the aponeurosis, rectus sheath and lineal alba, it may help to limit DRAM.The mother should adopt a pain-free position, with good The deepest layer of muscles within the abdominal corset, TrA is important in postural control, controlling the neutral spine position and giving support to the weight of the growing baby. By its attachment postural alignment. Sitting, standing, side-lying or four-point kneeling are good positions but she should avoid lying on her back after 16 weeks of pregnancy, because of the risk of supine hypotension. Figure 16.10 illustrates the transverses exercise, and Boxes 16.3 and 16.4 proved instructions for pelvic tilting and the TrA exercise.

Instruction in pelvic tilting • Place your hands on your abdomen• Gently tighten your tummy muscles and buttocks and allow the back of your waist to slump backwards. Your pubic bone rocks up towards you. Breathe normally and hold the tilt for 5–10 s• Relax and allow your back to hollow• Repeat a few times. This is pelvic tilting• The mid-way position is the neutral spine position and is safest for your back• Practicing the abdominal exercise is best done in the neutral spine position.

Instructions for the TrA exercise• Place your hands on lower part of abdomen• Take a gentle breath• As you breathe out, gently draw in and lift the lower tummy away from your hand, this time not allowing your back to move• Keeping the tummy in, continue to breathe normally a few times• Feel the muscle working under your hand as it supports the weight of your baby• Relax• Repeat up to 10 times, trying to hold each lift for 10 s, but don't hold your breath• Repeat this set 6–8 times a day• Try in different positions, and try to use this muscle during activity requiring effort.

THANKS FOR ALL