Postnatal Period

Original Editor - Safiya Naz
Top Contributors - Safiya Naz, Audrey Brown and Kim Jackson

Introduction[edit | edit source]

The postnatal or postpartum period is the period that occurs immediately after childbirth. The postnatal period a critical, yet often neglected period in a new parent's life. According to the World Health Organization (WHO)[1], most maternal and newborn deaths occur in this period, therefore, proper parent and newborn management and care are vital.

Mother Holding Newborn Baby

The postnatal period is generally distributed into three distinct, but continuous phases:[2]

  • Acute Phase: 24 hours immediately following delivery
  • Sub-Acute Phase: can last 2-6 weeks following delivery
  • Late Phase: can last from 6 weeks - 6 months following delivery[3]

The length of the Late Phase is dependent on major muscle tone and connective tissue recovery in the postpartum person. The physiological changes happening in the Late Phase are generally very gradual and subtle.[2]

Postnatal Clinical Presentation and Considerations[edit | edit source]

Physical Therapy's Role in the Postnatal Period[edit | edit source]

Physical therapy, through a combination of manual therapies, specific treatments (such as pelvic floor muscle training), and therapeutic exercise, can improve health outcomes for new mothers in the postnatal period. Physical therapy interventions may help with the following:

  • Improve mood
  • Improve cardiorespiratory fitness
  • Promote weight loss
  • Reduce the risk of postpartum depression and anxiety
  • Enhance psychological well‐being
  • Improve sexual health and sexual dysfunction
  • Lead to better outcomes assessing quality of life.[15][8][16][17]

Specific Interventions[edit | edit source]

Diaphragmatic Breathing[edit | edit source]

[18]

Diaphragmatic Breathing is a powerful breathing exercise to promote efficient respiration, bring awareness to breath control and postural control, enhance relaxation, and improve core muscle stability. [19]

Exercise[edit | edit source]

[20]

Numerous studies show positive effects of aerobic and strengthening exercises for people in the postnatal period. [12][15][16][17][21] [22]. The United States Department of Heath and Human Services (USDHHS), "recommended that healthy postpartum women who were not highly active or engaging in vigorous intensity physical activity should obtain at least 150 minutes of moderate intensity aerobic activity spread throughout the week. Those who were highly active could continue their physical activity into the postpartum period, provided that they remained healthy, and should discuss this issue with their healthcare provider. "[16] Additional guidelines suggest returning to pre-pregnancy exercise levels gradually and advise caution with resuming high-impact activity too soon after childbirth.

If the postpartum person is breastfeeding, light to moderate exercise does not seem to affect breast milk, whereas high-intensity exercise can increase lactate levels in milk.[17][22]

  • Specific, deep core strengthening and stability exercises can help heal diastatis recti and improve quality of life in postpartum people.[23]

Pelvic Floor Exercises[edit | edit source]

[24]

Pelvic floor muscle exercises are vital for addressing pelvic pain, urinary and fecal incontinence, and sexual dysfunction. [16]Pelvic floor exercises strengthen the pelvic floor muscles through muscular hypertrophy, allowing the muscles to better support the pelvic organs and structures and lessening the burden imposed on the supporting ligaments in and around the pelvis. Pelvic exercises also increase blood flow to the pelvic floor, which help expedite the healing of damaged tissues.

  • Kegel exercises, and other exercises that involve the repeated tensing and relaxing of the pelvic floor muscles, strengthen and improve sexual function in postpartum people. [25]
  • Biofeedback and electrical stimulation can also be used in concert with pelvic floor muscle exercises[8]
  • Pelvic floor exercises have been shown to help reduce symptoms of urinary and fecal incontinence [26]

Hydrotherapy (Aquatherapy)[edit | edit source]

Research has shown the efficacy of an aquatherapy protocol as an alternative or adjunct to medication for early postpartum pain reduction[27][28]Hydrotherapy has known effects to reduce pain, reduce muscle spasm and promote relaxation. A complete medical history of a postpartum person should be taken before attempting hydrotherapy to avoid health emergencies and negative health effects.

[29]

Clinical Takeaways[edit | edit source]

  • Obtain medical clearance from the postpartum person's primary care provider before beginning physical therapy intervention
  • Be aware of any pre-existing or prior medical conditions for the postpartum patient
  • Encourage a return to movement
  • Identify fear-avoidant behaviors early and address them
  • Teach the exercises that are appropriate.[16]
  • Include exercises and interventions that strengthen and stabilize the pelvic floor
  • Begin with low-intensity activity and gradually increase to moderate efforts
  • Women who are competitive athletes and those doing higher-intensity training before pregnancy can usually return to those levels fairly quickly.
  • If the postpartum person is on bedrest for a prolonged period of time, teach diaphragmatic breathing and vigorous circulatory exercises (ex. ankle pumps).

References[edit | edit source]

  1. WHO Recommendations on Postnatal Care of the Mother and Newborn. Geneva: World Health Organization; 2013 Oct. Executive summary.Available from: https://www.ncbi.nlm.nih.gov/books/NBK190090/
  2. 2.0 2.1 Romano M, Cacciatore A, Giordano R, La Rosa B. Postpartum period: three distinct but continuous phases. Journal of prenatal medicine. 2010 Apr;4(2):22.
  3. Chauhan G, Tadi P. Physiology, Postpartum Changes. StatPearls Publishing. 2020 Mar 15.
  4. 4.0 4.1 Chauhan G, Tadi P. Physiology, Postpartum Changes. [Updated 2020 Dec 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555904/
  5. da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy. 2015 Feb 1;20(1):200-5.
  6. DeLancey JO, Kearney R, Chou Q, Speights S, Binno S. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstetrics & Gynecology. 2003 Jan 1;101(1):46-53.
  7. Viktrup L, Lose G, Rolff M, Barfoed K. The symptom of stress incontinence caused by pregnancy or delivery in primiparas. Obstet Gynecol. 1992 Jun;79(6):945-9. PMID: 1579319.
  8. 8.0 8.1 8.2 Hadizadeh-Talasaz Z, Sadeghi R, Khadivzadeh T. Effect of pelvic floor muscle training on postpartum sexual function and quality of life: A systematic review and meta-analysis of clinical trials. Taiwanese Journal of Obstetrics and Gynecology. 2019 Nov 1;58(6):737-47.
  9. Fonti Y, Giordano R, Cacciatore A, Romano M, La Rosa B. Post partum pelvic floor changes. Journal of prenatal medicine. 2009 Oct;3(4):57.
  10. Cho HL, Lee DK, Seung JH, Kim DI, Lee TK. The clinical study of Postpartum Edema. The Journal of Korean Obstetrics and Gynecology. 2002;15(3):151-.
  11. Christenson A, Johansson E, Reynisdottir S, Torgerson J, Hemmingsson E. Women's perceived reasons for their excessive postpartum weight retention: a qualitative interview study. PLoS One. 2016 Dec 9;11(12):e0167731.
  12. 12.0 12.1 Farpour-Lambert NJ, Ells LJ, Martinez de Tejada B, Scott C. Obesity and weight gain in pregnancy and postpartum: an evidence review of lifestyle interventions to inform maternal and child health policies. Frontiers in endocrinology. 2018 Sep 26;9:546.
  13. de Winter J, de Hooge M, van de Sande M, de Jong H, van Hoeven L, de Koning A, Berg IJ, Ramonda R, Baeten D, van der Heijde D, Weel A. Magnetic resonance imaging of the Sacroiliac joints indicating sacroiliitis according to the assessment of spondyloarthritis International Society definition in healthy individuals, runners, and women with postpartum back pain. Arthritis & Rheumatology. 2018 Jul;70(7):1042-8.
  14. Tavares P, Barrett J, Hogg-Johnson S, Ho S, Corso M, Batley S, Wishloff K, Weis CA. Prevalence of Low Back Pain, Pelvic Girdle Pain, and Combination Pain in a Postpartum Ontario Population. Journal of Obstetrics and Gynaecology Canada. 2020 Apr 1;42(4):473-80.
  15. 15.0 15.1 Larson‐Meyer DE. Effect of postpartum exercise on mothers and their offspring: a review of the literature. Obesity research. 2002 Aug;10(8):841-53.
  16. 16.0 16.1 16.2 16.3 16.4 Evenson KR, Mottola MF, Owe KM, Rousham EK, Brown WJ. Summary of international guidelines for physical activity following pregnancy. Obstetrical & gynecological survey. 2014 Jul;69(7):407.
  17. 17.0 17.1 17.2 Roy, Brad A. Ph.D., FACSM, FACHE Postpartum Exercise, ACSM's Health & Fitness Journal: November/December 2014 - Volume 18 - Issue 6 - p 3-4
  18. https://www.youtube.com/watch?v=bQ5aSSHm6o0
  19. Thabet AA, Alshehri MA. Efficacy of deep core stability exercise program in postpartum women with diastasis recti abdominis: a randomised controlled trial. Journal of musculoskeletal & neuronal interactions. 2019;19(1):62.
  20. https://www.youtube.com/watch?v=DjLxmAUR3To
  21. Rajsekhar H, Sumalatha P. Physiotherapy Exercises During Antenatal and Postnatal International Journal of Physiotherapy. 2015 Oct 1;2(5):745-50.
  22. 22.0 22.1 Daley AJ, Jolly K, Sharp DJ, Turner KM, Blamey RV, Coleman S, McGuinness M, Roalfe AK, Jones I, MacArthur C. The effectiveness of exercise as a treatment for postnatal depression: study protocol. BMC Pregnancy and Childbirth. 2012 Dec;12(1):1-8.
  23. Thabet AA, Alshehri MA. Efficacy of deep core stability exercise program in postpartum women with diastasis recti abdominis: a randomised controlled trial. J Musculoskelet Neuronal Interact. 2019 Mar 1;19(1):62-68. PMID: 30839304;
  24. https://www.youtube.com/watch?v=VhrSG-R90QM
  25. El Nahas EM, Mohamed MA, Kamal HM. Postnatal rehabilitation of pelvic floor muscles using aerobic and Kegel exercises. Bulletin of Faculty of Physical Therapy. 2017 Jul 1;22(2):67.
  26. Deffieux X, Vieillefosse S, Billecocq S, Battut A, Nizard J, Coulm B, Thubert T. Rééducation périnéale et abdominale dans le post-partum: recommandations [Postpartum pelvic floor muscle training and abdominal rehabilitation: Guidelines]. J Gynecol Obstet Biol Reprod (Paris). 2015 Dec;44(10):1141-6. French. doi: 10.1016/j.jgyn.2015.09.023. Epub 2015 Oct 31.
  27. Adherhold KG, Perry L. Jet hydrotherapy for labor and postpartum pain relief. MCN: The American Journal of Maternal/Child Nursing. 1991 Mar 1;16(2):97-9.
  28. Batten M, Stevenson E, Zimmermann D, Isaacs C. Implementation of a hydrotherapy protocol to improve postpartum pain management. Journal of midwifery & women's health. 2017 Mar;62(2):210-4.
  29. https://www.youtube.com/watch?v=mVvzsFk6rPo

.