POST NATAL CARE - Cork University · PDF filepostnatal classes held on the wards, ... (CUMH). Immediate post natal care after vaginal delivery or C ... can also be a comfortable position

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POST NATAL CARE

INFORMATION AND EXERCISES TO HELP

YOU AFTER YOUR PREGNANCY

“WOMEN, BABIES AND THEIR FAMILIES ARE THE

CENTRE OF OUR SERVICE AS WE STRIVE FOR

EXCELLENCE AND INNOVATION”

PHYSIOTHERAPY DEPARTMENT CUMH

CHARTERED PHYSIOTHERAPISTS IN WOMEN’S HEALTH

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Introduction

This leaflet is designed to help you recover after your vaginal

or Caesarean section delivery. The information in the leaflet includes safe and effective exercises and advice to help

maintain a healthy back, abdomen (tummy) and pelvic floor muscles for life.

Women’s Health Physiotherapists provide further advice at the

postnatal classes held on the wards, during your inpatient stay, at Cork University Maternity Hospital (CUMH).

Immediate post natal care after vaginal delivery or C-section delivery

Rest

It is vital to have sufficient rest after childbirth to help your recovery. Listen to your body, do not push yourself.

Comfortable resting positions

Rest on your side and make yourself comfortable by placing pillows under your abdomen (tummy) and/or between your

knees.

This position is comfortable if you have stitches in either your

abdomen or your perineum (the area between your legs). This can also be a comfortable position for breast feeding your

baby.

Sitting

It can be uncomfortable to sit due to soreness at the

perineum. To ease the soreness while sitting, take two rolls of towels. Place them on the bed or a chair, parallel to each

other, with sufficient gap between them. Sit with one thigh on one towel and the other thigh on the second towel such that your perineum is placed between the towels and not touching

the bed or chair. Ensure your lower back is also well supported.

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Perching on a wedge pillow can also help relieve the pressure

on the perineum.

Looking after your Bladder

Make sure you empty your bladder within 2 to 3 hours of the

birth of your baby or following removal of the catheter. It is common not to feel the urge to go to the toilet to empty your

bladder, so just go anyway. Your midwife will check, by measuring, the volume of urine you pass following the birth of your baby. This is to ensure your bladder is working normally.

If you are having difficulty emptying your bladder at any stage, inform your midwife on the ward.

In order to help your bladder work normally go to the toilet regularly. Go every 3 hours to empty it, even if you are not feeling the urge to go. Aim to drink 1.5 litres of fluids every

day. Water is the best thing to drink. Limit caffeinated or fizzy drinks to 1-2 cups per day as these can irritate the bladder.

Do not ‘stop and start’ the flow of urine to test your bladder, this only confuses your bladder and can stop it working normally.

Looking after your Bowels

If you have stitches in your perineum, support them by

holding a wad of toilet paper or a sanitary pad firmly over the stitches while your bowels are opening. If you have had a C-

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section, supporting your abdomen wound with your hands or a folded towel may help.

Breathing out slowly as you move your bowels may help ease any discomfort you may have. Do not strain.

Increase your fibre and fluid intake to prevent constipation. Ask your pharmacist for product advice if you are prone to constipation. There is an advice leaflet on constipation on our

webpage http://www.cuh.hse.ie/Our_Services/Clinical_Support_Service

s/Physiotherapy/Services_Provided/Ante_and_post_natal_women/ for further information.

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Care for pelvic floor muscle tears/episiotomy

Your pelvic floor muscles can be injured during a vaginal birth

when the baby’s head is coming down the vagina and crowning. Some women tear naturally while others will have

an episiotomy.

An episiotomy is a surgical cut from the vaginal opening to the left or right side away from the anal sphincter muscle (back

passage).

Tears are graded from 1° (first degree) to 4° (fourth degree).

If you have a 3° or 4° tear a Women’s Health Physiotherapist will meet you during your inpatient stay to give your further advice and information.

Even if you have not received stitches, you may experience some soreness or pain in the perineal area. This can last from

a few days to weeks.

Pain relief

Pain killers such as paracetamol or ibuprofen can help relieve pain. If the pain gets worse or if you have an unpleasant

discharge ask your midwife, public health nurse or GP to check for signs of poor healing or infection. Redness may be a sign of infection.

‘Cold therapy’ such as ice packs or gel packs can relieve pain,

swelling and ease discomfort. If cold therapy is used in the first 2 to 3 days it should be applied for just 10 minutes and no more frequently than 2 hourly. It is very important that

the ice pack does not come into contact with your skin as this could cause a painful ice burn. You should wrap the ice in a

wet towel or facecloth and apply it to the perineum to reduce tissue swelling and pain.

Hygiene Change your pads regularly to reduce the risk of infection.

Showering or pouring warm water over stitches after going to the toilet can be beneficial. Always pat or blot the area dry, never rub. While in the hospital use the shower head or warm

water to soothe the area. At home continue to use the shower head or warms baths.

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Avoid perfumed products such as shower gels, bath salts, bubble bath, feminine wipes, vaginal deodorants, creams or

talcum powder. Do not use herbal or aromatherapy remedies without

consulting a qualified therapist or your doctor.

Pelvic floor muscle advice following vaginal and C-

section delivery

It is important to start your pelvic floor exercises within the first few days after your baby is born or when you feel able.

Your pelvic floor is made up of layers of muscles and tissues which stretch from your pubic bone at the front to your tailbone at the back.

Your pelvic floor muscles support your bladder, uterus (womb) and bowel and play a vital role in controlling your bladder and

bowel. They also affect how you experience sex. Pelvic floor exercises are essential whether you have had a vaginal or a C-section delivery.

Due to tenderness you may have in the muscles it is beneficial to start with an experimental slow squeeze within a day or

two following the delivery of your baby. Often tenderness and soreness can make squeezing your pelvic floor muscles difficult. Try to do a few gentle squeezes 3-4 times per day

and gradually progress as you feel comfortable. This will also help with healing as it improves blood flow and reduces

swelling in the area.

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Pelvic floor muscle exercises There are two different types of pelvic floor muscle exercise, a

slow pelvic floor muscle squeeze and a fast pelvic floor muscle squeeze.

Chose any comfortable position, such as lying on your side, on your back or supported sitting. Keep the muscles of your thighs, bottom and stomach relaxed.

Try and breathe normally as you do the exercises.

Slow pelvic floor muscle squeeze As you breathe out pull up the muscles of your back passage as if you are trying to stop passing wind. Hold for as long as

you can comfortably. This may only be for a second or two initially. Aim to hold for 5 seconds.

Allow the muscles to relax and rest for 10 seconds. Repeat this 3-5 times.

As you breathe out pull up and lift the muscles at the front as if you are trying not to pass urine. You may feel the muscles

around your back passage squeeze also, this is normal. Hold for as long as you can comfortably. This may only be for a

second or two initially. Aim to hold for 5 seconds. Allow the muscles to relax and rest for 10 seconds. Repeat this 3-5 times.

Now squeeze both together .You may feel the lower part of

your stomach gently draw in, this is normal. Hold for as long as you can comfortably. This may only be for a second or two initially. Aim to hold for 5 seconds.

Allow the muscles to relax and rest for 10 seconds. Repeat this 3-5 times.

Aim to be able to hold for 10 seconds by 6 months following the birth of your baby.

After 2-3 weeks, once you are comfortable practicing the slow

pelvic floor muscle squeezes add in fast pelvic floor muscle squeezes.

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Fast pelvic floor muscle squeeze As you breathe out quickly pull up both the front and back

passage for 1 second. Let go and feel the muscles relax for 3 seconds. Repeat 3-4 times.

The Knack – Use this fast pelvic floor muscle squeeze exercise before you sneeze or cough. This helps prevent leaking from the bladder.

Advice on recovery following a Caesarean delivery

Follow the advice on rest and looking after your bladder and bowels described earlier in the booklet.

There are several layers of stitches in your lower abdomen

that will take time to heal so increase your activities gradually as you feel able.

Take regular pain relief as you require it in the first 1-2 weeks. In the first 2 days while your level of mobility is less than

normal, maintain circulation by bending your ankles and feet up and down briskly for 30 seconds every hour.

When lying on your back it may be more comfortable to place a pillow under your knees and feet to keep your feet raised

and supported. If lying on your side is uncomfortable place a small towel roll or pillow under your abdomen to give ease.

When coughing/sneezing/laughing, lean forward, support your stitches

with your hands or a towel roll or a pillow across your lower tummy area. In order to help your wound to heal

avoid any activities that cause strain for the first 6 weeks.

This would include prolonged standing, heavy work such as vacuuming and lifting anything heavier than your baby.

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Back care post C– section: Getting in and out of bed

Driving post C-Section Driving is normally safe after 5-6 weeks , however seek

clearance with your GP/Consultant at your 6 week check up. Ensure that you:

Check with your insurance company that you are covered.

Take a driver with you on your first journey.

Are able to concentrate as normal. Can wear a seat belt comfortably.

Can look over your shoulders and turn the steering wheel without discomfort.

Can perform an emergency stop without undue pain.

Try this by applying the brakes hard in a stationary car.

Getting out of bed

Roll over onto your side. Bring your hands across to grip

the edge of the bed for

support.

Drop both your legs over the edge of the bed.

Use your elbow and hands to push yourself into a sitting position.

Once you are sitting up, progress to standing slowly.

Getting into bed

Reverse the process.

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Taking care of you back and pelvis following the

birth of your baby

Your back and pelvis are particularly vulnerable to strain in the first 3 months following the birth of your baby. This is

because your abdominal and pelvic floor muscles are weaker as a result of the pregnancy and birth. Your pregnancy

hormones can also continue to have an effect on your pelvic joints.

Avoid stooping, twisting or bending over from your waist. This

can place a lot of strain on your lower back and pelvis. Instead try and have things up at a comfortable height so you do not

have to bend over.

When you are picking your baby up out of the cot lower the cot side if possible and bend your knees to avoid stooping

over.

Lifting and carrying

Take care with lifting heavy things for the first 3 months after your baby is born. If you have had a c-section you should not

lift anything heavier than your baby for the first 6 weeks.

If you need to work at a low

height bend your knees or kneel down rather than

stooping

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When lifting bend your knees and keep your back straight. If you feel strain gently draw in your lower tummy and or pelvic

floor muscles as you lift.

Keep whatever you are lifting close to your body to minimise strain. Holding it away from your body increases strain on

your back.

Avoid carrying heavy loads. For example instead of carrying a

baby bath full of water, use a hose/tap or a jug to fill and empty it. If you are carrying laundry or shopping, carry small loads or ask for help.

If you already have small children, kneel down to comfort them or sit and let them climb up to you instead of lifting. Let

them climb into the car seat by themselves if they can. When putting the baby in or taking the baby out of the car seat stay as close to the car seat as you can. Try not to

stretch from the door, rather place a knee on the seat beside their car seat to get as close as possible to it

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Feeding your baby

Pushing the buggy

If your back or neck are sore, using a hot water bottle

wrapped in a towel for 15-20 minutes at a time will help give ease. The second abdominal exercise below can also ease lower back soreness.

When sitting ensure your feet and your back are well supported. Avoid very low chairs

Use a small step under your feet and/or a cushion behind your back to make

yourself comfortable.

Use some pillows under the baby to bring them closer to you, this will allow

you to sit taller and take strain off your upper back and shoulders. If using a

breastfeeding pillow you may need an extra pillow underneath it. Placing a pillow under your arm to support it may

also help.

Alternate sides you feed and wind the

baby, particularly if you are bottle feeding.

If feeding in bed use pillows to maintain

a good upright position. Alternatively try lying on your side to breastfeed. It

may be more comfortable to sit out in a chair if you find it difficult to get a good

supported position in bed.

The handles of the buggy should be at the waist height if possible.

Stand tall and gently draw in your lower tummy when pushing

the buggy. This will help to ease the strain on your back when pushing.

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Abdominal Exercises for the first 6-8 weeks

postnatal: You can start these exercises immediately after the birth of your baby or when you feel well enough.

Exercise 1: Transversus Abdominus

This is your deepest abdominal muscle. It is like the body’s natural corset. It works gently all day long to support your abdomen. By doing this it gives support to your back and

pelvis. The easiest position to start this exercise is in side lying as in

the picture below. Once it becomes stronger in this position you can also practice it in sitting and standing.

Take the above given position.

Let your tummy sag. Breathe in gently. As you breathe out, draw your lower tummy in gently

towards your back as if you are pulling up the zipper of your pants.

It may also make it easier to feel the muscle work if

you place your hand on your lower tummy below your belly button. As you breathe out and draw the lower

tummy in gently, you should feel it move away from your hand.

Aim to start holding for 3 seconds and progress to

holding for 10 seconds. You should be able to breathe and talk while doing this

exercise. Try and increase the number of times you do this in a

row, start with 4-5 times, gradually increase to 10

times Little and often during the day i.e.4-5 times is good to

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practice this exercise, particularly in the first few weeks after your baby is born. This will help build up the

stamina of this muscle quickly for you. You may notice your pelvic floor muscles working while

doing this exercise. This is quite normal as both muscles work together to support your pelvis and back.

If you have had a c-section and are having difficulty

doing this exercise, you may in fact find it easier to do this exercise by first drawing up your pelvic floor and

then draw your tummy in gently. Exercise 2: Pelvic tilting

Lie on your back with your knees bent and your feet flat

on the bed/floor. You will feel a small gap between your lower back and

the bed/floor. Gently draw in your lower tummy muscle as in Exercise 1 and then roll your pelvis back to flatten your back completely onto the bed/floor.

If you find your abdominal muscles are doming or bulging forward go more gently with this exercise to

avoid this. Aim to start holding for 3 seconds and progress to

holding for 10 seconds.

Start off doing as many repetitions as you can comfortably. Gradually aim to build that you could do

10 repetitions in a row. Aim to do this exercise 1-2 times daily

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Diastasis Rectus Abdominus (Separation of

Abdominal Muscles) DRAM

The rectus abdominus muscle sits on top of all the other

muscles of your abdomen. DRAM is simply a thinning and widening of the tissue connecting the left and right sides of

the muscle.

A certain amount of separation in pregnancy is normal as it allows your abdomen to expand and make room for the

growing baby. Consequentially, doming, or bulging forwards of the abdominal muscles may have been noted during

pregnancy. You may have noticed this while trying to come to sitting from lying, or getting out of the couch or bath. Over a third of women can have a gap of two fingers or more after

their first baby.

Self-check for DRAM

Can be checked from 2 days to 1 week postnatal. This is a test not an exercise.

Lie on your back with knees bent and feet flat on the floor. Place one hand behind your head and the other on your tummy.

Sink your fingertips into the tissue just above your bellybutton. Your fingers must be pointing straight down

i.e. perpendicular to the floor and parallel to your waistband. With your abdominal muscles relaxed, roll your upper body off the floor into a “crunch”, making sure that your ribcage moves

Doming of the muscles when going from lying to sitting

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closer to your pelvis. It is important that you raise your head & both shoulders away from the floor. Use the hand behind

your head to help you to do this. You should feel the gap in your abdomen narrowing as you lift your head off the bed.

The muscle will feel hard around your fingers. If there is a gap greater than 2 fingers then you should follow the advice below.

Do’s & Don’ts

It is important to avoid heavy lifting and any activities that produce ‘doming.’

Get in & out of bed as shown on page 9. The exercises on pages 13-14 are safe to do and will help the recovery of the muscle.

Wear elasticated support underwear or an abdominal support for the first six weeks after the birth of your baby if it is

comfortable to do so. Wear it during the day when you are active and remove when going to bed at night. Avoid constipation as this will strain your tummy muscles, see

page 4. Repeat the test above at 6-8 weeks post partum. If it has not

improved or is still greater than 2 fingers width when you lift your head, contact a Chartered Women’s Health Physiotherapist who can assess & progress your exercises to

aid recovery. For details www.ISCP.ie/cpwh Our webpage

http://www.cuh.hse.ie/Our_Services/Clinical_Support_Services/Physiotherapy/Services_Provided/Ante_and_post_natal_wo

men/ has a more detailed information leaflet on this.

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Returning to Exercise Exercise should always be undertaken gradually. Walking is the best exercise to start with. You can start as soon as you feel able. To begin with go at a nice gentle pace

for 5-10 minutes. Gradually progress at a pace that suits you. Always remember to walk tall and draw in your lower tummy.

Low impact activities such as swimming or cycling can be resumed once your stitches have healed and you can sit comfortably – this usually after your 6 week check-up with

your GP. Avoid high impact exercise e.g. running, jumping, contact

sports, aerobics classes for 12 weeks post delivery. This is to allow time for your abdominal and pelvic floor muscles to recover.

Sexual Intercourse It is preferable to wait six weeks until your GP/Consultant check up to ensure your stitches are fully healed. However after that sexual relations may be resumed when you feel

ready. You are the best person to know when your body has fully recovered and you feel emotionally and physically ready

to resume sexual relations. Find a position most comfortable for you, use plenty of lubrication and start gently. If you have any concerns about physical or emotional issues

which prevent you resuming normal sexual relations with you partner or if you have persistent discomfort or pain with

intercourse discuss this with your GP/Consultant/Public Health Nurse/ Midwife or Physiotherapist.

Sore or Sensitive c-section scar It takes your scar about 6 weeks to heal fully. It is normal in the first few weeks after the birth of your baby for your c-

section scar to feel tender, itchy and numb. Once your scar has healed it is normal for the scar to be pink or red and

slightly raised. It should not be excessively sore or sensitive preventing you from doing your normal everyday activities. It takes about 2 years for your scar to fade to a smooth white

line.

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While your scar is healing the scar tissue may stick or adhere to the skin and muscles around it. This can restrict movement,

making the scar sensitive or painful. Massaging your scar once it has healed helps to reduce adhesions.

Before you massage your scar it must be fully healed i.e. no open areas or scabs. Check with your GP or consultant before you begin.

Please see our webpage to download a leaflet on how to do scar massage.

http://www.cuh.hse.ie/Our_Services/Clinical_Support_Services/Physiotherapy/Services_Provided/Ante_and_post_natal_women/

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Advice on your helping your baby’s development Tummy time

Remember to place your baby on their back for sleep. However when they are awake and alert placing them on their

tummy can really help their development. Babies achieve better head control and stronger muscles in their shoulders arms and necks when they commence tummy time from birth.

While they are on their tummies, babies move from side to

side which helps them to learn to crawl and reach.

Tummy time also helps to improve hand-eye co-ordination and babies develop better balance and co-ordination

You can start once your baby is born by placing the baby on your chest in

a semi-reclined position (ref Fig 1). Hold the baby facing you. This is a great way to play with your baby as

they have to lift their head to see your face, whilst also strengthening

their neck muscles. Fig. 1

As your child develops, you can progress onto tummy time on their playmat or the floor (Ref. fig. 2). Place mirrors and

brightly coloured toys in front of the baby to encourage them to lift and turn their head. A rolled up towel under their chest

can help your baby to raise their head. (Ref fig. 3)

Fig. 3 Fig. 2

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Use of baby walkers, door jam-jumpers and jumparoos Physiotherapists actively discourage their use. There are two

main reasons for this:- 1. Safety – even under supervision there are high

numbers of accidents reported every year, including; falling down stairs, head injuries, burns, scalds, and trapped arms/legs.

2. Delayed development – Contrary to belief, baby walkers

will not help your baby learn to walk. Using one too much may even delay their development. Children who use baby walkers very often use their tiptoes to move

around in the baby walker and this can delay normal walking. Your baby needs to learn to roll, crawl, sit and

play on the floor, in order to reach their developmental milestones and understand spatial awareness

Our recommendation is not to use baby walkers/ jumpers, however if you decide you want to use these, please ensure

your baby is supervised and never in them for more than 20 minutes at a time

Plagiocephaly -flattening of the skull The skull bones in a newborn infant are quite thin and flexible to

allow for passage through the birth canal. Quite often, a baby may show flattening of the skull at birth due to positioning in the

uterus or birth canal. This will usually correct itself once you follow the advice below. The same flexibility of the skull may result in flattening of the head after your baby is born if they

spend long periods of time with their head in the same position. Therefore to help correct or prevent flattening of the skull we

would advise the following: Sleeping Remember to place your baby on their back for sleep. Their

sleeping environment should be a firm surface, without comforters, pillows, or stuffed animals close to the baby’s head.

Their feet should be to the bottom of the cot / moses basket Whilst your baby is sleeping on their back, you can adjust the

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environment so that everything exciting is in the direction that encourages them to turn their head to their least favoured

side – for example, alter the position of any light source or mobiles. Try to alternate head position when your baby is

lying on their back if they do not have a favoured side. Repositioning your baby Encourage them to turn their head to their least favoured side

so they are not putting pressure on the flattened area. Overstimulate their least favoured side (by placing

toys/mirrors to that side) to increase awareness of it. Check how they are lying in the car seat or buggy too. Limit time in their carseat to when you are actually travelling. Whether you

breast or bottle feed your baby, change the arm you hold your baby in, to make sure they are turning their head both ways.

If they do not have a favoured side, approach equally from both sides when feeding. Play

It is important for babies to experience different positions during wakeful supervised periods, for example spending time

on their tummies or even on their sides. ‘Tummy time’ for play: The more time babies spend on their

tummies, the better the chance of stopping the flattening of their skull getting worse and allowing natural correction to begin, so play with them on their tummy. Babies like to learn

to lift their heads and look around them. Sidelying for play: Lie your baby on their side on a play mat

with a rolled towel behind them to prevent them from rolling back. This is a nice position for babies to learn to play in. If your baby has an area of flattening on one side then lay them

on their other side, otherwise lay your baby down equally on their right and left side to play.

Always make sure your baby is awake and not left alone when in these positions.

If you have any concerns regarding your child’s development, please contact your GP or your Public Health Nurse.

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Contact the CUMH Physiotherapy service if, 6 weeks following the

birth of your baby, you have:

Bladder or Bowel problems.

Vaginal discomfort/heaviness.

Pain on sexual intercourse.

Pain in the area between your legs around your vagina and/or tip of

your tailbone

Please discuss with your GP referral to your local chartered

physiotherapist if you have:

Pain or discomfort in your back or pelvis.

Doming of the tummy muscles at the belly button level of the

abdomen on bending, stooping or while coming to sitting from lying.

Require advice with regard to fitness and exercise post delivery.

Contact information

Physiotherapy Department CUMH

Tel no.—021 4920567

Cork University Maternity Hospital

Tel no. – 021 4920500

Website:

http://cuh.hse.ie/Our Services/Clinical Services/Cork University

Maternity Hospital

Acknowledgements

ACPWH (2006) Fit for Motherhood

ACPWH (2004) Fit and Safe to Exercise in the childbearing year