A woman’s body experiences several musculoskeletal and physiological changes during pregnancy.  Post-partum, most musculoskeletal changes reverse; however, a woman might have lingering joint pain and muscle weakness.  This pain and weakness may lead to problems with childcare, work function, exercise, and other daily activities.  Key changes and their management post partum to ease the transition are discussed below:

• During the 9 months of gestation, abdominal muscles are stretched and weakened, and lower back muscles may become shortened and tight with a resultant exaggeration of the lumbar lordosis or curve. Weak abdominals can lead to a diastasis recti, back pain, pelvic floor dysfunction (incontinence, constipation), and can also affect breathing.  Strengthening exercises at any stage can be helpful and can reduce or eliminate pain. 
   
• Due to the hormone relaxin being released during the pre-natal period, there is ligament laxity, which along with weak abdominal muscles results in poor posture.  Poor posture may lead to back pain, SI joint pain, or pelvic pain.  Correcting poor posture is very important both during and after pregnancy.  Physical therapists can educate patients about posture, especially with regards to carrying their baby, breastfeeding, and other daily activities.
   
• The most common pre-natal and post-partum complaint is back pain.  The incidence of post-natal back pain increases if it was present in the pre-natal period.  Back pain may be due to bad posture, weak abdominals, and weak trunk extensors.  Back pain may increase through the day and with activities.  Specific stretching and strengthening exercises are key to decreasing pain.
   
• During labour, the pelvic floor needs to stretch. If the muscles are tight and cannot release, perineal tears may result or an episiotomy may be performed.  Pelvic floor muscles can be stretched with pelvic floor exercises and manual stretching.  This may prevent a perineal tear or the need of an episiotomy. 
   
• Scar massage is important in patients who have had a perineal tear or an episiotomy.  If the scar in the perineum becomes shortened and adheres to underlying tissue, it can interfere with bladder, bowel, and sexual function. Scar massage should start 2-6 weeks post partum with approval from the physician.  The massage keeps the tissue supple and mobile and prevents adhesions. 
   
• If the woman undergoes a c-section, a scar is left in the lower abdomen. If the scar becomes adhered to underlying tissue, it can cause pain and interfere with bladder and bowel functions.  Sometimes, the scar will need to be mobilized and desensitized. 
   
• Post-partum, a woman should be assessed for a diastasis recti and if present, corrective exercises should be prescribed.  Isometric abdominal exercises should commence 24 hours after a vaginal delivery. 
  Often, women experience urinary incontinence, constipation, and/or dyspareunia (pain with intercourse) post-partum.  This is usually the result of weakness, muscle shortening and/or tears in the pelvic floor muscles.  As mentioned above, the pelvic floor muscles can be stretched and kept at an optimal length with specific exercises and manual therapy.  Pelvic floor muscles when exercised correctly will strengthen and may prevent bladder, bowel, and sexual dysfunction.  However, synergistic contraction of these muscles with the abdominals and proper breathing mechanics is very important.  
• Some women also complain of pelvic pain.  This is a broad term for groin, buttock, hip, sacro-iliac joint, vaginal, rectal, or tailbone pain.  Patients may describe the pain as a sharp, stabbing pain which increases when changing positions and moves down the leg.  Physical therapists can release tight muscles which is often helpful for relieving pelvic pain.
   
• A common complaint post-partum is upper back pain.  This pain is usually a result of bad posture when carrying the baby, breastfeeding, changing diapers, and other activities.  The mother should remember to support her back with pillows and positioning when breastfeeding and bring the baby to the breast and not the breast to the baby.  Upper back strengthening is extremely important as well.   
   

Pregnancy and childbirth are an amazing and wonderful time in a woman’s life.  Although, a woman’s body readily adapts to pregnancy and childbirth, she should be educated and receive guidance about these changes.  It is essential for the mother to take care of herself in order to take care of her baby.  Most of the musculo-skeletal and physiological changes reverse after delivery, however, sometimes the changes do not reverse and symptoms linger.  Physical therapists can educate the patient and treat the cause with proper treatment to enhance the quality of life of the patient.  

REFERENCES:

Noble E, Essential exercises for the childbearing year: A guide to health and comfort before and after your baby is born. 4th ed. 2003.

Polden M, Mantle J. Physiotherapy in obstetrics and gynaecology. Ist ed. 1990.