10.1 Antepartum and Postpartum Physical Therapy

Antepartum and Postpartum Physical Therapy

Use the obstetric history, symptoms and examination to plan movement during pregnancy and to rebuild activity after birth. Screen for complications before interpreting symptoms as normal pregnancy changes or a musculoskeletal problem.

Maternal Physiological Adaptations During Pregnancy

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Supine Hypotensive Symptoms

In the latter half of pregnancy, the uterus can compress the inferior vena cava when the patient lies flat. Reduced venous return can lower stroke volume and blood pressure. Ask about positional dizziness, nausea and lightheadedness. Pallor and sweating may accompany the symptoms.

Saudi MOH guidance advises avoiding exercises lying on the back, particularly after the fourth month. ACOG Committee Opinion 804 flags a possible fall in venous return during supine exercise after 20 weeks. Select side-lying, seated or standing alternatives. The effect depends on position and the individual. In MRI studies, the extent of caval decompression varied with the angle and pregnancy group.

Diastasis Recti Abdominis (DRA)

DRA is widening of the linea alba between the rectus abdominis muscles. The European Hernia Society uses a separation greater than 2 cm as a practical definition. The guideline suggests ultrasound or calipers at 3 cm above the umbilicus for more precise measurement. Record the landmark, position and muscle activity so follow-up is comparable. An estimate by finger width can be used for screening. Interpret width alongside symptoms, functional difficulty and healing when selecting exercise.

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Ask which activities are difficult, and observe breathing and abdominal wall behavior during a task such as a head lift or getting up from bed. Teach a comfortable starting exercise and progress toward the activity goal. Use a visible bulge to guide task modification and use comparable measurements to assess the gap over time. A controlled curl-up program in women 6 to 12 months postpartum improved measured strength without worsening the distance. Early loading still depends on healing, symptoms and current capacity. A targeted abdominal contraction or pelvic floor practice may be useful when the examination identifies a corresponding goal.

Pelvic Girdle Pain (PGP) and Lumbar Radiculopathy

Pregnancy-related PGP may occur near the posterior iliac crest and gluteal fold, at the pubic symphysis or both. Rolling in bed, stairs and single-leg loading can reproduce the symptoms. Lumbar radiculopathy becomes more likely with concordant weakness, sensory change or a reflex difference. Examine the spine, hip and neurological findings as indicated. Pain distribution, provocation and neurological findings each inform the differential.

• Active straight leg raise (ASLR). When brief supine testing is suitable, the original test asks the patient to lift each extended leg about 20 cm and rate difficulty from 0, no difficulty, to 5, unable to perform. It measures perceived task difficulty. Less effort with pelvic support can guide a support trial.
• Posterior pelvic pain provocation (P4). With the hip flexed, stabilize the opposite side of the pelvis and apply a controlled load along the femur. Reproduction of familiar deep gluteal pain supports posterior PGP in context.
• FABER. Observe the location and familiarity of symptoms with flexion, abduction and external rotation. Posterior symptoms can support a pelvic source. Groin pain prompts consideration of the hip. Use the findings with the rest of the examination.

Worked case. At 28 weeks, a patient reports familiar buttock and posterior thigh pain while rolling, climbing stairs and dressing on one leg. She has symmetrical reflexes, strength and sensation. A brief, tolerated assessment reproduces the familiar pain with P4. She rates the right ASLR 4/5, then 1/5 with support. This pattern favors PGP and shows that support may help with a task. Consider a trial of a non-rigid lumbopelvic belt, offer exercise and movement advice, and use seated dressing if it eases symptoms. Reassess walking or stairs with and without the support. NICE NG201 supports physiotherapy referral for exercise advice, a non-rigid belt or both.

Exercise During Pregnancy

For uncomplicated pregnancy, the Saudi MOH healthy pregnancy guide uses about 150 minutes of moderate activity per week. ACOG 804 also supports 150 minutes of moderate-intensity aerobic activity. An example is 30 minutes of walking on five days. Someone previously inactive can start with shorter bouts and progress. Use the talk test and perceived effort, adapt the mode to balance and symptoms, and include appropriate strengthening. Water exercise, walking and stationary cycling are options after appropriate screening. Avoid contact or high fall-risk activities and overheating.

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Examples that preclude structured exercise under the 2019 Canadian guideline include ruptured membranes, premature labor, unexplained persistent vaginal bleeding, preeclampsia and placenta previa after 28 weeks. That guideline lists gestational hypertension and symptomatic anemia as relative contraindications requiring discussion with the obstetric clinician. Use the current local obstetric protocol and patient-specific instructions when deciding about planned exercise.

Stop the session and contact obstetric services promptly for warning signs such as vaginal bleeding, suspected amniotic fluid leakage, regular painful contractions, breathlessness before exertion, dizziness, headache, chest pain, weakness affecting balance or calf pain or swelling. Activate emergency assessment for chest pain, marked breathing difficulty, collapse or heavy bleeding.

Postpartum Rehabilitation and Return to Running

Saudi MOH postpartum guidance supports a gradual resumption after an uncomplicated vaginal birth as the patient feels ready, and recommends asking the obstetric clinician when to start after cesarean birth or complications. Light daily movement has a different purpose and load from sport. As healing and tolerance permit, progress from gentle walking and simple exercises toward aerobic and resistance training. The Saudi public-health goal of 150 minutes of moderate aerobic activity per week is a later activity goal. Progression depends on healing, symptoms and birth history.

• Early activity: Choose short walks or comfortable mobility when medically appropriate. Review perineal or incision healing, bleeding, pain and bladder or bowel symptoms. Follow obstetric instructions for wound care and complications.
• Reconditioning: Progress tolerated tasks such as sit-to-stand, calf raises, cycling or longer walks. Check the response during activity and later that day or the next.
• Preparing for running: Assess the patient's goals, prior running, walking tolerance, calf and single-leg capacity, pain, leakage and vaginal heaviness. Choose a graded walk-run plan when readiness supports it. An international Delphi panel favored a person-specific timeline and progressive loading after recovery. It called for validation of proposed readiness criteria.

Sudden heavy or increasing bleeding, chest pain, breathing difficulty, unilateral leg swelling or pain, severe headache or visual change, or fever warrants urgent medical assessment. Vaginal heaviness, leakage or pain during loading warrants pelvic health assessment and adjustment of the exercise plan.