Chapter 22 Physical preparation for childbirth and beyond, and the role of physiotherapy

After reading this chapter and practising the suggested activities, you will:

• have increased your awareness of the effects of pregnancy, labour and the postnatal period on the musculoskeletal system

• understand the benefits of exercise during pregnancy and postnatally

• feel competent to advise women in your care on appropriate exercise and strategies to minimize the symptoms of any musculoskeletal dysfunctions they are experiencing

• have an understanding of the role of physiotherapy in relation to women during the childbearing year and history of the specialty

• know when and how to refer women in your care to a women’s health physiotherapist, where available.

Introduction

This chapter aims to equip midwifery students and midwives with the knowledge and skills required to understand issues such as exercise, good posture, relaxation techniques and effective physical preparation for pregnancy and childbirth, plus common musculoskeletal dysfunctions in pregnancy and childbirth. This will enable them to advise and support women in their care and recognize situations when referral to another professional is indicated. The author is a women’s health physiotherapist and will refer to the role throughout, with further information on the specialty towards the end of the chapter.

Exercise and sport during pregnancy

Pregnancy is a time when women are often receptive to health education messages. This can include the introduction of exercise as not just having short-term benefits during the pregnancy and childbirth period, but also holding long-term health gains. There is evidence that exercise during pregnancy can benefit both the woman and fetus (RCOG 2006a) and is harmful to neither, provided the pregnant woman is progressing normally and healthily (Artal et al 2003). Therefore it is suggested that women should be encouraged to start, or continue with, appropriate exercise to derive the associated health benefits (NICE 2008, NICE 2010, RCOG 2006a). These include a reduction in fatigue, varicosities and peripheral swelling; a lower incidence of insomnia, stress, anxiety and depression; and, possibly, weight-bearing exercise in pregnancy may result in a shorter labour and a decrease in delivery-related complications (RCOG 2006a). In addition, a randomized study of women with gestational diabetes (Bung et al 1991) found that more than three-quarters of those following an exercise programme demonstrated improved glucose tolerance, so exercise is recommended for this group (RCOG 2006b). There is no robust evidence that exercise will prevent the onset of gestational diabetes in women (Artal & Sherman 1999).

It has been suggested that babies born to exercising women may tolerate labour better and be less likely to demonstrate signs of stress, such as meconium (RCOG 2006a).

There appears to be some variation between what are considered absolute or relative contraindications to (aerobic) exercise in pregnancy (ACOG 2002) and conditions requiring medical supervision while undertaking exercise in pregnancy (RCOG 2006a). Guidance produced by physiotherapists (ACPWH 2004) suggests the contraindications and precautions indicated in Table 22.1.

Table 22.1 Absolute contraindications and precautions to exercise in pregnancy *

Absolute contraindication	Precaution
Serious cardiovascular, respiratory, renal or thyroid disease	Asthma
Poorly controlled type 1 diabetes	Diabetes type 1 if insulin regimens are well controlled and exercise is moderate – discuss with diabetic consultant, nurse or GP
Risk of, or current, premature labour	History of miscarriage
Cervical incompetence	Vaginal bleeding
History or risk of intrauterine growth retardation and premature labour – reduce activity after 12 weeks	Reduced fetal movement
Hypertension – should be discussed with the woman’s doctor	Pre-pregnancy hypertension
Placenta praevia after 26 weeks’ gestation – should be discussed with the woman’s doctor	Placenta praevia
	Vaginal bleeding
Hypertension – should be discussed with the woman’s doctor	Pre-pregnancy hypertension
Severe rhesus isoimmunisation
Sudden swelling of ankles, hands or face	Anaemia
Acute infectious disease
	Extreme obesity
	Breech presentation
	Extreme underweight (BMI <12)
	Heavy smoking
	Thyroid disease

* Adapted from ACPWH 2004.

The aim of exercise during pregnancy should be to maintain or moderately improve fitness levels (ACPWH 2004) without trying to reach peak fitness or train for competition (RCOG 2006a). It is impossible to go into any detail of different regimens within the constraints of this chapter, but the needs of different women will vary, based on whether they were a complete non-exerciser, non-regular exerciser, regular exerciser or elite athlete before conception (ACPWH 2004). Women should be advised to monitor their level of effort during exercise, to ensure that they are not overexerting themselves, and if using a gym, should seek advice from professional staff.

Commonly described tools are the talk test, Borg’s scale of perceived exertion, and heart rate (RCOG 2006a):

• During exercise, the woman should be able to hold a conversation, and not become too breathless to talk

• On a scale of ‘very, very light’ through to ‘very, very hard’ exertion, she should aim for ‘somewhat hard’; around the middle of the Borg scale

Women should avoid overheating during exercise, as a maternal core temperature over 39.2°C might be teratogenic in the first trimester (RCOG 2006a). They can minimize this risk by drinking sufficient fluids during exercise, and avoiding exercise in very hot conditions. Women must also know when to stop exercising, and seek a medical opinion. This includes onset of symptoms such as dizziness, faintness or headache; shortness of breath before exertion or breathlessness during exercise; any pain, e.g. abdomen, pelvic girdle; painful uterine contractions; decreased fetal movements; vaginal loss, urinary incontinence, ruptured membranes; swollen leg(s); muscle weakness (RCOG 2006b).

Regular exercisers familiar with a particular activity or sport, such as walking, aerobics, swimming or dancing, can usually continue with it.

Those unaccustomed to exercise should be advised to start with 15 minutes of continuous exercise three times a week, gradually increasing to 30-minute sessions four times a week or daily (RCOG 2006a). Exercise in water, often referred to as aquanatal exercise, may offer a feeling of weightlessness, and reduced jarring of the joints, possibly offering some relief from aches and pains, an increase in energy and better sleeping (Brook et al 2008).

Scuba diving is contraindicated during pregnancy as the fetus is not protected against decompression sickness and gas embolism, and women should be warned that contact sports and pursuits which might result in a fall, such as horse riding, could result in fetal trauma (ACPWH 2004, RCOG 2006a).

Readers are advised to access appropriate sources – for example, ACPWH 2004, RCOG 2006a and 2006b – for further and updated evidence-based information, before discussing recreational exercise with pregnant women in their care.

Reflective activity 22.1

What exercise groups are available specifically for pregnant or postnatal women in your area? If possible, ask to attend one, or check whether any women you know have attended them, and assess their value. Record this information for future reference.

Muscle groups

Two muscle groups that are affected more than others by pregnancy and childbirth because of their position, structure and function are those of the pelvic floor and abdominal wall. The pelvic floor is described and illustrated elsewhere within this book, but it is also useful to understand the structure and function of the abdominal muscles (Fig. 22.1).

Figure 22.1 Muscles of the abdominal wall. A. Right rectus abdominis. B. Right internal oblique and left external oblique muscles. C. Left transversus abdominis.

(Palastanga et al 2006, reproduced with permission)

The abdominal muscles have various roles, including protection and support for the abdominal contents. More specifically, their main functions are flexion of the lumbar spine (recti abdominis), side flexion and rotation of the spine (external and internal obliques) and postural support (transversus abdominis, working with the pelvic floor muscles) (Brook et al 2008). As pregnancy progresses, the abdominal muscles are stretched considerably by the gravid uterus, causing recti abdominis to become longer, wider and thinner (Y Coldron, unpublished PhD thesis, 2006). In addition, the linea alba (an area of connective tissue in the midline) may become wider and thinner (divarication) or even split (diastasis). Although there is little information on the effect of pregnancy on transversus abdominis (Brook et al 2008), its role along with the pelvic floor muscles – that is, support for the intra-abdominal organs, lower spine and pelvic girdle joints – is significant.

Many women’s health physiotherapists will include pelvic floor muscle and transversus abdominis exercises in any advice they give to pregnant women, whether it is in a parent education session, exercise class, or during individual assessment of a musculoskeletal problem. Midwives may wish to do the same.

Pelvic floor muscle exercises

There is evidence that pelvic floor muscle exercises during pregnancy can prevent urinary incontinence (Mørkved et al 2003) and reduce the likelihood of prolonged second stage labour (Salvesen & Mørkved 2004). The National Institute for Health and Clinical Excellence (NICE) has suggested that pelvic floor muscle training should be offered to women in their first pregnancy as a preventive strategy for urinary incontinence (NICE 2006a).

In non-pregnant women, research has suggested that a sizeable minority of women given verbal instructions on pelvic floor muscle exercises will not perform an optimum contraction (Bump et al 1991) and recent advice on the management of urinary incontinence suggests that a digital assessment of the muscles should be undertaken prior to commencing a course of exercises (NICE 2006a). Physiotherapists have been advised against such examination on pregnant women if there is a history of miscarriage or the woman has been advised to avoid sexual intercourse whilst pregnant (CSP 2003). Also, vaginal examination would not be practical in many situations when a pregnant woman is being advised on pelvic floor muscle exercises, e.g. parent education session, or exercise classes. Therefore, it is important that physiotherapists, midwives and any other health professionals teaching pelvic floor muscle exercises give clear instructions. There are many different ways to do this, including:

‘Imagine you are trying to stop yourself breaking wind, and at the same time trying to stop your flow of urine midstream’ (Brook et al 2008); the ‘lift’ analogy, i.e. closing the doors (a squeeze) and moving upstairs (a lift); the action of a vacuum cleaner (Bø & Mørkved 2007).

If women are not sure that they are contracting correctly, they could look at the perineum using a hand mirror, and see if the area lifts away from the mirror as they squeeze. Alternatively, they could try to stop the dribble at the end of voiding but should not stop midstream as this may disturb normal neurological activity (Bø & Mørkved 2007) and affect emptying.

Advice on how often to exercise and how many squeezes to undertake varies from author to author but a recent review of evidence suggests building up to 8–12 near-maximum contractions three times a day. In addition, any women experiencing stress or urge urinary incontinence should also squeeze before and during those activities which make them leak, e.g. cough, sneeze, on their way to the toilet (Bø 2007). A study of 23 pregnant women complaining of stress urinary incontinence (Miller et al 2008) showed they could reduce leakage by undertaking this anticipatory contraction, often referred to as ‘the Knack’.

Reflective activity 22.2

Try a series of pelvic floor contractions yourself. How can you best describe this to someone else? Try teaching this to a family member or friend who does not know anything about the pelvic floor.