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CHAPTER X
Independent Neurological Rehabilitation Unit, Medical University in Lublin
Samodzielna Pracownia Rehabilitacji Neurologicznej
Uniwersytetu Medycznego w Lublinie
ANNA KRĘGIEL, EWA KOŁODZIEJ, MARLENA ZAKRZEWSKA
Physiotherapy opportunities for women during pregnancy
and childbirth
Możliwości fizjoterapii kobiet w czasie ciąży i połogu
Pregnancy is a special time in woman's life. It is not a pathological condition, but
completely normal, that leads to a number of changes in the body of future mother.
These changes, anatomical and functional, observed mainly in the genital tract, have
an impact on the functioning of the cardiovascular, respiratory and movement systems. Not without significance are also, characteristic for this period, changes in the
area of water - mineral and hormonal economies. All of these changes are designed
to adapt woman’s body to fulfill an important task assigned to them by nature - to
ensure the right conditions for the growth of a new life.
During pregnancy, it is noted in a special way, typical of modern civilization
phenomena: sedentary lifestyle, stillness and the one-sidedness of movement during
professional work. In addition, a quite common occurrence is an insufficient
knowledge of both future parents concerning both pregnancy, labor and childbirth
and responsibilities to the new born child. In the face of these phenomena, preventive physiotherapy seems to be, not only beneficial, but even necessary for the good
of both the individual and society. It seeks to ensure women, being in different state,
with full mental and physical health through targeted actions in the field of general
improving kinesitherapy, specialized methods and psychotherapy [4].
Principles, objectives and organization of comprehensive physical therapy for
pregnant women
The basis for physical therapy for women during pregnancy is kinesitherapy,
covering all issues related to the treatment by means of movement and based on
medical gymnastics. Before starting exercising a woman should consult her gynecologist. The visit is intended to take account of possible contraindications against
their gymnastics practice or to obtain specific recommendations in the case of coexistence of diseases that do not eliminate the possibility of conditioning preparation
for the birth (dispanserial groups) [5, 14].
Contraindications for training include both the body’s general condition:
 acute febrile,
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 purulent processes,
 active tuberculosis,
 unstable heart failure,
 chronic appendicitis with an existing tendency to exacerbations,
 diabetes,
 recently passed inflammatory processes of small pelvic,
and the very pregnancy:
 all cases of uterine bleeding,
 threatened miscarriage,
 placenta previa, loosening up
 severe forms of pregnancy gestosis (toxaemia)
 cervial – isthmic insufficiency,
 polyhydramnios,
 multiple pregnancy,
 pregnancy with dead embryo inside,
 hypotrophy of the fetus (in the current pregnancy or history) [1, 14].
Exercises usually begin with free march with special attention being paid to the
proper posture. The pelvis should be set in a slight ante version with strained abdominal and buttocks muscles. This results in optimal reduction of lumbar lordosis
bent, the back is straight.
Starting positions the most commonly used are: lying, sitting, kneeling, and quite
rarely, standing. In the sitting position, till the end of pregnancy, exercises used are
to increase the range of spine’s motion (extensions, bending, twisting), while unwanted stretching of abdominal muscles is avoided. This position also makes it
possible to do exercises that improve blood flow, especially the distal parts of the
legs, as well as breathing exercises and stretching and loosening muscles. Lying
position is particularly useful for exercises preventing clots in the legs and for loosening places around joints and pelvic floor muscles. During lying the hole body can
achieve maximum of relaxation.
Principles conducting exercises include the following scheme: starting position,
essential exercise, reversion to the starting position, a short rest. Individual exercises
are combined with breathing, lead by means of diaphragm method (ventral), to fulfill the most of lung function. Exercises usually last for 15 - 20 minutes and are
followed by a 15 - minute relaxation. Sets should avoid exercises connected with
elements that can cause a shock to a body - jumping, jumping jacks, landings and
lifting weights and strength exercises. In the second half of pregnancy it is advisable
to involve in the exercises the other person [5].
Classes should be conducted at a frequency of at least two or three times a week
but most authors recommend women, who are prepared to effort connected with
giving a birth, to repeat those exercise everyday. They should be abandoned in case
when a paroxysmal pain occurs [14].
Childbirth is a big effort for a woman in labor, in the case of women giving birth
for the first time, it equals 40 - 50 km distance travelled without rest. In women
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whose exercise capacity is limited, effort during childbirth can cause disruption of
homeostasis and as a consequence a danger to childbirth. The primary objective of
physiotherapy in pregnancy is to prepare the organism for the increased effort and
changes in the organism itself [11]. Physical exercises affect the neural mechanisms
that control skeletal muscle function and therefore have an impact on both the processes of stimulation and inhibition. These include neuronal groups involved in the
control of movements at all levels of the central nervous system, which in turn leads
to the improvement of nervous and muscular coordination. The aim of the exercises
is the reduction or elimination of imbalances and motor coordination. The objective
is also to increase the efficiency of gastrointestinal smooth muscles and abdominal
organs and pelvis, which prevents constipations, common in pregnancy [14].
PHYSIOTHERAPY IN PREGNANCY
Physio – prophylaxis of adverse changes in pregnancy – birth school
The preparation for childbirth is the process of taking knowledge and adapting it
to woman’s own emotions. It is also a means of looking for your own ways to cope
with what pregnancy, childbirth and puerperium entails. At such school the emphasis is primarily put on the reorientation of woman’s maternal attitude and on it’s
fullest commitment to the labor itself. Making a woman aware that, despite appearances, labor is, most of all, a difficult and groundbreaking moment in the child’s
life, is the fundamental idea of labor’s psycho - prophylaxis. Knowledge passed to
the mother is to affirm her conviction that the child's condition after birth depends
on her, as well as to encourage to natural childbirth. A natural way of giving birth is
recognized as a task that a properly prepared woman is able to play consciously,
actively and efficiently. Birth school allows not only to prepare pregnant women for
the physical effort, but can also break the fear barrier and mental preparation for
childbirth. Obtained knowledge has a positive influence on women’s attitudes, anxieties and fear towards birth [2, 4, 10, 16].
The problem of reduced physical activity among pregnant women is mainly due
to the current view that, physical activity during this period should be the reduced or
even eliminated. This supports the passivity of women in this field. Therefore, it is
essential to encourage women to do dosed physical effort by means of exercises
conducted in the birth school. Specialist physical exercises - kinesi stimulation prepare them for the next stages of pregnancy and to hold an active, effective and
active labor by systematic stimulation of the whole organism [12, 22].
Physical preparation of women for the birth is achieved through: exercises shaping correct body posture, general improving exercises, learning the proper breathing
corresponding to the systolic wave process, learning effective pushing methods with
the use of abdominal pressure and neuromuscular training used to optimize the effort
during the labor. Sets of exercises need to take account of their typological characteristics, appropriate pace and adjust them to the stage of pregnancy. The principle
of the gradation of difficulty is also observed. What is more, training system should
be simple enough that course participants can repeat them every day at home [5, 14].
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The moment of starting classes depends on the will of the people concerned. According to the survey, favorable rest and exercise changes (low pulse rate, gas exchange improvement, increase in energy efficiency of the muscles) are formed in the
body after just 4 - 5 weeks of regular exercise. This time well enough to adapt to the
emergence of cardiovascular and acid-base balance of the body, mainly obtained by
adjusting the number of training sessions, while the load is reduced due to a specific
condition that is pregnancy [16, 21].
The founder of Polish birth school, professor Włodzimierz Fijałkowski, recommends participants to start exercises as early as possible. Therefore, methodological
training assumptions cover the whole duration of the pregnancy:
 the first trimester - till 14th week. The purpose of the classes, during this time, is
to teach pregnant woman full, deep breathing, stretching and loosening muscles,
which will create optimal conditions for the development of the fetus. A gradual
adaptation of mother’s cardiovascular system to exercises, which are associated
with pregnancy and childbirth begin in this period. Exercises of distal and proximal parts of the legs, improving blood circulation and preventing swelling and
varicose veins are introduced, breathing and relaxation exercises. In terms of
breathing the training of abdominal and thoracic track is included, tightening and
loosening of abdominal pressure, avoiding exercises that may cause a rapid increase in pressure in central parts of abdominal. Since the beginning of pregnancy it is good to improve the muscular system, in particular the muscles involved
in childbirth. This can be achieved by learning the selective tightening and loosening them in different starting positions, with a particular focus on the gluteus
muscles and the muscles of the perineum with the anus.
 the second trimester – 15th – 32nd week. The main aim of the classes, during
this period, is to maintain full range of motion in the joints, especially in the
spine, increase in muscles flexibility, as well as mastering the ability of their tensioning and releasing. Women doing exercises should pay particular attention to
the need of maintaining good body posture in order to avoid pain in the lumbosacral area.
From 15th till 22dn – 23rd week abdominal pressure and perineum muscle’s
training is essential, increased joint mobility in the lower pelvic area, the development of spine’s flexibility, as well as exercises of long muscles of the back. It is also
important develop in pregnant woman the skills of loosening perinea muscles with
tensing abdominal pressure muscles at the same time.
In the period from 24th to 28th week proper breathing exercises are applied
combined with abdominal pressure action, exercises with gradually decreased load,
as well as relaxation exercises.
In the 29th – 32nd week training includes exercises used in the earlier stages of
pregnancy. The breathing is being improved to be adjusted to the course of all three126
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phase of dilation - to 5 cm in diameter, from 6 to 8 cm and from 9 cm to full dilation
of the cervix. Pushing techniques are introduced. The position during the second
stage of labor, preferred by the creators of birth school, is supported kneeling or
squatting position. Class duration: 30 - 40 minutes.
 third trimester- 33rd – 40th week. The aim of the classes is to stimulate respiration and circulation, as well as the fight against swellings and stimulate peristalsis. The objective is to increase the flexibility of perineal muscles, increase the
flexibility of sacroiliac joints and hip joints and spine. It is also good to obtain
automatism in doing exercises with simultaneous maintenance of a deep, rhythmic breathing. Women who are in the advanced stages of pregnancy should, during exercise, perform rhythmic, deep breathing, mainly of the breast type. During
classes the position is used, which will allow for the relaxation of the long back
muscles and abdomen. They also emphasize strengthening exercises of the foot
arch (in lying and sitting position). Relaxation exercises and the ones stretching
perineum’s muscles and increasing the mobility of sacroiliac joints, hip and lumbar parts of the spine are particularly important during this period. The pregnant
woman should also learn to obtain a comfortable position for maintaining her
well - being, as well as the transition from one to the other without too much effort. Breathing exercises carried out during this period are of multiple types – it
may be a static, deep breathing or the dynamic one connected with the movement of hands and partially of the trunk and respiratory muscles relaxation. It is
important to make women know that some of general improving exercises are directly useful to 'plan' birth. For this purpose, feigned pushing and a couple relaxation is introduced. Class duration: 20 - 35 minutes [5, 14].
Physiotherapy of functional disorders of the women’s movement system during
pregnancy - pains, swellings
Symptoms of both movement and lymphatic systems appear gradually along
with increasing size of the growing baby in the womb. The beginnings of back pains
are observed in the second half (20 - 22 week) of pregnancy. As a result of stretching the intervertebral and lumbar-sacral ligaments and excessive pressures and loads
on the spine in the lumbar-sacral segment, being a result of shifting the center of
body’s gravity for about 2 cm to the front, there is an increased susceptibility to the
damage of the lower intervertebral discs. Back pains, often observed during this
period, may indicate a problem with the fibrous ring. What is characteristic for
pregnant women is that the pain is not accompanied by root symptoms. In addition,
relaxation of the ligaments of the spine, particularly strong at the end of pregnancy,
is the cause of consolidation of abnormal body posture, which in turn leads to increased pelvic anteversion, increased lumbar lordosis and intensified back muscle
and lower limbs tension [14].
The purpose of physiotherapy in order to avoid back pains or therapy of those
pains in pregnant women is mainly providing them with guidance on how to function in everyday life:
 avoidance of harmful influence of shocks and vibration,
 keeping your back upright during working, working position must be stable,
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 long-term stay in a sitting position requires an appropriate chair (with handrails,
wide seat, lumbar support), during sitting it is advisable to use a footrest or stool,
 when working in a standing position woman must often move body weight from
one leg to the other,
 lifting things requires a squat position, back should remain straight and the thing
being lifted should be kept close to the body; it allows to avoid jerking during
lifting,
 wearing shoes is done in a sitting position,
 lying down and sitting needs to be done slowly; when returning to a standing
position a woman needs to remember to rotate on the side and support with arms
and legs,
 morning starting is advisable (mild muscle stretching by means of smooth
movements), gait should be flexible (in comfortable shoes)
 when lying down or during a long car ride it is necessary to support the lumbar
spine area by using, for example a rolled up towel [2, 5].
Among physiotherapeutic activities used to reduce the symptoms of back pains
and edemas, particularly frequent in the lower limbs, the massage it is good to mention. In pregnant women, due to changed physical conditions, other starting positions, than used in the other patients ,are used: kneeling supported by the hands, sit
kneeling with the knees spread widely and the back of the head and torso being on
an elevation - table, back of a chair, a sako bag or a few pads arranged on the front
as well as lying on the side. During the massage, gentle techniques are applied stroking, rubbing, gentle pressure , remembering that around lumbosacral area there
are situated nerve roots are innervating genital organs. The usage of too strong pressure could lead to a miscarriage or premature birth [24, 32].
Lymph oedemas, appearing later than back pains (in the last trimester of pregnancy), can be reduced through massage on a back lying position with the legs being
over the body, for instance on several pillows. Masseur can then rub and press your
legs or gently shake them. This allows for the free flow of blood towards heart,
thereby improving the drainage of lymph. Manual lymphatic drainage (MLD) is also
effective. MLD has two components: the stimulation of lymphatic vessels activity
and draining absorptive systems and drain the existing edema through them. This
type of massage is based on four basic grips, called Vodder’s grips:
 fixed circular motions,
 swivel grip,
 pumping grip,
 a draw grip [5, 32].
An interesting solution to the problems associated with pains and lymphoid
swellings, that accompany women in the last months of pregnancy, is kinesiotaping.
The techniques used, included to soft tissue therapy, by their influence on the fascia,
muscles and ligaments, can have a positive impact on reducing adverse disorders in
the field of biomechanics of body changed by pregnancy. The appropriate plaster
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application causes both the subjective reduction of pain in lumbar-sacral area, as
well as the objective reduction of lower limb circuits compared to the preapplication state, which proves the effectiveness of the method. One of its main
advantages is the lack of invasiveness. Kinesio Tex plasters are similar to the skin in
their physical properties, which allows them to be used on pregnant women in a
simple and safe way. They are non-allergenic and their right construction causes
passing positive information through the skin and sensory receptors. What is more,
plasters are easily accepted by future mothers because they do not limit the ability to
perform daily activities. This allows to maintain a therapeutic effect for 24 hours a
day, over a period from several days to several weeks, thus becoming a costeffective method that excludes additional risks. The possibility of an individual
approach to the problems and needs of every pregnant woman, by matching available techniques to the existing problems, is also important [20, 23, 25, 26].
Among many available applications of kinesiotaping, most commonly used, with
pregnant women are those, which help future mothers in better coping with pains
caused by increased impact on the movement system. This method may be a factor
supporting the work of abdominal muscles. With proper plaster application there is a
possibility, depending on the woman’s needs, of increasing or decreasing the tension
of abdominal rectus muscle and of external and internal oblique muscles. The effect
of appropriately selected application will be restoration of these muscles working as
the 'corset', supporting the correct posture and preventing back pains. Furthermore,
kinesiotaping, in this case, will act as a protection against excessive stretching of the
skin and the formation of stretch marks. Simultaneously to plaster application to
abdominal area, the application to lumbosacral area is often used . The purpose of
doing it is to stabilize and support muscles and ligaments. With this action a symmetrical alignment of spine rectifier’s muscles tension is obtained. The application
on sacroiliac area will cause stabilization of this area and improve the flow of
lymph. The use of both applications will reduce the felt pain. In the third trimester of
pregnancy, many women feel discomfort connected with the growing pressure of the
uterus on the diaphragm. Growing fetus reduces free movement of this muscle and
thus, causes difficulties in breathing. Pressure made on richly innervated diaphragm
causes pain of this organ, as well as a high possibility of feeling discomfort in rib’s
area and even the pectoral girdle. Properly made application reduces pain and makes
it easier to breath. Kinesiotaping also offers safe ways to deal with limb lymphoedema, especially legs, which is a common problem for pregnant women. Lymphatic
techniques facilitate lymph drainage from those areas by reducing the skin and fascia pressure on lymphatic vessels and canals. Swelling reduction improves the comfort of functioning of future mothers [8, 20, 25, 26, 29].
Another way to eliminate back pains are hatha yoga exercises. Set of exercises
originating from India offers body relaxation, resulting in better energy transfer and
learning free, full breathing. Exercises calm down and energize at the same time.
They stretch muscles, joints and ligaments using the force of gravity and body's
natural abilities. In addition, they result in a better contact with woman’s own body,
which allows her to relax tightened parts of her body consciously. The combination
of spiritual and physical spheres can combat mentioned ailments. [3] Characteristic
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for yoga is the occurrence of ‘asans’, namely specific exercises done in various
positions. Exercises for pregnant women should be chosen with great care, to be
sure that the fetus will be provided with the maximum space to move and grow
freely. In addition, it is important that during performing of asanas woman is not
tired and that exercises do not cause additional tension in her muscles, which can
intensify existing back pains. Finally, it is worth remembering that all movements
are performed in the physiological range, which will prevent excessive stretching of
hormonally relaxed structures and therefore ensures the proper functioning of the
body. Among asanas used for both prophylaxis and treatment of pains in the lumbosacral area of the spine there are: trikonasana, parśvakonasana, Sarvangasana,
virabhadrasana II and many others. They are designed to strengthen back’s muscles
and relieve tension of paraspinal muscles, resulting from both overload and prolonged stressful situations [30].
An interesting way, that could be used in physiotherapy of pregnant woman’s
movement system is Alexander technique called psycho-physical re-education
method or sensory. It teaches conscious restoration of naturalness and psychophysical freedom of the organism, which leads to elimination of harmful habits straining
the organism or restricting the freedom of it’s actions, especially concerning daily
movements and behaviors. It’s special nature lies in the fact that it does not propose
any additional exercises and psycho – physical regimes but teaches an objective
observation of oneself and conscious choice of action, the most effective for a given
function [32]. The Alexander’s technique is based on the belief that the relation
between parts of the central axis of the body (the head-neck-back ratio) is a congenital mechanism that organizes and controls vertical posture, movement and coordination of the whole body. 'Primary control' is the reflection of involuntary positioning
of the head, in such a way, that along with straight back it forms a functional unit,
which allows to initiate it’s movements. With the proper head-neck-back ratio, the
balance and motion can be achieved with minimal muscle tension. However, this
ratio is often disturbed by abnormal muscle tensions caused by stress or bad movement habits. Hence the need for conscious learning of owns control of natural reflexes, that means controlling, through the implementation of issued commands to
oneself and elimination of harmful to movement system habits. This is done by
performing exercises during next lessons, where teacher ‘s repeated touch stimulation done in combination with targeted action leads to production of automation of a
specific motor activity.
Basic position that provides the best possible environment to operate hands,
while performing daily activities, is the position of 'monkey', in which by means of
slight shifting the center of gravity toward heels the unnecessary muscle tension is
minimized. This results in lower energy consumption, making pregnant woman
feeling less fatigue. There are also few positions that are particularly useful in the
functioning of pregnant women in order to minimize back pains:
 stride, especially useful when pushing objects, the movement is then run from
legs and trunk as a whole, upper,
 limbs give the activity a certain direction,
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 squat - squatting and kneeling as preparation for taking this position during labor
in order to make it simpler,
 supported kneeling and movements in this position, allowing training of back
muscles and exercising,
 coordination of limb’s movements relative to the head-neck-back ratio.
Recommended in Alexander’s technique constant, conscious control of ones own
body posture through above mentioned body weight transfer to the back, as well as
paying special attention to abdominal and pelvic floor muscles and their training,
causes reduction of pain of lower parts of the spine. This technique also makes effects in overpowering edemas, in both lower and upper limbs because loosening of
previously tightened muscles, chest expansion or resting in the proper positions
results in improved lymphatic drainage to the lymphatic vessels [6].
Postpartum physiotherapy - kinesitherapy after physiological childbirth and
cesarean section, the procedure in case of post-operative scars.
Pregnancy is a time of many changes both physical and mental. Giving birth to a
healthy child brings woman a lot of joy and satisfaction and enables her to realize
that one of the most important tasks of life has just been satisfied, initiating the
second phase of child’s care, already in a phase outside of uterus. It is also a sign
that there came the time to deal with mother’s body, in order to restore full physical
activity in the shortest possible period of time. Through the use of physical exercises
faster tissue regeneration, strengthening and regulation of muscle tension, as well as
faster collapse of the uterus are achieved. A woman quickly observes her better
mood, sleep and relaxation improvement, bladder and gastrointestinal tract
regulation, often restoration of pre-pregnancy appearance. Exercises also help in
preventing complications, such as phlebitis of lower limbs or thrombosis.
Taking into account the gradual return of physical fitness, childbed is divided
into three periods: the first-covers the time up to 6 hours after the birth, the second
lasts from 7th day to 6 weeks, the third-till the moment of full activity recovery. For
each of these periods appropriate set of exercises is chosen. First exercises are
performed shortly after woman gives birth to placenta. The purpose of these exercise
is to release tension of perineal muscles and pelvic and the most commonly used is
so called Poręba’s grip. This exercise is about slight pressing of elbow edges of
both hands, just above groins, in order to pull the uterus upward with simultaneous
tensing and loosening woman’s buttocks, which results in tensioning and relaxation
of the muscles surrounding the urethra. The aim of exercises used in the first six
days after the birth is to restore flexibility to abdominal and pelvic floor muscles, to
prevent lowering of the uterus. What s more, they affect keeping good posture and
improve the respiratory, blood circulation and metabolic systems. They are made
mainly in lying position. Exercises recommended at this time are primarily
respiratory and isometric. Erect after childbirth is early (5 - 6 hours) and therefore
the task of the physiotherapist is to teach woman proper getting out of bed, taking
into account the protection of the perineum and pressure reduction within the
internal organs. In the second period of childbed exercise positions include lying,
kneeling and standing and the very exercises are more intense. They start from
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repeating the sequence from the previous period. However, the biggest attention
should be paid to the improvement of pelvic floor and abdomen muscles [4].
Exercises done during childbed usually refer to the restoration of smooth body
functioning after a physiological childbirth. A woman who had cesarean section,
which is the most common surgical procedure in obstetrics should be treated in a
different way. The movement treatment will be split into periods and days. Exercises
start from movements within distal parts of upper and lower limbs. Then erect is
carried out taking special care of the existence of a fresh wound – therefore
synergistic quadriceps muscle exercises are introduced, repositioning exercises to
lying on your side, combined with breathing exercises are included. After doing so a
dynamic limb’s movement is increased by incorporating both shoulder and hip
joints. Then women can start trying to walk around the bed and in the final period of
hospitalization - the rotational movements of the hips, torsional movements of the
trunk and movements involving, to bigger extent, abdominal muscles. During
exercising, it is worth remembering, that after a cesarean section, there is no need to
protect the pelvic floor and perineum, because they were not extended. However,
special attention should be paid to abdominal muscles, which should be strengthen
in lying on woman’s back position in the first three weeks after surgery [7].
In addition to the overall improvement, there is also a need for appropriate taking
care of existing wound at first and then of the post-operative scar.
The wound, depending on its location and depth, can heal as follows:
 as ‘rapid adhesion’ that is, direct healing (slot fills up with plasma and lymph,
which are solidified, resulting in a formation of granulation tissue. There is no
inflammatory process, linear scar creates, which can be gradually absorbed and
disappear)
 granulation - indirect and delayed healing (in the case when the wound has rough
edges and it exists on a large area and depth. The healing process starts from the
wound’s bottom where granulation tissue appears. Inflammatory changes often
occur. The effect of such healing is a broad surface scar).
 healing under a scab – here direct and indirect healing takes place. As the result
there can be linear or surface scar [28].
If soon after the operation there will be no physiotherapist action, adhesions in
the area of the forming scar may develop because surgical incision damages not only
fascia but also the structure of tissues lying beneath it. The scar is not only a
cosmetic problem. Its formation leads to movement and displacing disorders of
subcutaneous tissues and if the healing process is disrupted, it can lead to the
production of scar tissue also in the abdominal fascial system (thoracolumbar –
abdominal fascia, lateral fascia), in larger and smaller systems, peritoneum,
intestinal mesentery and in ligaments connecting the viscera. If available
physiotherapeutic techniques - soft manual therapy and massage do not recreate full
motion of tissues within abdominal cavity - the peritoneal contracture will be so big
that every movement of the body will transfer the energy on the spine, which will
result, just in a few months after the surgery, in pain in the lumbar area and changes
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in posture. Therefore, to a typical set of exercises used in the postoperative period,
already in the second day , exercises that require lying on the stomach twice a day
for thirty minutes are introduced. In this way, abnormal structures within the wound
are avoided [5, 15, 17, 31].
In the therapy of postoperative scar the usage of techniques from manual soft
tissue therapy bring positive results. Before working with the patient it is important
to investigate scars. It consists of evaluation of its weight, texture, contour,
pigmentation, flexibility, functionality and sensitivity. If in the area within the scar
points or zones of increased pain are observed, the first step is to loosen them. The
technique selection depends on the skills of a physiotherapist. There is a possibility
of using post isometric muscle relaxation (PIR), muscle energizing techniques
(TEM) and release points loosening. After describing these points an appropriate
manual therapy is applied within the scar area. The work starts from an indirect
release of tissues surrounding the scar by using dynamic and static rolling
techniques and by longitudinal, lateral and oblique stretching of tissues lying in the
right proximity of the scar. Importantly, the therapy of soft tissues connected with
the scar should begin only after complete healing of the wound. Techniques mobilizing tissues around the scar are applied after at least 3 - 4 weeks after surgery,
whereas techniques directly related to the scar may be used after next 2 - 3 weeks. If
the work with a scar starts too early, there is a risk of prolonged healing process and
stimulation of its overgrowth. During therapy, both the therapist’s hands and patient’s skin must remain dry [9, 13, 15, 17, 18, 19, 31].
In the case of a scar, a favorable action from physiotherapist’s side is also the use
of massage that improves blood and lymph circulation, accelerates granulation
process and acts against contractures. The use of massage requires appropriate
procedures taking into account stages of wound healing:
 1 period - during healing it is worth using consensual massage and lymphatic
drainage within the proximal parts of the wound.
 2 period - after healing period when a classical massage is the used strategy,
which, in this case has the effect of relaxation, growth improvement, flexibility
and elasticity of soft tissues. Loosening of structures allows to work on a scar
that remained after cesarean section.
During working on a scar by means of massage a specified sequence of actions is
required, dividing it into stages:
 stage 1, in which the work is directed to a wound. Among classical massage
techniques strokes with sliding movements, as well as rubbing are selected,
 stage 2, in which we use the same techniques only the direction of the work is
different –movements are directed from the scar,
 stage 3 is the time to start a scar. The techniques used at this stage are stronger
and masseur’s actions is more determined. The technique available in this case,
is the one of rolling along the scar’s edges, using thumb, as well as in its radial
direction. It is also affected by deep segmental rubbing and patting and gentle
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tapping of adhesion’s area. Hardening of the scar leads to a reduction in the sensitivity to external factors, especially the touch, and at the same time it removes
deep adhesions. Classic massage should work in a normalizing way on excessive
soft tissue tension and stimulate the processes of skin renewal and redevelopment within the scar [28].
The above mentioned the kinesiotaping method is also used after childbirth.
Plaster applied within the abdominal area will work regenerating and will improve
the circulation in this area. Used for scars after cesarean sections, kinesiotaping will
improve its flexibility and will accelerate healing. In breast-feeding women, the
correct application will ease the flow of milk, which will prevent the formation of
clots and associated with them inflammations. What is more it will improve the
visual appearance of the breasts [8, 20, 23].
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ABSTRACT
Physiotherapy of pregnant women and of childbed period carries the ability to
provide comfort to women, both physical and mental. There are several methods that
allow pregnant women to survive this period in full health, that eliminate pains arising as a result of the changes taking place in their organism. Working with pregnant
patients is the issue that is still not very popular and often overlooked. The reason
for this may be an unjustified fear of therapists from working with these female
patients. In addition, often symptoms reported by women are treated as inevitable in
this particular period. There is, therefore, a need to promote the available methods,
as well as a continuous search for new solutions in this area.
STRESZCZENIE
Ciąża to szczególny okres w życiu kobiety. Profilaktyka fizjoterapeutyczna dąży
do zapewnienia kobiecie w stanie odmiennym pełnego zdrowia psychofizycznego
poprzez ukierunkowane działania z zakresu kinezyterapii ogólnousprawniającej,
metod specjalistycznych oraz psychoterapii. W pracy omówiono zasady, cele i
organizację kompleksowej fizjoterapii kobiet ciężarnych, ze szczególnym
uwzględnieniem kinezyterapii będącej elementem szkoły rodzenia. Przedstawiono
postępowanie profilaktyczne pozwalające na zapobieganie bólom kręgosłupa w
odcinku lędźwiowo – krzyżowym, a także fizjoterapeutyczne metody specjalne,
mające działanie lecznicze w przypadku zaistnienia objawów bólowych – masaż,
kinesiotaping, jogę oraz techniki Alexandra. Praca opisuje również sposoby pracy z
kobietami w połogu.
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