Tips for After a Caesarian Section

Those of you that have been through or will be going through a C-section rather than a vaginal delivery might notice a difference in recovery after the birth. You might not go through the pains of labour, you might be unlucky enough to have to do both but you will definitely realise that your body will need to recover once the baby is out. Your body will be sore in many different places and recovery time will be longer in comparison to vaginal delivery.

Rest whenever you get the opportunity in the first 4-6 weeks. A good form of general exercise is walking, starting with as little as 5-10 minutes daily and gradually building the time up to 30-40 minutes over the first 2 months. It is also important to do specific exercises to strengthen and stabilise the lower trunk. This includes pelvic floor muscle exercises, transverse abdominal exercises and pelvic tilts. I will go into more detail on these specific exercises next week.

It is also important to move in and out of bed correctly. Pretend you are still pregnant (yay). Move slowly and try to avoid using the abdominal muscles in the first 4-6 weeks. To get in: sit on the edge of the bed, lean down onto your elbow towards the pillow, bend your knees and lift your legs onto the bed, then roll onto your back. Reverse this action to get up.

When coughing and sneezing support your lower abdominals by placing your hands or forearms over the caesarean wound. Contract the pelvic floor muscles before the cough or sneeze. To clear your chest take three slow deep breathes in and out, then huff (as if to steam up a mirror), then support your cough as above.

Avoid all unnecessary lifting (so lots of excuses can be made to the hubby about housework.) Avoid lifting heavy objects (anything bigger than the baby) for the first 4-6 weeks. To lift, keep your back flat, draw your tummy in, squeeze your pelvic floor muscles and bend your knees. Keep the object close to you as you lift it up. Use your legs to take the weight of the lift and not your back. So avoid strenuous housework - this definitely includes but is not limited to the laundry basket and the bucket of water to wash the floor.

Driving should be avoided for 6 weeks but you will need to contact your insurance company for individual policies. You must be able to do an emergency stop without hesitation or pain before you can drive again.

You must also speak to your own doctor about pain relief, especially if you are breast feeding.

If you are suffering from pain would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

SPD After Labour

Symphysis pubis dysfunction (SPD) is a common condition found during pregnancy, presenting as pain around the pubic joint area. It is a separation by this joint that leads to pain, caused by the hormone relaxin that is produced in your body during pregnancy. Once the baby is born, the level of the hormone decreases (but is mimicked if you are breast feeding), and the pain will start to go away.

Well this is the scenario in most cases, however for some people this pain can linger or even start after labour itself. Due to the hormone relaxin, your ligaments are more soft and stretchy to enable your baby to be born. Due to this, labour itself (especially if it is a traumatic birth or you delivered in stirrups) can cause a separation at the symphysis pubic joint.

SPD after labour will get better but in some cases it can take time. The good news is there are things that can be done to speed this healing process along, one of those being physiotherapy. After your physiotherapist has assessed you they will give you lots of advice on movement techniques such as keeping your legs closer together during activities that you need to carry on with your daily living. They will help you find comfortable positions to carry out tasks that are important to you. They may also decide to give you crutches if they feel you will benefit from them, along with a specially designed SPD belt (this is different from a back support belt). They will also guide you on specific exercises and design you a personal home program exercise session. Of course this program will also include pelvic floor exercises that every woman should include into her daily routine.

If you feel you need to, you can also take pain killers and over the counter anti-inflammatories. It is important to remember that you can only take anti- inflammatories after labour once the baby is out and NOT if you are still pregnant and suffering from SPD. This is true even if you are breast feeding. If you are pregnant and suffering from SPD, you can only take over the counter pain killers such as Acamol and must go to your doctor if you need something stronger.

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If you are suffering from SPD and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

Cold Weather and Joint Pain

First of all I hope everyone enjoyed the snow and stayed warm. I am also very sorry for rescheduling some of your appointments this week due to the snow. I also had a number of patients contacting me this week about increased pain, so that is the inspiration behind this week's blog.

Yes, the cold can increase your joint pain, however there is some conflicting evidence.

Studies have found a strong relationship between cold damp days and increased joint pain. One suggested reason is that changes in barometric pressure can cause this. Another suggestion is the colder temperatures can cause changes in the viscosity of joint fluid. Other studies suggest there is no link between pain and cold weather at all. However what I do know for sure is many of my patients complain of more pain in the colder weather.

So what can be done? Stay warm. Apart from wearing an extra jumper exercise can also help. Warm ups are called warm ups for a reason and it is imperative to warm up extra vigilantly in the cold weather. It is easy to get lazy in the cold weather but important not to. Just make sure your chosen sport is not down hill skiing, snowboarding or sledging; keep it safe if you are pregnant.

Keeping a healthy diet can also help as can a hot water bottle, as long as it is not lying over your bump. Baths can also be relaxing but if you are pregnant make sure the water is not too hot as it can make you dizzy when it comes to standing up, and saunas should be avoided. This is because the heat makes your blood vessels wider and this can cause light headedness and fainting.

Your body will do a brilliant job in keeping your unborn baby warm so it is just yourself you need to worry abut here. It is you that becomes susceptible to the cold during pregnancy. As your bump gets bigger and there is more surface area for heat to be lost through the colder you may feel, so make sure you dress properly for these cold wintery days.

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If you are suffering from pain and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

Diary with a Capital Pee: Keeping a Bladder Diary

When trying to improve any area of your life you will only know if you have done so by recording the figures and measuring the change. This is the reason I ask my patients who come to me for pelvic floor rehabilitation to keep a diary. In the diary I ask them to jot down the following activities:

• Date / time of day
• Type and amount of fluid intake
• Type and amount of food eaten
• Amount of urine excreted (small, medium, large)
• Amount of leakage (small, medium, large)
• Activity engaged in when leakage occurred
• Was an urge present? (Yes or No)
• Change of pad required?

It is very important for all women to be doing their pelvic floor exercises every day. The reason being that we have so many factors against us that we need to be one step ahead of the game. Pelvic floor muscles get weakened with every pregnancy. 65% of pregnancies come with incontinence. Although lots of women then have no incontinence problems once the baby is out, it is important to remember that the muscles have been weakened so exercise is still crucial.

If you are lucky enough not to fall in the above 65% you are still not home free because the actual delivery can also cause weakness. 60% of women who have had 4 or more babies complain of incontinence.

I am very pro breastfeeding, it has many advantages and I do it myself, but unfortunately it is also a contributing factor, due to hormones. As mentioned in previous blogs, relaxin weakens joints and ligaments, and it takes 3 months for this hormone to leave our bodies after birth - but while we are breastfeeding, this hormone is mimicked. It is more important for breastfeeding mums to do their exercises and they often see little improvement for there efforts – but it would be far worse if they don't.

Another contributing factor is the neurological one. It is important to remember your pelvic floor contracts reflexively before we cough or sneeze. Reflex inhibition is the brain’s way of protecting a part of the body that is damaged. Unless these reflexes are re-established, chronic injury can be a result. You are probably more familiar with ankle sprain, and probably know that if the ankle is sprained badly there is a tendency for that ankle to twist and give way again. When treating sports injuries the physio concentrates on retraining the protective reflex action of the muscles around the ankle. There is no point in treating the joint without re training the reflex. So to it is the same with pelvic floor after childbirth. The protective reflex contraction of the pelvic floor when you cough or sneeze is lost, but this protective reflex can be re-learnt. You can teach yourself to actively squeeze and lift before each cough or sneeze.

Even if you do not suffer incontinence post-birth, the muscles have gone through a real beating and exercise to regain strength should start no later than 24 hours post delivery.

The pelvic floor muscles fatigue like all other muscles do. It is important to realise that fatigue is also a contributing factor to the fall of the pelvic floor. Therefore rest is also important, especially just after giving birth.

Quite often if you have recurrent cystitis/urine infections it can lead to bladder instability. It is the inflammation in these cases that is the cause of your incontinence.

Now let's mention menopause. Many women sail through life blissfully unaware of the time bomb ticking away between their legs. Quite often they are totally unaware of the stresses and strains that have weakened their pelvic floor until they reach menopause and this is the final straw. During menopause the oestrogen level drops. Oestrogen factor is also responsible for the thinning effect that can occur within the vagina and urethra. Meaning the pelvic floor needs to be stronger.

Ageing can also take a toll on your pelvic floor like it does with all your muscles, so too with constipation, chronic cough and being overweight.

As you can see the odds are against us women, but the dairy helps monitor all aspects of the bladder routine and can hopefully help show the effects of exercise and work out what needs to be changed.

If you are suffering from incontinence and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

Carpel tunnel syndrome in pregnancy

Carpel tunnel syndrome is commonly described as pain, tingling and numbness in your hands. The carpal tunnel is a small tunnel that runs from the bottom of your wrist to your lower palm. Feeling and movement is controlled by the median nerve that runs through this tunnel. During pregnancy it is common to have mild swelling, caused by a build up of fluid. This swelling can place pressure over the nerve and cause the symptoms described above. This fluid can also be responsible for what some people call the pregnancy glow.

Around 60% of pregnant women can suffer from carpel tunnel syndrome to varying degrees, more commonly in the second and third trimester. The majority of people that suffer from it tend to suffer very mildly and also temporarily, with most cases disappearing soon after birth. However, for the unlucky minority it can linger for several months and very rarely a bit longer.

Symptoms can often be worse at night and can cause you to wake up. Changing your sleeping position can often be helpful, ensuring you are not resting on your hands (You better make sure you sleep while you are pregnant because we all know what happens after the baby comes...) Shaking your hands can also help to reduce the tingling. Changing the position of your arm and hand can also be helpful. Flexing your wrists and fingers throughout the day can also help. Sometimes a physiotherapist might also use ultrasound to reduce the pain.

Wrist splints are normally the biggest helper. They help keep your wrist straight which maximises the space in the carpal tunnel.

Often changing the positions of your wrist during activities that cause the pain can help. For example, think about adjusting the height of your office chair so your wrists are straighter when typing, or resting your hands on a pillow either straight or extended while sleeping (with the wrist splints also)

Pregnancy yoga can bring many advantages during pregnancy but it's particularly helpful with reducing the symptoms of carpel tunnel syndrome. Other wrist and arm stretches and exercises may also be recommended to strengthen the muscles in the hand and arm.

If you are suffering from carpel tunnel syndrome and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

Ergonomics and Pregnancy

When taking a history of a patient I always ask about social history, their lifestyle, family life and job situation. Now you may think this is just chit-chat, while others conclude that I am just plain nosy. But in actual fact the answers to these questions can tell me a lot about the patient's health.

Ergonomics in its simplest sense is making sure that the things you work with do not cause you harm. Ergonomics is very important for those that are not pregnant, and this is multiplied during pregnancy due to the quick postural changes seen over a pregnancy. If you are in a office job all day it is important to stretch regularly, get up from your desk and take a quick walk.

Ensuring the height of the chair is correct is also important, and the knee bend should be at 90 degrees with a foot stool to support your feet if you are on the shorter side. You should also sit at a 90 degree angle at the hips. Lumbar support for the lower back is also important, and this can be achieved with a small pillow. Your wrists should be straight when typing. The vision distance should be 18-24 inches, positioned at eye level.

If you want to start a new trend in the office you could even bring your gym ball along and switch between your chair and gym ball, this is a great exercise just by sitting on it and you probably won't even realise it.

Whether you are in a class room, office or factory, most jobs require carrying of equipment (or children). Posture here is very important, ensuring the object is not too heavy. Don't bend your back but rather bend your knees down towards what you are picking up, holding it close to you at mid level.

Remember if you think the object is too heavy to carry, don't carry it, get someone to help you or get someone to carry it for you.

I have always liked a tidy home but a reorganisation of the work place can also be important too. Ensuring regular objects are placed at waist height and not on the top or bottom shelf is really important.

Repetitive movements are also a good thing to avoid, like constantly clicking a computer mouse. However, if it cannot be avoided it should be performed in the best way possible, in this case with your wrist in a horizontal position.

If you are suffering from any type of muscle problem and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com.  I can arrange to see you in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.  

Rib Flaring: Don't Let It Flare Up During Your Pregnancy

Rib flare is one of those less common conditions, found in pregnancy during the second and third trimester. Many pregnant women often complain of their growing baby poking and prodding them - “I feel a leg kicking through me.” Often you will place your hands over the bump just for the excitement of feeling your baby kick. Usually your husband is in the next room, he runs in to feel the baby kick and misses it each time. Well life would be simpler if they just carried the baby throughout the pregnancy, and then they could feel every kick along with the morning sickness, nausea and any other symptom that may occur....

This pain is a direct result of your baby and uterus getting bigger and poking and prodding into you. In pregnant women the demand for oxygen is increased. You will exhale more carbon dioxide which triggers the respiratory system to increase the respiratory rate slightly, and this is the reason you may find yourself more breathless during strenuous activity. Your diaphragm will have to work harder as well. 

You may find the baby beginning to press up and under your ribs and chest. This is the uterus ascending as the abdomen stretches upward and outward, so the baby can grow. The growing baby can obstruct the descent of the diaphragm, which is needed for deep breathing. Hence the pressure pushes the rib cage out sideways and forwards, known as rib flaring and causing a lot of pain. It can also lead to shoulder pain due to the nerves of the diaphragm referring pain there. 

Your growing breasts can also place added pressure onto your ribs, so a good supportive bra which is not underwired is really important.

Good posture can help relieve some of this pain as slouching will put added pressure onto your abdomen. So sitting up with shoulders back is a good start to relieving the pain.

Exercises that open your rib cage up are also really useful here. Stand facing a wall. With your feet 40cm from the wall, cross your arms in front of your face. Then lean your crossed arms on the wall sliding them up the wall above your head and stretching yourself up as far as possible. Hold the position for as long as comfortable. This lifts the diaphragm and rib cage up off the uterus. Practicing doorway chest stretches can also be helpful because they, too, will help rotate the shoulders up and back, which can also help lift the ribs away from the uterus.

Breathing and relaxation exercises can also help. There are also several hands-on techniques that your physiotherapist can do to gently stretch and lift your ribs away from the uterus. 

If you are suffering from rib flaring and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com.  I can arrange to see you in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.  

Useful tips after birth

Now many of you may think that this topic is not physiotherapy-related, but the job of a women’s health physio sometimes involves treating patients within hours of them giving birth. In these cases, we provide general advice on advisable body positions, as well as treating the patient for the uncommon discomforts post-labour.

My number one tip of the day would be to keep drinking water, and lots of it. You may quite often hear many of the different medical professionals say this, but this is because it affects so many systems in the body that it is an all round good substance for the body. Many might recall the soreness down below when urinating. Now the water can change the pH of your urine making it sting less. If you find it very painful when you urinate then you can pour water on yourself, down the toilet whilst urinating. I might also add that doing your pelvic floor exercise can also increase the healing time as it increases blood flow. (There is just no escaping those pelvic floor exercises).

While on the topic of soreness, some patients have told me they have difficulties in sitting on a hard chair. So here is another piece of DIY make it yourself equipment advice. Take a towel and roll it up into a sausage shape. Then place the towel in a horse shoe shape on the chair and sit on the chair, thus relieving you of putting pressure on the pain. 

While you are not in company or even if you are you can put some ice on the sore area. The recommended method would be to use a bag of frozen peas wrapped in a tea towel. It is best to do this 10 minutes at a time, giving yourself a 10 minute brake before repeating. 

One of the less talked about problems that can follow is constipation. Whilst on the toilet, put a foot stool (mind the pun) under your feet to raise your legs, knees bent hips flexed above 90. This creates a smoother route for the stool to exit your body.  

I don’t talk about it much, as physiotherapists are very much advocates for exercise, but do remember to rest after giving birth. Birth is a wonderful and traumatic event on your body and rest will help improve healing times.

If you suffer from any type of muscle pain during or after pregnancy and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com.  I can arrange to see you in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

Breastfeeding: Don't Let it be a Pain in the Back(side)

There are many advantages for both you and your baby to breastfeeding. I am personally very much in favour and breastfed all 3 of my babies. However, this is not the place to go into the pros and cons of bottle and breastfeeding; there are many sites that have detailed discussions on that to help you make informed decisions.   

However, I do notice that some women that breastfeed tend to complain of back pain. Now this does not have to be the case. I do sympathise, especially with those middle of the night feeds that all you want to do is feed the baby and put them back to bed. But if you do one extra thing every time you feed it can spare you a lot of pain in the future.

It is very common to pick up the baby, let the baby latch on and for you to be in a sitting position with your back titled towards one side with your baby resting on your lap whilst feeding. However if you place a pillow on your lap and the baby on top of the pillow then there is no need to bend down towards the baby as the baby is at the right height to feed from you. 

The next question you are probably wondering is, am I asking you to go out and buy those fancy feeding pillows that cost a lot of money. No I certainly am not. The breastfeeding pillows that look like 3/5 of a circle are very beneficial and if you have one I strongly encourage you to use it. That is because it gives a lot of extra support to your back as well as preventing you from leaning down. I also would recommending purchasing one of those pillows if you are prone to back ache or already suffering from back ache. 

If you do not suffer from back ache and this is merely preventative then any old pillow (or two if needed) will do the job of raising your baby higher up to you to prevent you leaning and twisting your back in positions that can cause pain. 

Another important thing to remember is to ensure that you are wearing a bra that fits your properly - not just when you are breastfeeding but at any stage of your life. This is another tip that can help prevent back pain.

If you suffer from antenatal or postnatal back pain and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com.  I can arrange to see you in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.  

Pelvic Floor: Key Questions to Ask Yourself

Due to my short break from writing because of the chagim, I thought I would go back to the pelvic floor muscles before I move on to a host of different topics that some of you may not have heard of.

The onset of incontinence is gradual but never unnoticed. It is the body’s way of telling us that things are not quite as they should be. Leaking urine can bring on a downward spiral with loss of self respect as well as anxiety and depression. 

The initial leaking is called stress incontinence, caused by weakening of the muscles that keep urine stored inside the bladder. These muscles, called the pelvic floor muscles, fail to fight forces which push down from the abdomen when you laugh, sneeze, run or jump.

If left untreated, stress incontinence can lead to urgency and frequency. An example of this could be when running to the bank before closing time you suddenly feel dampness between your legs. You take a quick diversion to the toilet to check that this is not obvious to the outside world, you don’t really feel the need to go but as your mother probably told you better to be safe than sorry and you go to the toilet. Anxiety can begin to set in out of fear of a re-occurrence, causing you to take a trip to the toilet just in case, to really make sure your bladder is empty, thus establishing a pattern of frequency. 

Before you know it you are a confirmed toilet hopper, you know all the ladies toilets in town and which petrol stations along your driving route have conveniences too. You will then start to cut down your fluid intake (don’t ever do this) and before you know it you are laughing this situation off with all your friends, they are laughing in a supporting sympathetic way or are laughing because they have these same problems.

The three main symptoms are stress incontinence, urgency and frequency.  Stress is when leaking from a high impact movement. Urgency is the really strong need to pass urine that if ignored you feel you will probably end up with wet knickers. Finally frequency, which is how frequent you are going to the toilet. A combination of any of these three can be present.

Most people consider their toilet habits normal, however if the answer to any of the following questions is no, then your habits are not normal and it is time to really step up your exercises to your pelvic floor muscles to more than 3 times a day, which is the prescribed amount for people who do not suffer from this. It might also be the time to seek physiotherapy help as there are much higher success rates when treatment is started earlier on.

• Do you go to the toilet 4 to 6 times each day only?

• Do you sleep through or get up only once through the night?

• Do you have dry knickers all the time?

• Do you pass 300-400mls each time? 1 mug is approx 250mls

• Do you pass water easily, without straining or stopping and starting?

• Do you find urinating is painless and quite a comfortable thing to do?

If you suffer from any type of incontinence and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com.  I can arrange to see you in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.