Virtual physical therapy after birth: 23 things you can do too

Over the past 3 years Covid inspired many physical therapists to get creative with our care. By offering video visits, I could reach people who might have difficulty coming into the clinic due to physical frailty, mental health barriers, access to safe and affordable transportation and lack of childcare options among many other reasons.^[1]

One of the groups that feel a huge sense of relief when I say that we can meet online are my patients who have recently given birth or have had a pelvic surgery.^[2] Unlike other Telehealth visits, where the meeting can occur with the patient sitting at a desk or at a dining room table, I hope to meet with people while they are lying in bed. 

The fact that I want my patients to be comfortable in bed or on the couch is often surprising. I have had multiple patients tell me that they prepared for our initial meeting by putting on make-up and sitting upright in a chair that increased their pain. When people start to move out of their chair, I am watching their facial expressions. I am listening to their wincing. I am observing how they might be holding onto a wall or other furniture as they walk back to bed. This provides me with clinical information about pain level, dynamic postural stability and possible fall risk.

Being more physically comfortable allows people to share their experience while being more physically relaxed. I get to hear about the surgery or birth experience, whether what happened in the hospital matched their expectations.^[3] I get to listen. I can start to build a therapeutic alliance, screen for mental health concerns, physical safety, and housing security. I tailor the initial visit and subsequent visits to meet the patient where they are at. 

One of the groups that feel a huge sense of relief when I say that we can meet online are my patients who have recently given birth or have had a pelvic surgery. Unlike other Telehealth visits, where the meeting can occur with the patient sitting at a desk or at a dining room table, I hope to meet with people while they are lying in bed. 

Dr. Noa S. Goodman

At the same time, my training as a physical therapist provides me with the expertise to look at wounds and provide education about signs and symptoms of infection. Wound infections from C-sections usually occur 4-7 days after the initial surgery, after the patient is already at home.^[4],^[5] Anyone who has experienced surgery, large or small, is worried about “undoing the surgery.” They are worried that the stitches will fail and that the wound will reopen. 

Pain is scary. If the surgery or birth was traumatic, it is more likely that the patient will have more pain.^[6] As a result, patients are afraid to stretch and stand up a little taller. Some patients have told me that they were so scared of standing that they crawled on all fours from their bed to the toilet. As a physical therapist, Telehealth visits provide a wonderful opportunity to teach people other ways to move, helping people get in and out of bed with increased ease and independence. Sometimes patients are provided with binders and I can instruct them on how to safely use them. Many patients like to hug a pillow into the incision site when they are moving from sitting to standing and while sitting on the toilet, similar to how some patients receive a pillow to hug after heart surgery. These little tips can make a huge difference. 

Throughout the visit, I am still looking at the patient’s face, respiratory rate and looking for any signs of nausea, dizziness, shortness of breath and facial swelling. I will ask the patient about headaches and if they have taken their blood pressure since coming home.^[7] Many patients do not know that they are at risk for Postpartum Preeclampsia up to 6 weeks following delivery.^[8] If someone has an infant at home or is caring for more than one person, often the medical concerns promptly shift from the person who was pregnant to the rest of the family. But signs and symptoms of postpartum preeclampsia, postpartum hemorrhage, postpartum cardiomyopathy and postpartum infection are medical emergencies that cannot wait until the in-person gynecological visit, usually scheduled 3-6 weeks after delivery. 

Wound infections from C-sections usually occur 4-7 days after the initial surgery, after the patient is already at home. Anyone who has experienced surgery, large or small, is worried about “undoing the surgery.” They are worried that the stitches will fail and that the wound will reopen.

Dr. Noa S. Goodman

By having a Telehealth visit days after returning home, very personal concerns can be addressed early. With expertise in pelvic floor physical therapy, I can start to address patient concerns about any birth injuries, prolapse, genital dryness, and urinary or bowel symptoms, including the dreaded constipation. Safe return to movement is key, especially for many Americans, who may not have more than a couple of weeks to recover after giving birth before needing to return to work. Unfortunately postpartum care is not a right in this county. It is a privilege. Many people are unable to make it to their postpartum appointments for the same reasons listed at the beginning of this essay, including financial barriers.

The initial education that patients receive in the hospital is foundational. If you are able to provide Telehealth to your patients while they are still in the inpatient setting, I am including a list of 23 things that I could potentially do. Many of the items on this list are things that we are regularly offering to patients after orthopedic surgeries such as knee, hip and spine surgeries, but are not routinely offered to our patients postpartum.

I encourage you to look into Telehealth options for your patients in the week after delivery. These patients might be overwhelmed, exhausted, in pain, thrilled to no longer be pregnant or feeling just fine. But they went through a major physiological change and deserve to be cared for as much as any other person, especially when the postpartum patient’s focus is often on the infant and the rest of the family.

What I (Noa S. Goodman, Physical Therapist ) can do over Telehealth:

1. I can look to see if a patient is dizzy moving from lying down to sitting. Someone who just had abdominal surgery just experienced a lot of blood loss. They continue to lose blood and are at risk of hemorrhage. I can be the first person to say, “Tell the nurse.”
2. I can look to see if the patient is experiencing signs and symptoms of postpartum preeclampsia. I can ask if they have a headache, if they feel their heart racing, if they are having a difficult time breathing. Again, I can be the first person to say, “Tell the nurse.”
3. I can educate the patient about signs and symptoms of postpartum preeclampsia and prevalence, particularly in the 6 weeks following birth
4. I can instruct someone in how to get in and out of a hospital bed with less pain
5. I can instruct someone how to stand up, lift their baby, move into a recliner if possible, and position themselves and their newborn more comfortably
6. With training, I can instruct the patient in initiating basic breast/chest feeding
7. I can instruct someone on how to walk to and from the bathroom
8. I can instruct someone on how to breathe during a bowel movement
9. I can problem solve with positioning for having a bowel movement, possibly using a stool under their feet while having a bowel movement
10. I can problem solve if the patient is experiencing difficulty urinating, especially if they were catheterized, with breathing techniques and positioning
11. If the patient is experiencing urinary incontinence, fecal or flatal incontinence I can provide education and recommend that the patient obtain a prescription from an MD in the hospital for continuity of care back into Pelvic Physical Therapy postpartum
12. I can educate the patient about clogged milk ducts and how I can provide Therapeutic Ultrasound in the outpatient clinic to improve the patient’s ability to clear the ducts so that they can produce an optimal amount of milk for their baby
13. I can provide education on pelvic organ prolapse and pelvic heaviness. Even patients who have given birth via C-section can have pelvic heaviness and swelling
14. I can provide education on the lymphatic system and how to position your body and use breathing to reduce abdominal swelling around the incision site 
15. I can provide education about hormonal changes that include a significant drop in estrogen that can contribute to mental health issues, joint and muscle aches and pain, and vaginal/frontal canal burning and dryness.
16. I can guide patients in how to don/doff an abdominal binder that is hopefully provided in the hospital
17. I can provide education and guidance about how long to wear the abdominal binder: how many hours per day, for how long after birth
18. I can provide basic wound care education, including signs and symptoms of an infection, when scar mobilization will be appropriate and when it is appropriate, teach patients scar mobilization techniques either in person during an outpatient visit or over Telehealth after discharge
19. I can provide safe mobility exercises to reduce the risk of blood clots, back pain and general muscle deconditioning
20. I can prepare the patient for the car ride home, placing a pillow between the incision site and the place where the seat belt crosses over the lap. 
21. I can prepare the patient for getting into their house, ask the patient to practice going up and down stairs with a physical therapist in the hospital. If they need to hold on to the bassinet while walking in the hallway, discuss obtaining a walker for home use. Using a bassinet on wheels with a newborn is both dangerous for the patient and the baby.
22. If the patient’s baby is in the NICU, the patient will need to exert energy moving from home back to the hospital. Via Telehealth, the patient can begin to learn about energy conservation for safe cardiac health postpartum
23. I can teach energy conservation techniques, such as baby-wearing, caring for multiple children, and nutritional intake

 

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^[1] Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved [date graphic was accessed], from https://health.gov/healthypeople/objectives-and-data/social-determinants-health

^[2] Mittone, Diletta F., et al. “Women’s satisfaction with telehealth services during the COVID-19 pandemic: cross-sectional survey study.” JMIR pediatrics and parenting 5.4 (2022): e41356

^[3] Kempe, Per, and Marie Vikström-Bolin. “Women’s satisfaction with the birthing experience in relation to duration of labour, obstetric interventions and mode of birth.” European Journal of Obstetrics & Gynecology and Reproductive Biology 246 (2020): 156-159

^[4] Zuarez-Easton, Sivan, et al. “Postcesarean wound infection: prevalence, impact, prevention, and management challenges.” International journal of women’s health (2017): 81-88.

^[5] Owen J, Andrews WW. Wound complications after cesarean sections. Clin Obstet Gynecol. 1994;37(4):842–855. Fitzwater JL, Tita AT. Prevention and management of cesarean wound infection. Obstet Gynecol Clin North Am. 2014;41(4):671–689

^[6] Borges, Natália Carvalho, et al. “The incidence of chronic pain following Cesarean section and associated risk factors: A cohort of women followed up for three months.” PloS one 15.9 (2020): e0238634

^[7] Bigelow, C. A. (2014). Risk Factors for New-Onset Late Postpartum Preeclampsia in Women Without a History of Preeclampsia. AJOG

^[8] Al-Safi, Z. E. (2011). Delayed Postpartum Preeclampsia and Eclampsia. ACOG, 1102-1107.