Introduction

Throughout a woman’s life cycle, specific gender differences need to be recognized for their relevance to rehabilitation. Recent research has shown repeatedly that women have specific and distinct physiological processes that extend beyond the obvious considerations of anatomy and hormones, including differences in symptoms of heart attack and metabolism of medications. Clearly, the pregnant or postpartum patient presents a unique gender-based clinical challenge for the physical therapist. Although pregnancy is a time of tremendous musculoskeletal, physiological, and emotional change, it is nonetheless a state of wellness. Pregnant women are typically well motivated, willing to learn, and highly responsive to treatment suggestions. For many women, the therapist is able to assess and monitor the physical changes with the primary focus on maintaining wellness. The ability to educate women about the role of exercise and health promotion during this key life transition provides a significant professional opportunity and responsibility.

Justification

Health department mainly provides maternal care through the MOH offices as a primary care. Some private organizations also conduct workshops and awareness programs to provide knowledge regarding maternal care. According to the annual health bulletin 2014, the cruel death rate (CDR) was 6.2 per 1,000. According to government hospital statistics (government institutions only) the corresponding maternal mortality ratio (MMR) is 19.3 per 100,000 live births. Therefore it is very important to consider maternal care as one of the major part in the health sector.
Objectives

⦁ To develop awareness and control of posture during and after pregnancy
⦁ To learn safe body mechanics
⦁ To develop upper extremity strength for the demands of infant care
⦁ To promote increased body awareness and a positive body image
⦁ To prepare the lower extremities for the demands of increased weight bearing and circulatory compromise
⦁ To develop awareness and control of the pelvic floor musculature

⦁ To maintain abdominal function and prevent or correct diastasis recti
⦁ To promote or maintain safe cardiovascular fitness
⦁ To learn about the changes of pregnancy and birth
⦁ To learn relaxation skills
⦁ To prevent impairments associated with pregnancy
⦁ To prepare physically for labor, delivery, and postpartum activities
⦁ To provide education on safe postpartum exercise progression
⦁ To develop awareness of treatment options for pelvic floor dysfunction

Physical activities and high risk pregnancy

⦁ Preeclampsia

Preeclampsia is a serious complication of pregnancy occurring in about 2% to 8% of women. It is defined by increases blood pressure and protein in the urine, but women often suffer no symptoms initially. Preeclampsia might interfere with food and oxygen passing to the baby, by constriction of blood vessels in placenta, thus inhibiting baby’s growth and causing preterm delivery. It may also affect the mother’s kidneys, liver, brain and or clotting system.

Physical activity has been shown to increase blood flow and reduce risk of high blood pressure. So there is the potential for exercise to help prevent pregnant women developing preeclampsia (Meher S., et al 2006)

⦁ Glucose intolerance and gestational diabetes mellitus

Gestational Diabetes Mellitus (GDM) is one of the most common complications of pregnancy (Tobias D K., et al 2011) GDM is associated with a wide range of adverse outcomes for women and their babies(Bain E., et al ). A study found that women who engaged in physical activities before and during pregnancy experienced 69% reduced risk of developing GDM (Dempsey J C., et al 2004).

Benefits of physical therapy for pregnancy

⦁ Weight management

Weight gain during pregnancy, is known as gestational weight gain (GWG). Excessive GWG is associated with high risk of gestational diabetes mellitus (GDM), hypertension, cesarean delivery and postpartum weight retention. Regular physical activity during pregnancy can reduce GWG by an average of 6.8 pounds compared to women who do not exercise regularly.

⦁ Cardiac and respiratory fitness

Pregnancy is accompanied by many cardiac and respiratory changes that begin during the fifth week of gestation and last until about a year after delivery, Cardiac output and blood volume increase up to 40%. Tidal volume and oxygen consumption (VO2) also increase to supply the oxygen requirements of the fetus.
Aerobic exercise such as static cycling and general floor exercise programs, at least two to three times per week is recommended to maintain cardiovascular fitness, reduces ventilatory demands, enhances the breathing pattern and eventually inhibits exertional breathing problems occur in pregnancy.
⦁ Exercise and psychological wellbeing

Pregnancy can also be a time of major emotional changes. Many women suffer alterations in mood and even prenatal depression. Recent studies have estimated the prevalence of depression during pregnancy to be between 10% and 20%.
The women who keep fit during pregnancy are more relaxed and cope better with the emotional and physiological strains of pregnancy, this is attributed to a number of positive effects from exercise such as weight management, better body image and self-esteem, improved sleep, and increased energy levels.
Exercise is also proven to be effective in treating antenatal depression (El-Rafie, M. M., et al
2016).

⦁ Back pain and postural awareness

Pregnant women typically develop lumbar lordosis, which contribute to the very high prevalence (50%) of low back pain in pregnant women. Exercise, in general, in addition to lumbar stabilization exercises can help to reduce the intensity of back pain.
⦁ Labor outcomes

Pregnant women who maintain a regular exercise routine may experience less pain and shorter labor. This is attributed to the exercise effect on inducing metabolic and hormonal changes that may impact uterine contractility and endurance.
Exercises during pregnancy are also associated with reduced need for Cesarean section.

⦁ Urinary incontinence

Pelvic floor strengthening exercises during pregnancy are helpful in prevention and reducing the symptoms of urinary incontinence.
⦁ Diastasis recti abdominis strengthening

It is generally recommended that women with diastasis recti abdominis (separation of the abdominal muscles) avoid abdominal strengthening exercises, such as curl-ups, until they are able to consult with a physiotherapist.
⦁ Effects on the fetus and the new born

Exercises are not associated with birth weight reduction (Nascimento S L., et al 2012). And found to reduce the risk of preterm birth (Katch V., 2017).
Exercises boost the neuro-behavioral profile and orientation level of the new born; they are more alert and interested in their surroundings, and less demanding on their mothers. Also, babies of physically active pregnant women are lighter and leaner than offspring from nonphysically active pregnant women (Katch V., 2017).

A study that compared placental growth and morphometric measurements found faster placental growth rate, and greater scores on the morphometric indexes of placental function with exercising pregnant women (Clapp J F., et al 2000).

References

Annual health bulletin (2014), Ministry of health and indigenous medicine, Sri Lanka

Bain E, Crane M, Tieu J, Han S, Crowther C, Middleton P. Diet and exercise interventions for preventing gestational diabetes mellitus.

Clapp III JF, Kim H, Burciu B, Lopez B. Beginning regular exercise in early pregnancy: effect on fetoplacental growth. American journal of obstetrics and gynecology. 2000 Dec 1;183(6):1484-8.

Dempsey JC, Sorensen TK, Williams MA, Lee IM, Miller RS, Dashow EE, Luthy DA. Prospective study of gestational diabetes mellitus risk in relation to maternal recreational physical activity before and during pregnancy. American journal of epidemiology. 2004 Apr 1;159(7):663-70.

El-Rafie, M. M., Khafagy, G. M., & Gamal, M. G. (2016). Effect of aerobic exercise during pregnancy on antenatal depression. International journal of women’s health, 8, 53-7. doi:10.2147/IJWH.S94112
Katch V. Pregnancy And Physical Activity( 2017, February, 5). Retrieved from http://michigantoday.umich.edu/pregnancy-and-physical-activity/.
Kisner C, Colby L A, Therapeutic exercise foundations and techniques, 5th edition, Publisher: Margaret Biblis 2007.
Meher S, Duley L. Exercise or other physical activity for preventing pre‐eclampsia and its complications. Cochrane Database of Systematic Reviews. 2006(2)
Nascimento SL, Surita FG, Cecatti JG. Physical exercise during pregnancy: a systematic review. Current Opinion in Obstetrics and Gynecology. 2012 Dec 1;24(6):387-94.

Tobias DK, Zhang C, Van Dam RM, Bowers K, Hu FB. Physical activity before and during pregnancy and risk of gestational diabetes mellitus: a meta-analysis. Diabetes care. 2011 Jan 1;34(1):223-9.