1/18

Physiotherapy in Pregnancy and Postpartum Care

Evidence-Based Assessment, Treatment and Management

A Comprehensive Clinical Approach

2/18

Learning Objectives

By the end of this session, learners will be able to:

Identify common musculoskeletal and pelvic floor conditions during pregnancy and postpartum
Understand physiological changes that impact assessment and treatment
Apply evidence-based assessment techniques for pregnancy-related conditions
Implement safe and effective treatment interventions
Recognize red flags requiring medical referral

            Session Duration: 60 minutes

            Format: Interactive presentation with case studies and discussion

3/18

Physiological Changes in Pregnancy

Hormonal Changes

Relaxin: Peaks at 12 weeks, causes ligamentous laxity
Progesterone: Affects connective tissue elasticity
Estrogen: Influences collagen synthesis and joint stability

Biomechanical Adaptations

Weight gain: Average 11-16kg (25-35lbs)
Center of gravity: Forward and upward displacement
Postural changes: ↑ lumbar lordosis, thoracic kyphosis

Pelvic Changes

Widening of pubic symphysis (2-3mm normal)
Increased SI joint mobility
Diastasis recti development

Cardiovascular Considerations

Increased cardiac output (30-50%)
Supine hypotensive syndrome after 20 weeks
Exercise modifications required

4/18

Common Conditions During Pregnancy

45-75% Pregnancy-related low back pain

20% Pelvic girdle pain during pregnancy

60% Diastasis recti during pregnancy

18-75% Stress incontinence prevalence

Key Clinical Presentations

Musculoskeletal

Lumbar spine pain
Posterior pelvic pain
Symphysis pubis dysfunction
Thoracic spine dysfunction
Carpal tunnel syndrome

Pelvic Floor & Core

Urinary incontinence
Pelvic organ prolapse
Diastasis recti
Pelvic pain syndromes
Core muscle dysfunction

5/18

Pregnancy-Related Low Back Pain

Evidence Base

Prevalence: 45-75% of pregnant women experience some form of back pain

Impact: Significant functional limitations and reduced quality of life

Classification

Lumbar Pain

Similar presentation to non-pregnant low back pain
Often mechanical in nature
Typically responds to movement
May radiate into legs

Risk Factors

Previous history of back pain
Multiparity
Physically demanding work
Psychological factors
Higher BMI

Posterior Pelvic Pain

Pain in sacroiliac region
May radiate to buttocks/posterior thighs
Often described as deep, aching
Worse with prolonged sitting/standing

Combined Presentation

Mix of lumbar and pelvic symptoms
More complex clinical picture
Often requires multimodal approach

6/18

Pelvic Girdle Pain (PGP)

20% During pregnancy

7% Persists postpartum

Clinical Characteristics

Location: Pain in symphysis pubis, sacroiliac joints, or both
Radiation: May include buttock pain
Quality: Deep, aching, sometimes sharp
Functional impact: Walking, climbing stairs, rolling in bed, getting dressed

Symphysis Pubis Dysfunction

Pain at pubic symphysis
Clicking or grinding sensation
Worse with weight-bearing activities
May have visible separation

Sacroiliac Joint Pain

Unilateral or bilateral
Pain with prolonged positions
Difficulty with single leg activities
Morning stiffness common

7/18

Diastasis Recti & Pelvic Floor Dysfunction

Diastasis Recti

60% During pregnancy

32% At 12 months postpartum

Definition & Impact

Separation >2.7cm at umbilicus
Widening and thinning of linea alba
Reduced core stability
Potential back pain contributor
Aesthetic concerns

Pelvic Floor Dysfunction

Types of Dysfunction

Stress incontinence: Leakage with cough, sneeze, exercise
Urge incontinence: Strong, sudden urge to urinate
Mixed incontinence: Combination of stress and urge
Pelvic organ prolapse: Descent of pelvic organs
Pelvic pain: Various pain syndromes

                    Key Point: Stress incontinence affects 18-75% during pregnancy and continues postpartum in 6-29% of women
                

8/18

Assessment Principles

Safety Considerations

Position modifications: Avoid prolonged supine after 20 weeks
Symptom monitoring: Dizziness, shortness of breath, chest pain
Contraindications screening: High-risk pregnancy factors

Comprehensive Assessment Framework

Subjective Assessment

Detailed pain/symptom history
Functional limitations
Pregnancy history and complications
Exercise history and goals
Psychological factors
Support systems

Objective Assessment

Posture analysis (standing, sitting)
Movement quality assessment
Muscle strength and endurance
Joint mobility and stability
Specialized tests (condition-specific)
Functional movement screens

9/18

Evidence-Based Assessment Tools

Low Back & Pelvic Pain

Validated Outcome Measures

Pelvic Girdle Questionnaire (PGQ): 25 items, activity and symptom subscales
Pregnancy Mobility Index (PMI): Functional assessment
Roland Morris Disability Questionnaire: Back-specific disability

Pain Provocation Tests

P4 Test: Posterior pelvic pain provocation
ASLR: Active straight leg raise test
Patrick’s Test: Modified for pregnancy
Symphysis Pubis Stress Test

Core & Pelvic Floor Assessment

Diastasis Recti Assessment

Palpation method: Supine with head lift
Ultrasound imaging: Gold standard
Measurement points: Above, at, below umbilicus
Assessment positions: Rest and contraction

Pelvic Floor Assessment

ICIQ: International Consultation on Incontinence Questionnaire
Internal examination: When appropriate and consented
Real-time ultrasound: Non-invasive option
Oxford Grading: 0-5 muscle strength scale

Best Practice: Combine subjective questionnaires with objective measures for comprehensive assessment

10/18

Evidence-Based Exercise Therapy

Strong Research Support

Multiple high-quality RCTs demonstrate that structured exercise programs significantly reduce pain and improve function in pregnancy-related conditions.

Exercise for Low Back & Pelvic Pain

Effective Interventions

Stabilization exercises: Deep abdominal and multifidus focus
Water-based exercise: Particularly effective for pain relief
Strengthening: Gluteal and hip muscles
Mobility exercises: Pelvic tilts, gentle stretching
Postural education: Ergonomic advice

Program Principles

Individualized prescription essential
Progressive loading
Functional integration
Regular reassessment

Specific Techniques

Core Stabilization

Transversus abdominis activation
Multifidus recruitment
Coordinated breathing patterns
Progressive challenge positions

Pelvic Girdle Stability

Specific stabilizing exercises
Pelvic belt/support when indicated
Activity modification strategies
Load management principles

                    Key Success Factor: Supervised programs show superior outcomes to unsupervised approaches
                

11/18

Pelvic Floor Muscle Training (PFMT)

Cochrane Review Evidence (2017)

PFMT significantly reduces urinary incontinence during pregnancy and postpartum. Supervised programs are more effective than unsupervised training.

Evidence-Based PFMT Protocol

Training Parameters

Frequency: 3 times daily
Intensity: Near maximal contractions
Duration: 6-8 second holds
Fast contractions: 3-6 quick contractions
Minimum program: 8-12 weeks
Progression: Increase hold time and repetitions

Teaching Techniques

Anatomical education
Correct muscle identification
Avoid breath holding
Monitor for accessory muscle use

Functional Integration

Pre-contraction with cough/sneeze
Lifting technique coordination
Exercise integration
Daily activity incorporation

Progression Stages

Stage 1: Awareness & Isolation

Muscle identification
Basic contractions

Stage 2: Strength & Endurance

Progressive hold times
Increased repetitions

Stage 3: Functional Training

Task-specific training
Position variations

12/18

Treatment Modalities & Safety Guidelines

Safe Manual Therapy

Recommended Techniques

Gentle joint mobilizations
Soft tissue massage
Myofascial release
Craniosacral therapy
Lymphatic drainage

Positioning Modifications

Side-lying positions
Supported prone (with pregnancy pillow)
Avoid prolonged supine (>20 weeks)
Use of wedges and supports

Physical Modalities

Safe to Use

Heat therapy (local, <20 minutes)
Cold therapy/ice
TENS (transcutaneous electrical stimulation)
Acupuncture (qualified practitioners)

Contraindicated

Ultrasound over gravid uterus
Interferential current over abdomen/pelvis
Shortwave diathermy
Deep heat modalities
High-intensity laser therapy

13/18

Postpartum Considerations

Return to Exercise Timeline

Immediate Postpartum (0-6 weeks)

Week 1-2: Deep breathing, gentle walking
Week 2-6: Basic core activation, pelvic floor exercises
Gentle stretching: Neck, shoulders, back
Posture awareness: Feeding positions

6-8 Weeks Post

Medical clearance required
Gradual return to pre-pregnancy activities
Progressive core strengthening
Return to impact activities (when appropriate)

Special Considerations

Caesarean Section Recovery

Additional 2-4 weeks recovery
Scar tissue management
Avoid heavy lifting (6-8 weeks)
Progressive abdominal loading

Breastfeeding Considerations

Continued relaxin effects
Postural strain from feeding
Adequate hydration essential
Supportive bra importance
Joint protection strategies

24-45% Persistent back pain at 6 months postpartum

14/18

Red Flags & Referral Guidelines

Immediate Medical Referral Required

Severe, constant pain not relieved by rest or position changes
Neurological symptoms: Numbness, weakness, bowel/bladder dysfunction
Signs of infection: Fever, chills, unusual discharge
Vaginal bleeding (especially postpartum after initial cessation)
Severe headaches or visual changes (preeclampsia signs)
Chest pain or severe shortness of breath
Severe abdominal pain

Specialized Referral Indications

Obstetric/Medical Consultation

High-risk pregnancy complications
Pregnancy-induced hypertension
Gestational diabetes management
Placental complications
Multiple pregnancy concerns

Mental Health Support

Signs of perinatal depression
Anxiety disorders
Posttraumatic stress (birth trauma)
Significant sleep disturbances
Social isolation

Pelvic Floor Specialists

Severe prolapse (grade 2+)
Complex pelvic pain syndromes
Refractory incontinence
Sexual dysfunction
Chronic constipation

Surgical Consultation

Severe diastasis recti (>5cm)
Refractory symphysis pubis dysfunction
Herniation concerns
Severe pelvic organ prolapse

15/18

Clinical Case Studies

Case 1: 28-week Pregnant Woman with Low Back Pain

Patient: Sarah, 32 years old, G2P1, office worker

Presentation: Increasing low back pain over past 4 weeks, difficulty sleeping, struggling with daily activities

Assessment Findings

Increased lumbar lordosis
Weak gluteal muscles (4/5)
Tight hip flexors
Poor workplace ergonomics
PGQ score: 45/100

Treatment Plan

Core stabilization program
Gluteal strengthening exercises
Hip flexor stretching
Workplace ergonomic modifications
Sleep positioning education
Pelvic support belt trial

Case 2: 6-week Postpartum with Stress Incontinence

Patient: Emma, 29 years old, first-time mother, vaginal delivery

Presentation: Urine leakage with cough, sneeze, and exercise. Wants to return to running.

Assessment Findings

Weak pelvic floor muscles (Oxford grade 2/5)
Unable to stop urine mid-stream
ICIQ score: 12/21
Diastasis recti: 3cm at umbilicus
Good motivation for exercise

Treatment Plan

Structured PFMT program
Core rehabilitation
Graduated return to running protocol
Bladder training techniques
Lifestyle modifications
6-week review and progression

16/18

Key Takeaways & Clinical Pearls

Evidence-Based Practice Points

Exercise therapy is first-line treatment for pregnancy-related musculoskeletal conditions
Pelvic floor muscle training significantly reduces incontinence risk when properly prescribed
Individualized assessment is crucial due to varied presentations and risk factors
Safety considerations must guide all interventions throughout pregnancy and postpartum
Multidisciplinary approach often required for optimal outcomes

Clinical Pearls for Success

Assessment & Treatment

Start conservative, progress gradually
Education is key: Empower patients with knowledge
Consider biopsychosocial factors in treatment planning
Regular reassessment and modification of treatment plans

Patient Relationship

Build strong therapeutic relationships – enhances outcomes
Validate concerns and normalize common experiences
Include partners/support persons when appropriate
Collaborate with healthcare team for comprehensive care

Remember: Every pregnancy is unique

What works for one patient may not work for another. Individualized, evidence-based care combined with clinical expertise and patient preferences leads to the best outcomes.

17/18

Resources & References

Key Systematic Reviews

Cochrane Review (2017): Pelvic floor muscle training for prevention and treatment of urinary and fecal incontinence in antenatal and postnatal women
Cochrane Review (2015): Interventions for preventing and treating low-back and pelvic pain during pregnancy
Mota et al. (2015): Exercise for treatment of diastasis recti abdominis – systematic review

Professional Organizations

International Association of Women’s Health Physical Therapists (IAWH-PT)
Royal College of Obstetricians and Gynaecologists (RCOG)
American College of Sports Medicine (ACSM)
International Urogynecological Association (IUGA)

Assessment Tools

Pelvic Girdle Questionnaire (PGQ)
International Consultation on Incontinence Questionnaire (ICIQ-SF)
Pregnancy Mobility Index (PMI)
Edinburgh Postnatal Depression Scale (EPDS)

Continuing Education

Women’s health physiotherapy courses
Pelvic floor certification programs
Pregnancy and postpartum exercise specialist training
Manual therapy for pregnancy-related conditions

                    Stay Current: Research in this field is rapidly evolving. Regular continuing education is essential for evidence-based practice.
                

18/18

Remember: Evidence-based practice + Clinical expertise + Patient values = Optimal outcomes

Contact information and resources available for follow-up