ANTENATAL AND POSTNATAL EXERCISES WITH EVIDENCE

ANTENATAL AND POSTNATAL EXERCISES WITH EVIDENCE

1. ANTENATAL AND POSTNATAL EXERCISES WITH EVIDENCE By Ziona

2. OVERVIEW Physiology of Pregnancy Physical and physiological changes during each trimester Guidelines for Exercise in Pregnancy Evidences for antenatal exercises Postnatal Evidences for postnatal exercises

3. CHANGES DURING PREGNANCY STRUCTURAL CHANGES METABOLIC CHANGES PHYSIOLOGICAL CHANGES INCREASE IN BODY WEIGHT

4. STRUCTURAL CHANGES UTERUS : Volume- increases gradually. Reaches to about 5-7liters. Size - Increase in size is due to the hyperplasia and hypertrophy of the myometrium and due to the growth of the foetus. Weight- non-pregnant uterus-> 30-50g end of 3 rd trimester- 1,000- 1,200g. Shape- non-pregnant uterus- pyriform shape. 12 th week- globular 3 rd trimester- pyriform

5. VAGINA : increased size increased blood supply. Deposition of glycogen increases in the epithelial calls due to the increased secretion of estrogen. The pH in vagina becomes less than 3.5

6. CERVIX : Increase in number of cervical glands. The blood supply of cervix is increased. Mucus secretion increased. The tough cervix becomes soft.

7. FALLOPIAN TUBE : Hyperplasia of epithelial cells. Blood supply is increased. Because of the increase size of uterus, the fallopian tubes are pushed upwards.

8. OVARIES : Follicular changes are not seen in ovary and ovulation does not occur. Corpus luteum enlarges and secretes a large quantity of progesterone and little estrogen which is essential for maintaining pregnancy. This continues for 3 months and then corpus luteum degenerates. By this time placenta develops fully and takes over the function of secreting estrogen and progesterone. This continues for the entire term

9. MAMMARY GLANDS : Changes occur due to the activity of estrogen and progesterone. Development of new and more ducts. Formation of more number of alveoli. Deposition of fat Increased in size Increase in vascularization

10. Physiological changes CARDIOVASCULAR SYSTEM The blood volume increases by 40%, from 4.0 to 5.5 litres. greater increase in plasma than in red cells, haemoglobin level falls to about 80%. effect is called a dilution anaemia physiological anaemia of pregnancy Supine hypotension Diastolic and systolic blood pressure Alteration in the venous blood pressure 20% decrease in peripheral resistance

11. RESPIRATORY SYSTEM Shortness of breath Increased basal oxygen consumption and minute ventilation Increase their ventilation by breathing more deeply Subcoastal angle – 68 to 103 degree

12. IMMUNE SYSTEM slightly depressed More prone for pneumococcal pneumonia, influenza or poliomyelitis Reactivation of latent virus CMV or herpes Passive antibodies from 6 th week of pregnancy to 9 months of age

13. DIGESTIVE SYSTEM Hyperemesis gravidarum Esophagus: decreased competence of lower oesophageal sphincter which leads to heart burn. Stomach: decreased gastric secretions. Decreased motility leading to slower emptying times. Progesterone causes decreased tone leading to nausea.

14. URINARY SYSTEM Progesterone dilation of renal pelves and ureters Later, uterus compresses the ureters at the pelvic brim, causing a slowing of the urine flow. The musculature of the ureters is slightly hypotonic so they dialate and also seem to elongate to circumvent the enlarging uterus. This leads to pooling and stagnation of urine causing a predisposition to urinary tract infections.

15. MUSCULOSKELETAL SYSTEM Relaxin, progesterone, oestrogen and cortisols increase in joint laxity and range. Postural adaptations that occur at pregnancy, such as a forward shift in the centre of gravity anterior pelvic tilt increase in lumbar lordosis and thoracic kyphosis In fact, 75% of women demonstrate a more posterior posture, one in which the weight of the uterus is carried posterior to the normal centre of gravity.

16. Despite major anatomical changes, the kinematics of gait during pregnancy were found to be remarkably unchanged. There is a significant increased use of hip extensor, hip abductor and ankle plantar flexor.

17. NERVOUS SYSTEM Mood liability, anxiety, insomnia, nightmares, food fads and aversions, slight reductions in cognitive ability and amnesia Water retention causes unusual pressure on nerves, particularly those passing through canals formed of inelastic materials like bone and fibrous tissue for eg the carpal tunnel resulting in neuropraxia Occasionally pregnant women complain of traction on nerves which can be due to increased weight

18. Common discomforts of pregnancy Urinary frequency Constipation Haemorrhoids Nausea/ vomiting Heartburn Fainting Varicose vein Vulval varicosities

19. Odema in lower limbs Backache Tender breasts Muscle cramps Carpal tunnel syndrome Insomnia

20. ANTENATAL The antenatal period is defined as before birth, during or relating to pregnancy according to the Oxford Dictionary (2014). Hence, it can be said that the antenatal period would consist of the 40 weeks of gestation endured during a full term pregnancy.

21. ANTENATAL CARE is a holistic package provided for an expectant mother by healthcare professionals during the pregnancy. A series of services will be provided from various healthcare practitioners such as general practitioners (GP), gynecologists, obstetricians, midwives and also physiotherapists specializing in women’s health (NHS Choices, 2013).

22. importance of antenatal care is that it constitutes of health and socioeconomic condition screenings of the expecting family. It is vital for the following reasons: To increase the possibility of specific adverse pregnancy outcomes. To provide effective therapeutic interventions. To ensure maternal education of planning and going through a safe birth. To prepare parents of pregnancy emergencies and how to deal with them.

23. ROUTINE Routine antenatal check up Antenatal screening Plan an antenatal care During the first visit , pregnant woman should be given information regarding: Folic acid supplements Food hygiene, including how to reduce the risk of a food-acquired infection Lifestyle, including smoking cessation and the risks of recreational drug use and alcohol consumption Antenatal screening tests

24. During the next visit pregnant woman should be given information regarding: How the baby develops during pregnancy Nutrition and diet, including vitamin D supplements Exercise, including pelvic floor exercises Antenatal screening tests Pregnancy care Breastfeeding and workshops Antenatal classes Maternity benefits.

25. Plan the care that patient will get throughout pregnancy Identify any occupation related potential risks Measure height and weight and calculate patient's body mass index (BMI) Measure blood pressure and test urine for protein Find out whether patient is at increased risk of gestational diabetes or pre-eclampsia Ask of any known mental illness and signs of depression Offer an ultrasound scan at 18 to 20 weeks to check the physical development of the baby. Antenatal classes can be started as soon as possible, as it will be ease and prepare the woman for delivery

26. At 16 th week The doctor should give information about the ultrasound scan which will be offered at 18 to 20 weeks and help with any concerns or questions that the patient's have. Review, discuss and record the results of any screening tests Measure blood pressure and test patient's urine for protein Consider an iron supplement if patient is anaemic.

27. 16 th – 20 th weeks Ultrasound scan will be done to check the physical development of the baby. 25 th weeks Check abdominal size Measure blood pressure and test urine for protein.

28. 28 th weeks Check the size of the abdomen Measure blood pressure and test urine for protein Offer more blood screening tests Offer first anti-D treatment if patient is rhesus D-negative.

29. 31 st weeks Review, discuss and record the results of any screening tests from the last appointment Check the size of abdomen Measure blood pressure and test urine for protein.

30. 34 th week Doctor should give patient information about preparing for labour and birth, including how to recognise active labour, ways of coping with pain in labour and patient's birth plan. Review, discuss and record the results of any screening tests from the last appointment Check the size of abdomen Measure blood pressure and test urine for protein Offer second anti-D treatment if patient is rhesus D-negative.

31. 36 th week Information regarding: Breastfeeding, including hints and tips for success Caring for the newborn baby Vitamin K and screening tests for newborn baby Patient's own health after the baby is born Being aware of the ‘baby blues’ and postnatal depression. Check the size of abdomen Check the position of the baby and discuss options to turn the baby if he or she is bottom first (breech position) Measure blood pressure and test urine for protein.

32. 38 th week Doctor should give patient information about what happens if pregnancy lasts longer than 41 weeks. Check the size of abdomen Measure blood pressure and test urine for protein.   40 weeks Doctor should give patient information about what happens if pregnancy lasts longer than 41 weeks. Check the size of abdomen Measure blood pressure and test urine for protein.

33. 41 st weeks Check the size of abdomen Measure blood pressure and test urine for protein Offer induction of labour

34. Pre-exercise medical screening Overall health, obstetrical history and medical risks are reviewed. Considered factors include: Age General physical condition Exercise history Risk factors for coronary heart disease Orthopedic history and musculoskeletal risks Medication use History of pulmonary disease Anticipated type of exercise Handicaps or disabilities Current and past obstetric history

35. Benefits of Exercise During Pregnancy Maintain healthy body weight and avoid excess fat accumulation Maintain or improve cardiovascular fitness, muscular strength and endurance, and flexibility Decreased musculoskeletal complaints such as back pain Decreased minor discomforts of pregnancy Improved posture and body mechanics, which may improve coordination, balance, and body awareness Reinforced principles of breath awareness and relaxation Prevention and treatment of problems associated with gestational diabetes, hypertension, and preeclampsia (hypertension due to (cause being placenta) 20 weeks later, protein in urine , eclampsia - with seizures (magnesium sulphate) Stress reduction and enhanced self-image Possible easing of labor with fewer complications of delivery and faster postnatal recovery

36. Guidelines for Exercise During Pregnancy in Healthy Women Obtain medical clearance before participation. The exercise prescription should be individually based. Regular mild to moderate exercise routines are preferable to intermittent activity. Gradually increase exercise intensity and duration if previously sedentary. A maximum heart rate limit up to 155 b/min is recommended, although levels of intensity higher than this can be prescribed on an individual basis. Walking, cycling, swimming, low-impact aerobics, and stretching are recommended activities.

37. Do not exercise in the supine position after the 4th month. Don't stand motionless for long periods of time. Stop exercising when fatigued and do not deliberately reach a point of exhaustion. Get plenty of rest. Do not perform exercises that could cause a loss of balance. Eat an additional 150–300 calories a day and drink plenty of fluids before, during, and after exercise. Emphasize complex carbohydrates to replace muscle glycogen stores. Do not exercise when it is hot or humid or when febrile. Wear clothing that is cool and allows ventilation.

38. Bouncing, jerky movements should first be reduced and then avoided during the 3rd trimester. Avoid high-altitude activities and scuba diving. Participation in competitive sports is acceptable during the first 16 weeks of pregnancy if risk is accepted, but contact sports should be avoided thereafter. Lifting light to moderate weights is encouraged to develop or maintain strength, but the valsalva maneuver should be avoided. Know the warning signs to discontinue exercise and consult with prenatal health advisor Adapted from Clapp (1998), CSEP (1996), ACSM (1995), ACOG (1994), and RACOG (1994).

39. Warning signs to terminate exercise while pregnant Vaginal bleeding Dyspnoea before exertion Dizziness Headache Chest pain Muscle weakness Calf pain or swelling (need to rule out thrombophlebitis) Preterm labour Decreased fetal movement Amniotic fluid leakage

40. Absolute Contraindications Severe cardiovascular, respiratory or systemic disease Uncontrolled hypertension, diabetes or thyroid disease Ruptured membranes Incompetent cervix Preeclampsia or toxaemia Multiple pregnancy (triplets, etc.)?? Poor fetal growth Previous uterine rupture

41. Relative Contraindications History of repeated (3 or more) miscarriage or premature labor Diabetes History of rapid labor or poor fetal growth Early pregnancy bleeding Sedentary lifestyle with very poor fitness Breech presentation after 28 weeks Palpitations or arrhythmias Anemia or iron deficiency Extreme under or over weight

42. 1st Trimester - 0-12 weeks AIMS AND OBJECTIVES: Antenatal Education Maintenance of Anaerobic and Aerobic capacity – antenatal exercises. Nutritional Education Ergonomic/Body mechanic

43. DEEP BREATHING EXERCISES FOOT ANKLE EXERCISES

44. 2 nd Trimester - 13- 24 week Continuation of first trimester exercises Ergonomic advises Core stabilization exercises Aerobic exercises

45. 3 rd Trimester - 25- 38weeks Progression of exercises. Aiming to treat Neuromusculoskeletal discomforts. Ergonomic advise Education on Stages of Delivery Teach and train Positions for Delivery Teach relaxation techniques to use during pregnancy.

46. AEROBIC TRAINING

47. Absolute contraindications to aerobic exercise during pregnancy Haemodynamically significant heart disease Restrictive lung disease Incompetent cervix/cerclage Multiple gestation at risk for premature labour Persistent second or third trimester bleeding Placenta praevia after 26 weeks gestation Premature labour during the current pregnancy Ruptured membranes Pregnancy induced hypertension

48.  Relative contraindications to aerobic exercise during pregnancy 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 Heavy smoker Severe anaemia

49. Pregnant women should be encouraged to perform combined ( aerobic + resistance ) exercise to improve an important health outcome as in cardiorespiratory fitness and urinary incontinence. Benefits of aerobic or resistance training during pregnancy on maternal health and perinatal outcomes: A systematic review. Maria Perales et al, 2016

50. Effects of aerobic exercise training on maternal and neonatal outcome: a randomized controlled trial on pregnant women in Iran Zahra ghodsi et al , 2014   Exercising on a bicycle ergometer during pregnancy seems to be safe for the mother and the neonate

51. Aerobic exercise for women during pregnancy Kramer M S et al, 2006 Regular aerobic exercise during pregnancy appears to improve (or maintain) physical fitness. This review of 14 trials involving 1014 pregnant women, found that pregnant women who engage in vigorous exercise at least two or three times per week improve.

52. MODALITIES

53. Treatments for pregnancy-related lumbopelvic pain: a systematic review of physiotherapy modalities Gutke A et al, 2015 For lumbopelvic pain during pregnancy, the evidence was strong for positive effects of acupuncture and pelvic belts. The evidence was low for exercise in general and for specific stabilizing exercises. The evidence was very limited for efficacy of water gymnastics, progressive muscle relaxation, a specific pelvic tilt exercise, osteopathic manual therapy, craniosacral therapy, electrotherapy and yoga. For postpartum lumbopelvic pain, the evidence was very limited for clinic-based treatment concepts, including specific stabilizing exercises, and for self-management interventions for women with severe disabilities.

54. PELVIC AND LOW BACK PAIN

55. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Liddle S D et al, 2015 There is  low -quality evidence that exercise (any exercise on land or in water), may reduce  pregnancy -related  low-back pain  and moderate- to  low -quality evidence suggesting that any exercise improves functional disability and reduces sick leave more than usual prenatal care. Evidence from single studies suggests that acupuncture or craniosacral  therapy  improves  pregnancy -related  pelvic pain , and osteomanipulative  therapy  or a multi-modal  intervention  (manual  therapy , exercise and education) may also be of benefit.

56. Recommendations for physical therapists on the treatment of lumbopelvic pain during pregnancy: a systematic review. van Benten E et al, 2014 All included studies on exercise  therapy , and most of the studies on interventions combined with patient education, reported a positive effect on  pain , disability, and/or sick leave. Evidence-based recommendations  can be made for the use of exercise  therapy  for the treatment of lumbo pelvic pain during pregnancy.

57. STRESS INCONTINENCE

58. Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. Morkved S et al,2014 22 randomised or quasiexperimental trials PFMT during pregnancy and after delivery can prevent and treat UI. A supervised training protocol following strength-training principles, emphasising close to maximum contractions and lasting at least 8 weeks is recommended. PFMT is effective when supervised training is conducted. Given the prevalence of female UI and its impact on exercise participation, PFMT should be incorporated as a routine part of women's exercise programmes in general.

59. Effect of Kegel exercise to prevent urinary and fecal incontinence in antenatal and postnatal women: systematic review Park S H et al, 2013 Kegel exercise can prevent  urinary  and  fecal incontinence . Therefore, a priority task is to develop standardized Kegel exercise programs for Korean pregnant and postpartum women and make efficient use of these programs.

60. Pelvicfloor muscle training for prevention and treatment of urinary and fecal incontinence in antenatal and postnatal women: a short version Cochrane review. Boyle R et al, 2014 For women who are continent during pregnancy, PFMT may prevent  urinary   incontinence  up to 6 months after delivery. The extent to which mixed  prevention  and  treatment  approaches to PFMT in the postnatal period are effective is less clear that is, offering advice on PFMT to all pregnant or postpartum women whether they have  incontinence  symptoms or not.

61. Gestational diabetes

62. Diet and exercise interventions for preventing gestational diabetes mellitus. Bain E et al, 2015 Results from 13 RCTs (of moderate quality) suggest no clear difference in the risk of developing GDM for women receiving a combined  diet  and  exercise   intervention  compared with women receiving no  intervention . 

63. Exercise for pregnant women for preventing gestational diabetes mellitus Han S et al, 2015

64. POST NATAL PERIOD WITH EVIDENCES

65. 3 phases of postnatal rehabilitation Phase 1: First 8weeks Phase 2: 8-12 weeks Phase 3: After 12 weeks Postnatal Status: Normal Delivery Forceps Delivery CS

66. Stage 1 : 6 to 8 weeks NORMAL DELIVERY Breathing exercises Relaxation exercises Epidural pain relief Isometrics Pelvic floor exercises LSCS Coughing techniques Chest care Limb movements DVT Post surgical pain Relaxation techniques Pelvic floor ex

67. Stage 2 and 3 Warm up exercises Mild aerobic training FITT principle Moderate aerobic exercise

68. AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGIST Type Mode Intensity Frequency Duration Progression Aerobic walking, aerobic
dance, swimming, cycling. Moderate 3-4 METS. 50-60% VO2 max.
RPE: 12-16 30 minutes per day most days of the week. 20-60 minutes as per patient tolerance. Increase exercise duration slowly. Flexibility
Aquatic exercise ROM ex’s full mobility Strength Light weights/increased reps. 12 reps, individually tailored with monitoring.

69. REFERENCES Vairajothi K, Chitra TV, Baranitharan R, Mahalakshmi V. A comparative study of the therapeutic effect of pelvic floor exercises and perineometer among women with urinary stress Incontinence. IJOPT, 2005, volume 5; number 1, pg 33-36. Amar TA. Stabilization exercises in postnatal low back pain. Indian Journal of Physiotherapy and Occupational Therapy. 2011, Vol. 5, No.1. Mantle J et al. Physiotherapy in Obstetrics & Gynaecology, 2 nd edition. Ferreira CWS, Alburquerque-Sendn F. Effectiveness of physical therapy for pregnancy-related low back and/or pelvic pain after delivery: A systematic Review. Physiotherapy Theory and Practice, 2012; 1-3. (published online).

70. Stuge B, Lærum E , Kirkesola G, Vøllestad P. The Efficacy of a Treatment Program Focusing on Specific Stabilizing Exercises for Pelvic Girdle Pain After Pregnancy A Randomized Controlled Trial. SPINE Volume 29, Number 4, pp 351–359, 2004