The physical changes to a women’s body as related to pregnancy are multiple. The centre of mass changes, there is more pressure on the organs, and there is increased weight to be carried. All of this in a relatively short span of time often leads to back pain, pelvic pain and urinary incontinence. In fact, over two thirds of pregnant women experience back pain, one fifth experience pelvic pain and over 40% experience urinary incontinence in their first pregnancy – with half remaining incontinent at 8 weeks post-partum, and one third experiencing a new onset of incontinence after childbirth. So how can physiotherapy help in pre and post natal women?

Evidence shows that group training programs designed and delivered by physiotherapists can relieve lower back pain, pelvic pain and urinary incontinence in pregnant women.

A randomized controlled trial by Morkved et al., of 289 pregnant women showed that 12 weeks of specially de-signed group training by a physiotherapist was effective in preventing lumbo-pelvic pain at 36 weeks of preg-nancy. The trial group participated in physiotherapist lead exercises 60 minutes a week from the 20th through the 36th week of pregnancy. There were significantly fewer women in the training group that reported lumbo-pelvic pain during pregnancy and after delivery.

A Cochrane review conducted in 2007 looked at interventions for preventing and treating back and pelvic pain in pregnant women, and found evidence for strengthening exercises, pelvic exercises, and water gymnastics reduc-ing lower back pain intensity better than standard prenatal care.

Another study by Morkved et al. of 301 pregnant women showed strong evidence for the prevention of urinary in-continence after a 12 week intensive pelvic floor muscle training supervised by physiotherapists at both 36 weeks of pregnancy and 3 months post-partum.

Harvey’s 2003 study of pregnant women showed that post-partum pelvic floor muscle training appeared to be ef-fective in decreasing post-partum urinary incontinence.

In 2005 the Canadian Physiotherapy Association and the Society of Obstetricians and Gynecologists of Canada issued a joint policy statement on Postural Health for Women and the Role of Physiotherapy. With respect to pregnant women, the joint policy statement recommends:

1. Physiotherapist directed pelvic floor muscle training to prevent urinary incontinence during pregnancy and after delivery.

2. Physiotherapist directed core stability training to prevent and treat back and pelvic pain during and following pregnancy.

While pre and post natal exercise programs are common, and they help many mothers, they may be harming oth-ers. An informal survey of a small number of these programs revealed;

– most lack even a basic screening, assessment or continued monitoring
– exercises were not adapted for any pain, posture or incontinence issues
– key factors such as the presence of a diastasis recti or caesarean section delivery were not addressed programs
– presented exercises that were contraindicated or not suitable for pregnant women in general
– there was no accommodation for the stage of pregnancy or post-partum status
– exercises presented in group class settings were the same for all participants, regardless of ability, stage of pregnancy and health status

How Can Physiotherapy in Pre and Post Natal Women Help?

It is within the scope of practice of a physiotherapist to properly assess, treat and educate pregnant women in effective and safe exercises that have been shown to decrease back pain, pelvic pain and urinary incontinence – throughout their pregnancy and post-partum.

A good physiotherapist delivered program for pregnant women would;

1. Screen patients to ensure they could safely participate in an exercise program;

2. Assess patients for posture, strength, flexibility, balance as well as any musculoskeletal issues that could have a bearing on pregnancy;

3. Instruct patients on how to perform exercises safely and effectively;

4. Utilize an individualized approach – even in a group setting;

5. Enable group discussion and education regarding pre and post natal issues.

The goal of such a program would be to offer women improved prenatal fitness – that would lead to a healthier and easier pregnancy and delivery. A good program would also offer an integrated approach to health care – and share detailed assessment findings with the participant’s primary and pregnancy health care providers. As well, for women who are experiencing a high risk pregnancy, private sessions should be arranged with strict observa-tion of the health care provider’s restrictions with a focus on maintaining the pelvic floor and alleviating pain.

In researching this subject matter, this author discovered that the ideal program as described above – does not exist in our area. This program will be added to the authors personal practice. The program will be delivered in two parts
– one for pre natal mothers called ―Deliver Strong‖, and
– one for post natal mothers called ―Restore the Core‖.

Further program details will be sent to all Guelph area MD’s, but please feel free to contact the author directly through South City Physiotherapy of you would like more information.

I look forward to helping make sure that your pregnant patients are at their best for the birth of their baby.

References

Britnell, SJ et al. Postural health in women: The role of physiotherapy. Journal of Obstetrics and Gynaecology Canada 2005;27:493-510.
Harvey, MA. Pelvic floor exercises during and after pregnancy: A systematic review of their role in preventing pelvic floor dysfunction. Journal of Ob-stetrics and Gynaecology Canada, 2003;25:487-498.
Morkved S, Salvesen KA, Schei B, and Bo K. Does group training during pregnancy prevent lumbopelvic pain? A randomized clinical trial. Acta Obstet Gynec 2007;86:276-282.
Morkved S, Bo K, Schei B, and Salvesen KA. Pelvic floor muscle training during pregnancy to prevent urinary incontinence: A single-blind randomized controlled trial. Obstetrics & Gynecology 2003;101:313-319.
Nordahl K., Petersen C., Jeffreys R. Fit To Deliver: An Innovative Prenatal and Postpartum Fitness Program. Hartley and Marks Publishers Inc., 2005.
Pennick VE, YoungG. Interventions for preventing and treating pelvic and back pain in pregnancy (Review). Cochrane Database of Systematic Reviews 2007;(2):CD001139.
Stuge B, Gunvor H and Vollestad N. Physical therapy for pregnancy-related low back and pelvic pain: a systematic review. Acta Obstet Gynecol Scand 2003;82:993-990.