Causes
Impairments from conditions such as thoracic outlet syndrome (TOS) or carpal tunnel syndrome (CTS) may be caused by one or more of the following in pregnancy: postural changes in the neck and upper quarter, fluid retention, hormonal changes, or circulatory compromise. Overall, women are three times as likely as men to experience carpal tunnel syndrome. […]

Significance
All joint structures are at increased risk of injury during pregnancy and during the immediate postpartum period. The tensile quality of the ligamentous support is decreased, and therefore injury can occur if women are not educated regarding joint protection. There is much controversy regarding the impact of postpartum hormone levels; however, elevated levels have been […]

Varicosities are aggravated in pregnancy by the increased uterine weight, venous stasis in the legs, and increased venous distensibility.
Characteristics
Varicosities can present in the first trimester, and are more prevalent with repeated pregnancies. They can occur in the lower extremities, the rectum (hemorrhoids), or vulva. Symptoms usually include heaviness or aching discomfort, especially with dependent leg […]

All exercise programs for high-risk populations should be individually established based on diagnosis, limitations, physical therapy examination and evaluation, and consultation with the physician. Activities must address patient needs but should not further complicate the condition.
Develop good rapport with the patient and instill trust. Closely monitor the patient during all activities; re-evaluate her after each […]

Characteristics
Sacroiliac pain is localized to the posterior pelvis and is described as stabbing deep into the buttocks distal and lateral to L5/S1. Pain may radiate into the posterior thigh or knee but not into the foot. Symptoms include pain with prolonged sitting, standing or walking, climbing stairs, turning in bed, unilateral standing, or torsion activities. […]

Back pain commonly occurs because of the postural changes of pregnancy, increased ligamentous laxity, and decreased abdominal muscle function.
Incidence
Back pain is reported by 50% to 70% of pregnant women at some point during pregnancy; this condition contributes to lost work days and decreased functional ability. In addition, symptoms may continue in the postpartum period, with […]

Teach the patient to perform the corrective exercise for diastasis recti exclusive of other abdominal exercise until the separation is decreased to 2 cm or less. The rationale for this is that, due to the angle of attachment of the obliques into the linea alba, there is a possibility that trunk rotation exercises will perpetuate […]

Test all pregnant patients for the presence of diastasis recti before performing any abdominal exercises. This test should be repeated throughout the pregnancy and appropriate modifications made to existing exercises.
Instruct patients to perform a self-test on or after the third postpartum day for optimal accuracy. Until 3 days after delivery, the abdominal musculature has inadequate […]

• Abdominal massage or kneading. Have the patient lie supine or on the left side. This is very effective and typically done with either long or circular strokes. Begin on the right side at the ascending colon, stroking upward, then stroke across the transverse colon from right to left and down the descending colon, then […]

The combined influence of hormones, weight gain, and postural changes of pregnancy contributes to a variety of impairments (in addition to pelvic floor dysfunction that was described in the previous section) that can be addressed with physical therapy.
Diastasis Recti
Diastasis recti is separation of the rectus abdominis muscles in the midline at the linea alba. The […]

A cesarean section is the delivery of a baby through an incision in the abdominal wall and uterus rather than through the pelvis and vagina.. General, spinal, or epidural anesthesia may be used.
Significance to Physical Therapists
Cesarean section (C-section) delivery is now at an all-time high in the United States. In 2004, the rate was 29.1% […]

Knee-chest position with buttocks elevated above heart level. An air embolism, although rare, can occur when the buttocks are elevated and the uterus moves superiorly. The pressure change causes air to be introduced into the vagina and uterus, where it can enter the circulatory system through the open placental site. A pregnant woman is at […]

As the abdomen enlarges, it becomes impossible to comfortably assume the prone position. Exercises that are usually performed in the prone position must be modified.
Standing Push-Ups
Patient position and procedure. Standing, facing a wall, feet pointing straight forward, shoulder-width apart, and approximately an arm-length away from the wall. The palms are placed on the wall at […]

Center of Gravity
The center of gravity shifts upward and forward because of the enlargement of the uterus and breasts. This requires postural compensations to maintain balance and stability.
• The lumbar and cervical lordoses increase to compensate for the shift in the center of gravity, and the knees hyperextend, probably because of the change in the […]

They should be initiated and progressed at the intensity that the woman is able to safely control. Slow, controlled breathing is emphasized while developing the stabilizing function of the muscles.
Precautions
• Because the trunk muscles are contracting isometrically in many of these abdominal exercises, there is a tendency to hold the breath; this is detrimental to […]

Considerable changes occur in the woman’s body as the pregnancy progresses.
Weight Gain During Pregnancy
Current recommendations for weight gain during pregnancy are an average of 25 to 27 lbs.
Changes in Organ Systems
Uterus and Related Connective Tissue
Uterus. The uterus increases from a prepregnant size of 5 by 10 cm (2 by 4 inches) to 25 by 36 […]

There are some circumstances where exercise is contraindicated or requires very specific restrictions and precautions.
Absolute Contraindications
• Incompetent cervix: early dilation of the cervix before the pregnancy is full term
• Vaginal bleeding, especially second or third trimester
• Placenta previa: placenta is located on the uterus in a position where it may detach before the baby is […]

• It is strongly recommended for all women to participate in mild to moderate exercise, for both strength and cardiopulmonary benefits, 15 to 30 minutes/session, most days of the week. Individualized programs, based on prepregnancy fitness level, are preferable.
• Currently, there are no data in humans suggesting that pregnant women need to decrease their intensity […]

Suggest that your patients discuss with their physicians any guidelines or restrictions to exercise before engaging in an exercise program, either in a class or on a one-to-one basis. As always, follow your state practice act for physical therapy regarding referral, evaluation, and treatment.
Examination. Individually examine each woman before participation to screen for pre-existing musculoskeletal […]

Potential Impairments and Functional Limitations
Stress, pain, and muscle imbalances from faulty postures
Poor body mechanics; related to lack of knowledge, changing body size and caring for growing child
Lower extremity edema and discomfort from altered circulation, varicose veins
Pelvic floor dysfunction
• urinary or fecal incontinence
• organ prolapse
• hypertonus
• poor episiotomy healing
• poor proprioceptive awareness and disuse atrophy
Abdominal muscle […]

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 […]