Pregnant With Possibility

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December/January 2001

By Peggy Maas, PT

PTs can broaden their patient population with expectant mothers who can benefit from physical therapy in activities of daily living, ergonomics in the workplace, and fitness considerations.

Expectant mothers might not be the first patient population that comes to mind when thinking of physical therapy clients; however, PTs can offer a wide spectrum of aid, from injury rehabilitation to relaxation training, to modifications and training for activities of daily living, and recommendations for exercise.

Physiological and Structural Changes in Pregnancy

An understanding of the physiology and the structural changes of pregnancy is essential before serving this population. Such knowledge ensures that the therapist can make appropriate clinical decisions.

Many of the dramatic changes that occur during pregnancy are mediated by the changing hormone levels. Progesterone and estrogen are the well-known agents of change in salt and water balance, slowed peristalsis, and changes in respiration. These hormones also impact a woman in more subtle areas, such as the slight alteration in the quality of the speaking voice and the tendency toward a bloody nose.

Relaxin, secreted by the corpus luteum, softens ligaments. The concentration of this hormone is highest early in pregnancy, though its best-known role is allowing the pelvic joints to gap for the vaginal delivery of the baby. There is debate about how long relaxin continues to play a part in ligament integrity postpartum. Clearly, joints are more vulnerable under the influence of relaxin, and this impacts the choice of manual therapy intervention as well as exercise recommendations.

A number of changes affect the respiratory system for women during pregnancy. Respiratory threshold drops, oxygen consumption increases by 14%, tidal volume increases, and the expiratory reserve and residual volume decrease—all creating a very efficient breathing mechanism. The diaphragm elevates and the ribs swing up and out like the handles of a bucket, increasing the rib cage circumference by about 6 cm. Because of this adaptation, the volume of the thoracic cavity does not change even at term.

Cardiovascular changes include a 50% increase in blood plasma volume, with a smaller increase in the red blood cell component, thereby creating a decreased hematocrit. The cardiac output increases due to increased resting heart rate and stroke volume. Peripheral resistance decreases, which can create some blood pressure changes.

Many women experience a return of old musculoskeletal injuries during pregnancy. This is believed to occur because of altered mechanics and the hormonal effects on joints and tissues. Pain can occur at the costovertebral joints because of rib flaring. One musculoskeletal peculiarity of pregnancy is that the round ligament of the uterus develops a smooth muscle component that responds to quick stretch. Occasionally, rapid hip flexion or extension can elicit a quick, sharp pain in the lower abdomen or groin because of this development.

Activities of Daily Living

In the course of working with a pregnant patient, it is important to address the tasks of her daily life. This can be done in the clinic treatment space or in a group class setting. There are some basics to cover such as posture awareness, the use of proper lifting techniques, and body mechanics for all activities.

Posture and carriage are perhaps the most conspicuous and universal changes. Frequent self-assessment in front of a mirror can help women identify and correct problematic tendencies. Early in pregnancy, breasts become tender and enlarged. This can cause a round-shouldered posture and increased kyphosis. If this occurs, the lower cervical spine flexes and there is extension at the upper cervical spine to bring the gaze forward. Often the lumbar lordosis becomes more pronounced as the weight of the abdominal contents increases and the abdominal muscles become disadvantaged in their angle of pull. As the center of gravity moves forward, women compensate by bearing weight more posteriorly, through their heels. Sometimes habit or the desire to relieve pressure on one foot causes the pregnant woman to stand with her weight on one leg, hip thrown out to the side. This asymmetrical stance often provokes an irritable sacroiliac joint complex and an unstable pubic symphysis.

In addition, twisting on planted feet can aggravate problems with the pelvic joints. Household and community chores are fraught with the potential to twist and torque the spine and pelvic joint complex. An irritable sacroiliac area can be made worse by movements as simple as standing and twisting the torso in order to transfer groceries from a shopping cart into a car, or from a grocery bag to a cupboard. Because of ongoing shifts in center of gravity and extra weight, many pregnant women resort to poor lifting techniques.

Learning proper lifting and transferring of loads can prevent injury. Pregnant women need to be reminded to lift with feet apart for stability, bending the knees, and keeping the load close. Getting the load close is awkward when there is a large, gravid abdomen. If the load to be lifted is a child, the patient can be coached to have the child climb onto a stool or chair to make lifting easier. Assisting a child in and out of a car seat without twisting or reaching is one of the most difficult tasks, but it can be mastered in most cars with some logistical planning.

A good night’s sleep can be elusive for pregnant women. Ostensibly, the reason for this is urinary frequency. But finding a comfortable position can be a challenge. A firm mattress is vital, but a top layer of compliant foam, such as an egg-crate mattress, can provide extra comfort. Women are cautioned not to sleep in the supine position, especially during the latter stages of pregnancy. This is because of the risk of the heavy uterus compressing the inferior vena cava, thereby affecting venous return and, perhaps, blood flow to the fetus. A variety of pillow products are on the market to help support the pregnant woman in a side-lying sleeping position. In side-lying, the entire length of the top leg should be parallel to the mattress in order to minimize torque on the low back. Some women experience pain in the trochanteric region in side-lying. A partially inflated ring pillow placed under the patient, at the hip, can provide welcome relief.

Ergonomics

Frequently, pregnant women work under conditions that were not bothersome prior to pregnancy, but become so. Optimal sitting or standing posture and neutral wrist position are particularly relevant. Women are more susceptible to carpal tunnel and other compression syndromes during pregnancy because of the extra fluid throughout the body. Many of these problems can be addressed by working on posture. The relative height of workstations and the physical layout of equipment may need to be adjusted to avoid kyphotic posture and poor wrist alignment. Sometimes devices such as lumbar rolls or wrist rests can be helpful.

Women who stand much of the day must choose shoes with low heels and good support. Prolonged standing or sitting must include intervals of ankle range of motion activity or other exercises to avoid pooling of fluid in the lower legs. This helps reduce swelling and also reduces the chances of forming blood clots. Elevating feet when possible and wearing support hose may help with swollen or aching legs, and may also help women with varicosities. Increased breast size and weight have a deleterious effect on posture and a well-designed bra can reduce upper back strain. Lastly, an on-the-job program of stretching and changing positions can prevent misery by the end of the workday.

Fitness for Pregnant Women

The change in body image and physical energy can be troubling for pregnant women. Frequently, the PT is called on to give exercise recommendations.

From a functional perspective, it is important to determine that certain key muscles are included in the exercise regimen. High on the list of priorities are upper back extensors and scapular area muscles for posture, ankle muscles for stability and balance, quadriceps for good body mechanics, and pelvic floor strengthening to address the stresses that pregnancy places on those muscles. For easing low back pain, pelvic tilts can be performed in standing or quadruped positions, as supine should be avoided.

Pregnant women using gym equipment for strengthening must avoid using the Valsalva maneuver. Resisted adduction exercises can trigger sacroiliac joint problems, as can the multi-hip machines when used in large ranges of motion.

With the growth of the baby, sometimes it feels like there are daily changes in center of gravity. For this reason, pregnancy is not a time for activities requiring high-level balance and coordination. Other women continue with their sport activities through virtually the entire pregnancy. In 1994, the American College of Obstetricians and Gynecologists revoked its conservative guidelines for safe exercise during pregnancy. Currently, while research continues to examine safety issues, prudence is the guide.

The occurrence of diastasis recti impacts exercise regimens during pregnancy and in the postpartum phase. This common condition results from the elongation and softening of the linea alba. The split that occurs can be tested easily by having the woman lie on her back with her knees bent. When she lifts her head and shoulders, as in an abdominal crunch, a positive test reveals a longitudinal gap of two or more finger width between the rectus muscles. When there is a diastasis recti, abdominal exercises must proceed cautiously, and women should be informed of the vulnerability to back injury. After delivery, the woman can proceed with the rehabilitation program that involves a form of curl-ups with the diastasis manually opposed.

Knowledge about diastasis recti and other structural and physiological issues of pregnancy enables a rehabilitation professional to provide support, education, and guidance to pregnant women. In so doing, we can help transform a time of musculoskeletal challenges into a time to enjoy.

Peggy Maas, PT, is the clinical coordinator for Spine Education, Rehabilitation Services at Swedish Medical Center, First Hill, Seattle, and is also a clinical faculty member at the University of Washington, Seattle.

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December/January 2001