International Journal of Current Research and Review Original Research

DOI: http://dx.doi.org/10.31782/IJCRR.2021.131205

Effect of Physiotherapy Treatment in Early

Postpartum Period after Lower Segment Caesarean
IJCRR Section (LSCS)
Section: Healthcare
ISI Impact Factor
(2019-20): 1.628
IC Value (2019): 90.81
Purvi Patel1, Mansi Shah2, Lata Parmar3
SJIF (2020) = 7.893
Assistant Professor, College of Physiotherapy, Sumandeep Vidyapeeth an Institution Deemed to be University, Piparia, Waghodia, Vadodara,
1

Gujarat-391760, India; 2PG student, College of Physiotherapy, Sumandeep Vidyapeeth an Institution Deemed to be University, Piparia,
Copyright@IJCRR
Waghodia, Vadodara, Gujarat-391760, India; 3Professor & Principal, College of Physiotherapy, Sumandeep Vidyapeeth an Institution Deemed to
be University, Piparia, Waghodia, Vadodara, Gujarat-391760, India.

ABSTRACT
Background: The immediate postpartum period is more challenging for mothers who have had a caesarean delivery. The pain
presented after a caesarean section makes the recovery difficult and delays the mother’s mobility. This study aimed to evaluate
the effect of Physiotherapy treatment on Pain by VAS, Difference in PEFR and functional mobility by “time up and go” scale and
on cadence.
Method: Mothers with lower segment caesarean section (LSCS) eligible to participate in the study were divided into two groups;
routine nursing care only as to date was the practice. The experimental exercise group was given fixed physiotherapy protocol
from postoperative (POD) 1 up to the day of discharge. The severity of pain was assessed with the visual analogue scale on
POD 1 and the day of discharge and functional mobility was to be assessed with the “time up and go” scale and cadence on the
day of discharge. Peak expiratory flow rate was taken op Pod 1 and day of discharge.
Result: There was a significant reduction in VAS at rest and movement within the group (P<0.01). There was no significant
difference in VAS at rest and movement between the groups (P>0.05). There was a significant difference in mean PEFR at the
day of discharge within and between the group (P<0.01), there was no significant difference in TUG and CADENCE between
the group (P>0.05).
Conclusion: Early Postpartum physiotherapy was found to be beneficial in both the active patient group and also in the group
where education and demonstration were given.
Key Words: Early ambulation, LSCS, PEFR postpartum, Physiotherapy after caesarean section, Physiotherapy after childbirth, Post-
partum pain

INTRODUCTION were 7.1% in 1998 and increased up to 16.7% in recent

years.5,6
Pregnancy is a long and very special journey for women.1
Term pregnancy has traditionally defined as a duration of 10 A C-section is performed for the safety of the child and
lunar months or 9 calendar months and 7 days since the first mother which might be at the risk of vaginal delivery is per-
day of the last menstrual period.2,3 There are two types of formed (emergency CS) or there is the chance of any danger
delivery for birth: vaginal delivery and caesarean delivery. to the baby or mother with vaginal delivery (planned CS).7,8
With an incidence of around 25%, lower segment caesarean The most common reasons for a C-section are fetal distress,
section (LSCS) becomes the most common abdominal sur- prolonged labour, breech presentation, multiple gestations,
gery in the world performed on females.4 previous section and CS on demand.4-10 The lower abdomi-
nal transverse incision is adequate for the vast majority of
Births by caesarean sections, many of them unnecessary, caesarean operations. It has the advantages of cosmetic ap-
have started to increase, globally. India has the highest an- proval and minimal risk of postoperative complication.11,12
nual rate for CS among all the East Asian countries which

Corresponding Author:
Dr. Purvi Patel, College of Physiotherapy, SumandeepVidyapeeth an institution deemed to be University, Piparia, Waghodia, Vadodara,
Gujarat-391760, India; Email: purvi.cop@sumandeepvidyapeethdu.edu.in; purvi840@gmail.com
ISSN: 2231-2196 (Print) ISSN: 0975-5241 (Online)
Received: 05.11.2020 Revised: 09.01.2021 Accepted: 23.02.2021 Published: 22.06.2021

Int J Cur Res Rev | Vol 13 • Issue 12 • June 2021 155
 Patel et al: Effect of physiotherapy treatment in early post-partum period after LSCS

Post-natal care is necessary to ensure that no complications divided into two groups by even and odd method. One con-
have developed in the woman after childbirth. The imme- trol group and one was the experimental group. A total of 29
diate postpartum period even more challenging for mothers patients were recruited in the study. Out of which 14 were
who have had a caesarean delivery and most often occurs in in the control group and 15 were in the experiment group.
the hospital setting, where the majority of women remain for The Control group was verbally educated and demonstrated
approximately 2 days after a vaginal delivery and 3-5 days physiotherapy along with routine nursing care as to date was
after caesarean delivery. The pain presented after a caesarean the practice. The experimental group underwent a structured
section makes the recovery difficult and delays the mothers’ physiotherapy programme from post-operative (pod) 1 up
mobility.12,13,14 to the day of discharge in form of Assisted active and ac-
tive movements of the limbs like ankle toe movements, leg
Postpartum physiotherapy assessment can identify postural
slides, movement around the bed, bottom lift techniques us-
and structural weaknesses arising from the pregnancy, de-
ing crook lying, gentle exercises, such as pelvic rock, knee
livery, or postpartum conditions. Physiotherapy management
rolls from side to side, abdominal contraction on expiration,
should be comprised of ergonomics and education as the key
gluteal contractions, pelvic tilt exercises and ambulation.
components for women after childbirth. Exercise has been
Each exercise was performed 5-10 times. Ergonomic train-
proven to be beneficial during pregnancy as well as in the
ing was also given such as comfortable breastfeeding posi-
post-partum period for up to 24 weeks. Postpartum exercise
tions, sitting and lying on the bed, walking, elimination of
improves aerobic fitness, high-density lipoprotein-cholester-
urine, excretion of bowel material, diet, self-care and atten-
ol levels, insulin sensitivity, and psychological well-being.
tion to the newborn.23,24,25
Physical activity during postpartum is both a recommended
and an essential contributor to maternal health. Physiothera- The severity of pain was assessed with a visual analogue
pists instruct women in transverses abdominus, multifidus, scale (VAS) on pod 1 and the day of discharge and functional
and pelvic floor co-activation, which strengthens core stabil- mobility was assessed with the “time up and go scale”,26 and
ity and is beneficial in the prevention and treatment of back cadence by pedometer on the day of discharge. Peak expira-
pain.15-18 tory flow rate was taken on pod 1 and the day of discharge.
Early ambulation is one of the very important parts of ex-
tensive postoperative care. That indicates that along with Statistical analysis
other exercises, the patient should be mobilised out of bed as To check normality assumption descriptive statistics, nor-
soon as possible. A supervised programme within the first 24 mality plot, and Shapiro Wilk test was obtained for all data,
hours is best and this should be reinforced every two hours it was found that PEFR at baseline in the control group and
by the team. Effective postoperative pain relief is also impor- VAS on movement in the experimental group did not satisfy
tant to allow the patient to mobilize early.16,19 normality assumptions whereas all other parameters satis-
fied the normality assumptions. Therefore non-parametric
Several studies evaluated the effects of physiotherapy man- test was carried out for PEFR at baseline in control and VAS
agement in early post-CS patients and found that physiother- on movement in the experimental group. A parametric test
apy can improve the well-being of females after childbirth by was carried for all other variables. The same type of nor-
improving productivity and quality of life in the early stage mality check was done for difference (pre to post) of PEFR
of post caesarean section.20,21,22 In India however there are and VAS between the control and experimental group. It was
several hospitals where such services are yet to be provided. seen that only VAS on movement difference in the experi-
The present study was undertaken to identify the benefits of mental group was not satisfying normality assumptions and
physiotherapy post LSCS. this variable was dealt with non-parametric and the rest of all
with a parametric test.

MATERIAL AND METHODS

This interventional study was approved by SVIEC. Every
RESULT
consecutive mother who had undergone LSCS and was will- All data were entered into a Microsoft Excel sheet. Collected
ing to participate in the study was recruited with the approval data were analysed using SPSS and STATA software. De-
of the Obstetrician. Mothers with cardiac, respiratory, mus- scriptive statistics including mean, standard deviation (SD),
culoskeletal or neurological problems and who were suffer- and confidence interval (CI) were obtained.
ing from major pregnancy complication like severe anaemia,
pregnancy-induced hypertension, and postpartum haemor- Table 1 shows VAS at rest in both the groups and VAS on
rhage were excluded from the study. Participants were ex- movement in the control group was significantly reduced
plained about the study and a written informed consent form (P<0.01). Also, PEFR in the experimental group was sig-
was taken. Mothers eligible to participate in the study were nificantly increased (P<0.01). There was also a significant

Int J Cur Res Rev | Vol 13 • Issue 12 • June 2021 156
 Patel et al: Effect of physiotherapy treatment in early post-partum period after LSCS

decrease in VAS on movement in the experimental group the pain gait mechanism and may also stimulate the produc-
and an increase in PEFR in the control group as shown in tion of endogenous opiates.21,23
table 2. Table 3 shows the difference between the two groups
The present study found that PEFR amongst both the control
was not statistically significant for VAS on rest, cadence and
and experimental group was significantly lesser than normal
TUG whereas there was a significant difference for PEFR
values of the same age group. One study with regards to
at the time of discharge and a difference of PEFR pre and
PEFR quotes support from various other studies that PEFR
post physiotherapy. There was no significant difference in
progressively increases with advancing gestational age.
VAS on movement at baseline and at the time of discharge
Though Different measurement devices, differences in the
between the two groups. PEFR at baseline also shows no
timing of each measurement, differences in how the study is
significant difference as shown in table 4.
conducted, and differences in statistical methods may in part
explain these differing findings and conclusions concerning
changes in PEFR during pregnancy.30
DISCUSSION
They explain their findings on a mechanical basis, pointing
In the present study, a total of 29 patients who underwent out the effect of uterine enlargement and maternal weight
LSCS has recruited the study (14 in the control group and 15 gain and that the women in their study were of mixed eth-
in the experiment group). nicity. Further, the author also quotes Puranik et al. who
The control group comprised of participants who were just measured PEF with a portable flow meter in an Indian pop-
verbally educated and demonstrated physiotherapy (earlier ulation and found PEFR to decline throughout pregnancy.
this was also not done effectively and in some case, few They attribute their findings to inadequate nutritional status
instructions by nurses may have been given) whereas the and developing muscular weakness because of poor socio-
experiment group received a structured physiotherapy pro- economic status in the studied population. The observations
gramme to help prevent venous stasis, joint stiffness and of that study would not apply to all populations because of
peripheral oedema have been recommended and used.23,24,25 variations in ethnic, social, and economic conditions. Hence,
further studies would be warranted in different populations.30
Encouragement of deep breathing exercises to keep lungs
well ventilated, to decrease the risk of mucus accumulation
and increase the venous return also have recommended and CONCLUSION
used in the literature.21,23,24,25 Physical activity can be re-
sumed as soon as physically and medically safe. There are In the present study, the PEFR difference on day 1 and the
no published studies to indicate that, in the absence of medi- day of discharge in the control group showed a significant
cal complications, rapid resumption of activities will result increase (P=.001). PEFR difference on day 1 and the day of
in adverse effects.15 discharge in the experimental group also showed a similar
significant increase (P<0.01). Also, there was a significant
Lígia de Sousa et al., “concluded Post caesarean section pain
difference in mean PEFR on the day of discharge in the ex-
commonly rated as moderate leads to limitations of physical
perimental group (P<0.01) as compared to the control. Thus
activities for sitting down, standing up, and walking.[19] In
it has been seen that physiotherapy given post-partum both
the present study also the women rated their pain as moder-
structured and/or education in the present study was found
ate (mean VAS movement at 1st day in the control group
to be effective.
4.450, and in the experimental group 8.660) in activities like
sitting down, standing up, walking. In conclusion, there was significant pain reduction within
both groups. There was a significant increase in PEFR within
In the present study, VAS at rest and movement of the con-
the group and between the groups while other parameters
trol group on day 1 and discharge was significantly reduced
showed no difference between groups. There was no differ-
(P<0.01). VAS at the rest of the experimental group on day
ence between TUG & cadence. The study confirms the ben-
1 and discharge were significantly reduced (P<0.01).VAS on
efit of physiotherapy in both the active patient group and also
the movement of the experimental group on day 1 and at dis-
in the group where education and demonstration were given.
charge shows a significant decrease in VAS (P=.001). Sev-
eral studies also conclude that the physiotherapy program in
the early post-caesarean period reduces incisional pain.27-30
ACKNOWLEDGMENT
It has been recommended that women must be helped to ex-
periment to find comfortable positions for feeding, relaxa- The authors thank the Department of obstetrics & gynaecol-
tion and sleep, using pillows. Pain relief can occur rapidly ogy of Sumandeep Vidyapeeth. The authors acknowledge
if the mother’s weight is advantageously redistributed. It is the immense help received from the scholars whose articles
also theoretically possible that the muscle activity triggers are cited and included in references of this manuscript. The

157 Int J Cur Res Rev | Vol 13 • Issue 12 • June 2021

 Patel et al: Effect of physiotherapy treatment in early post-partum period after LSCS

authors are also grateful to authors/editors/publishers of all 14. Patnaik VV, Singla RK, Bansal VK. Surgical incisions—
those articles, journals and books from where the literature their anatomical basis Part IV-abdomen. J Anat Soc India.
2001;50(2):170-8.
for this article has been reviewed and discussed.
15. Watson ED, Oddie B, Constantinou D. Exercise during preg-
Authors’ Contribution nancy: knowledge and beliefs of medical practitioners in
South Africa: a survey study. BMC pregnancy child. 2015 Dec
P.P. - Drafting the article, critical revision of the article 1;15(1):245.
16. Fawcett J, Aber C, Weiss M, Haussler S, Myers ST, King C, et
M.S. - Data collection, data analysis and interpretation al. Adaptation to cesarean birth: Implementation of an interna-
tional multisite study. Nurs Sci Quart. 2005 Jul;18(3):204-10.
L.P. - Conception of the work, final approval of the version 17. Stepan H, Kuse-Föhl S, Klockenbusch W, Rath W, Schauf B,
to be published Walther T, Schlembach D. et al. Diagnosis and treatment of hy-
pertensive pregnancy disorders. Guideline of DGGG (S1-Level,
Source of Funding AWMF Registry No. 015/018, December 2013). Geburtshilfe
NIL und Frauenheilkunde. 2015 Sep;75(09):900-14.
18. Torkan B, Parsay S, Lamyian M, Kazemnejad A, Montazeri
Conflict of Interest A. Postnatal quality of life in women after normal vaginal de-
livery and caesarean section. BMC pregnancy child. 2009 Dec
The authors declare they have no conflict of interest. 1;9(1):4.
19. Sousa LD, Pitangui AC, Gomes FA, Nakano AM, Ferreira CH.
Measurement and characteristics of post-cesarean section pain
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 Patel et al: Effect of physiotherapy treatment in early post-partum period after LSCS

Table 1: Comparison within groups on day 1 and at discharge using Sharpio-Wilk test
Group Outcome Measure Mean SD T P-value*
difference
Control Difference of VAS on rest 1.8214 1.1477 5.938 0
group
Control Difference of VAS on movement 4.45500 2.0986 7.934 0
group
Experimental group Difference of VAS on rest 2.0133 .9819 7.941 0
Experimental Difference in PEFR -85.333 31.366 -10.537 0
group

P value <0.05 is considered statistically significant, SD= standard deviation

Table 2: Comparison within groups on day 1 and at discharge using Wilcoxon signed ranks test
Group Outcome Measure Mean SD Z P value*
difference
Experimental Difference of VAS on movement 8.6600 12.91200 -3.423 0.001
group
Control group Difference in PEFR 27.8571 16.72335 -3.207 0.001
P value <0.05 is considered statistically significant, SD= standard deviation

Table 3: Comparison between groups for normally distributed data

Outcome Measure Group Mean SD Mean difference T P value*
VAS on rest Control 1.821 1.1477 -.1919 -.485 0.632
Experimental 2.013 .9819
PEFR at discharge Control 149.29 26.736 -63.381 -5923 0
Experimental 212.67 30.582
Difference in PEFR Control 27.8571 16.72335 57.476619 -6.091 0
Experimental 85.3333 31.36574
Cadence Control 94.71 8.398 -5.286 -1.688 0.103
Experimental 100.00 8.452
TUG Control 9.60 1.117 0.377 0.894 0.379
Experimental 9.22 1.152

P value <0.05 is considered statistically significant, SD= standard deviation

Table 4: Comparison between groups for data which were not normally distributed using data Mann Whitney
U Test
Outcome Measure Group Mean SD Z P value*
VAS on movement at baseline Control 4.450 2.0986 -1.369 0.171
Experimental 8.660 12.9120
VAS on movement at the discharge Control 0 0 0 1.000
Experimental 0 0
PEFR at baseline Control 121.43 31.344 -0.617 0.537
Experimental 127.33 31.502

P value <0.05 is considered statistically significant, SD= standard deviation

159 Int J Cur Res Rev | Vol 13 • Issue 12 • June 2021