Physical Therapy in Pregnancy and Postpartum: Complete Guide

The period of gestation and the months immediately following childbirth represent a phase of profound physiological, anatomical, and psychological change in a woman’s life. During these nine months, the female body adapts to accommodate, nourish, and protect the developing fetus, undergoing significant biomechanical and hormonal variations. In this delicate scenario, pregnancy and postpartum physiotherapy is introduced as a fundamental medical discipline, aimed at preventing, assessing, and treating the numerous musculoskeletal disorders and perineal dysfunctions that may arise. The primary goal of rehabilitative intervention is not solely the resolution of painful symptoms, but the maintenance of maximum motor function and the improvement of the quality of life for the pregnant woman and new mother. It is imperative to emphasize that any rehabilitative pathway or therapeutic exercise program must be undertaken exclusively after careful clinical evaluation and prior authorization from your doctor or physical therapist, in order to exclude absolute or relative contraindications.

International scientific literature widely agrees on the benefits of a conservative and rehabilitative approach during the perinatal period. Postural changes, weight gain, and the action of specific hormones such as relaxin and progesterone lead to increased ligamentous laxity, altering joint stability, particularly in the pelvis and spine. This process, although physiological and necessary for childbirth, exposes musculoskeletal structures to a high risk of functional overload. Timely and targeted intervention allows for the management of these alterations, facilitating optimal recovery in the puerperium and reducing the incidence of long-term chronic conditions.

The importance of pregnancy and postpartum physiotherapy for women’s health

Pregnancy and postpartum physiotherapy addresses musculoskeletal changes in the spine, pelvis, and core through targeted exercise and education to optimize recovery and function. The rehabilitative approach in obstetrics and gynecology has undergone significant evolution in recent decades. Pregnancy and postpartum physiotherapy is no longer considered an accessory intervention, but rather an essential pillar in maternal and child care. Body changes begin as early as the first trimester and progressively intensify. The body’s center of gravity shifts anteriorly and superiorly, forcing the spine to compensate through an accentuation of lumbar lordosis and thoracic kyphosis. This postural realignment, associated with increased uterine volume and body weight, generates abnormal tensions on the paravertebral musculature, pelvic ligaments, and sacroiliac joints.

Biomechanical and physiological adaptations during gestation

From an endocrinological perspective, the placenta and corpus luteum secrete relaxin, a peptide hormone whose peak is recorded in the first trimester and in the weeks preceding childbirth. The primary function of relaxin is to remodel collagen, reducing the stiffness of the pubic symphysis and pelvic joints to facilitate the passage of the fetus through the birth canal (Vleeming et al., 2008). However, this systemic laxity affects the entire locomotor system, decreasing overall joint stability. The deep stabilizing muscles, particularly the transversus abdominis and multifidus, find themselves at a mechanical disadvantage due to the distension of the abdominal wall. Consequently, biomechanical load is transferred to passive structures, triggering inflammatory and painful processes.

The preventive and therapeutic role of movement

Therapeutic exercise, when correctly dosed and supervised, represents the most effective tool for counteracting the negative effects of these adaptations. Exercise prescription must be highly individualized. International guidelines recommend at least 150 minutes of moderate-intensity aerobic physical activity per week during pregnancy, combined with muscle strengthening exercises. Controlled movement promotes the maintenance of muscle tone, improves venous and lymphatic return (counteracting dependent edema), optimizes glycemic control (preventing gestational diabetes), and prepares the cardiovascular system for the exertion of labor. It is essential that every training program be structured and monitored by your doctor or physical therapist, who will adapt the workloads according to the gestational age and the specific clinical conditions of the patient.

Main musculoskeletal disorders in pregnancy and postpartum physiotherapy

The prevalence of musculoskeletal disorders during pregnancy is extremely high, affecting, according to various epidemiological studies, over 70% of expectant women. Pregnancy and postpartum physiotherapy addresses the functional diagnosis and treatment of these syndromes, which, if neglected, can become chronic and severely impair normal daily and work activities.

Low back pain and pelvic girdle pain (PGP)

Low back pain (LBP) and pelvic girdle pain (PGP) are the most frequently reported conditions. Although often confused, they present distinct etiologies and clinical pictures. Gestational low back pain typically manifests as dull pain in the lumbar musculature, exacerbated by prolonged standing or sitting, and is primarily related to compensatory hyperlordosis. Pelvic pain, on the other hand, is localized at the sacroiliac joints, buttocks, and/or the pubic symphysis. PGP is characterized by acute, sharp pain that worsens during asymmetric loading activities, such as walking, climbing stairs, turning in bed, or dressing while standing on one leg (Wu et al., 2004).

Sciatica and piriformis syndrome

True sciatica, caused by a disc herniation with root compression, is relatively rare in pregnancy (incidence below 1%). Much more frequent is so-called “false sciatica” or piriformis syndrome. Due to the external rotation of the lower limbs (the typical “waddling gait” of the pregnant woman) and pelvic instability, the piriformis muscle and other external hip rotators undergo spasm and hypertrophy, potentially compressing the sciatic nerve in its gluteal course. Physiotherapy treatment focuses on myofascial release, selective stretching, and rebalancing of the pelvi-trochanteric musculature.

Carpal tunnel syndrome and fluid retention

Hemodynamic alterations and increased plasma volume lead to physiological fluid retention, manifesting as peripheral edema. When edema affects the upper limbs, it can cause increased pressure within the carpal tunnel of the wrist, compressing the median nerve. Carpal tunnel syndrome in pregnancy presents with tingling, numbness, nocturnal pain, and weakness in the first three fingers of the hand. Conservative intervention involves the use of nocturnal splints, manual lymphatic drainage techniques, neurodynamic mobilizations, and ergonomic advice. In this case as well, assessment by your doctor or physical therapist is essential to monitor the evolution of the neurological picture.

Assessment and intervention in perinatal rehabilitation

The physiotherapy assessment process in obstetrics requires specialized skills and a deep understanding of pregnancy physiology. The professional must be able to distinguish physiological body adaptations from true pathological dysfunctions, promptly identifying any “red flags” (warning signs) that require immediate referral to a specialist physician (e.g., vaginal bleeding, premature uterine contractions, severe hypertension, sudden headache).

The multidisciplinary approach

Optimal management of the pregnant and postpartum patient is based on a team approach. The physical therapist works closely with the gynecologist, midwife, general practitioner, and, where necessary, with the nutritionist and psychologist. This synergy ensures comprehensive care, ensuring that every intervention is safe and aligned with the clinical course of the pregnancy. Communication between professionals is vital for monitoring parameters such as blood pressure, fetal growth, and cervical competence before undertaking any physical therapy.

Safe manual techniques during gestation

Manual therapy offers valuable support for pain control, avoiding or reducing the need for pharmacological therapies, which are often contraindicated in pregnancy. The techniques used must be gentle, non-invasive, and adapted to the patient’s posture (favoring lateral decubitus with support pillows or seated position). Therapeutic decontracting massage, myofascial release, low-velocity and low-amplitude joint mobilizations (avoiding high-velocity manipulations or thrusts to the lumbar and pelvic area due to ligamentous laxity), and the application of Kinesio Taping to provide mechanical abdominal support or lymphatic drainage are indicated. The use of instrumental physical therapies (such as Tecar therapy, ultrasound, electrotherapy) is generally contraindicated or requires extreme caution and severe topographic limitations, which is why it is mandatory to consult your doctor or physical therapist.

Therapeutic exercise and motor control

The heart of rehabilitative intervention is therapeutic exercise. The program focuses on restoring lumbopelvic motor control. Selective activation exercises for the transversus abdominis and pelvic floor muscles are taught, integrated with diaphragmatic breathing. Work is done on strengthening the gluteal muscles and scapular stabilizers to counteract thoracic hyperkyphosis. Particular attention is paid to postural education, teaching the pregnant woman how to perform postural transitions (e.g., from supine to sitting via the lateral decubitus position) to minimize stress on the linea alba and pelvic joints.

The pelvic floor: prevention and rehabilitation

The pelvic floor is a complex system of muscles, fasciae, and ligaments that closes the lower part of the abdominal cavity. Its functions are multiple: support of the pelvic organs (bladder, uterus, rectum), urinary and fecal continence, sexual function, and a biomechanical role in pelvic stability. During pregnancy, the pelvic floor is subjected to continuous mechanical stress due to the weight of the gravid uterus and the muscle-relaxing action of hormones.

Anatomy and function of the perineum

The perineal musculature, particularly the levator ani muscle, must possess both the strength necessary to support the viscera against gravity and increases in intra-abdominal pressure (coughing, sneezing, lifting weights), and the elasticity to stretch during the expulsive phase of delivery. A deficit in strength or coordination of this musculature can result in severe dysfunctions. The physiotherapy assessment of the pelvic floor, performed with gentleness and respect for the patient’s privacy, allows quantification of basal tone, voluntary contraction strength, endurance, and relaxation capacity.

Kegel exercises and biofeedback

Pelvic Floor Muscle Training (PFMT), commonly known as Kegel exercises, represents the first-line intervention for the prevention and treatment of perineal dysfunctions (Bo et al., 2017). It is essential that these exercises be learned correctly; studies show that a significant percentage of women perform the exercises incorrectly, pushing downward or contracting accessory muscles (gluteals, adductors) instead of lifting and closing the sphincters. The physical therapist can employ awareness techniques, vaginal examination (if not contraindicated), or electromyographic biofeedback instrumentation to ensure correct motor learning. The program includes phasic (rapid) and tonic (sustained) contractions, integrated into daily activities.

Prevention of incontinence and prolapse

Stress urinary incontinence is an extremely common symptom in the third trimester and postpartum. Starting a PFMT program from the early weeks of gestation significantly reduces the risk of developing incontinence both during pregnancy and in the months following delivery. Furthermore, a toned and elastic perineum is less prone to severe lacerations during labor and reduces the risk of long-term pelvic organ prolapse. In the weeks preceding delivery (from the 34th week), the physical therapist can instruct the patient in performing perineal massage, a self-massage technique aimed at improving the extensibility of vulvovaginal tissues, reducing the need for episiotomy.

Physical recovery in the postpartum period

The puerperium, which conventionally covers the six weeks following delivery, is a phase of recovery and readjustment. The body needs time to reverse the physiological modifications of pregnancy. The uterus undergoes involution, excess fluids are eliminated, and hormone levels stabilize. During this phase, physiotherapy plays a crucial role in guiding the new mother toward safe functional recovery, preventing complications, and facilitating the return to normal activities.

Diastasis recti abdominis: assessment and treatment

Diastasis recti abdominis (DRA) consists of the separation of the two muscle bellies of the rectus abdominis along the midline, due to stretching and thinning of the linea alba. It is a physiological phenomenon in the third trimester, present in 100% of pregnant women, necessary to allow fetal growth. However, in the postpartum period, the inter-recti distance (IRD) should progressively decrease. If the separation persists beyond physiological limits (generally considered pathological if greater than 2-2.5 cm at the umbilical level) and is associated with a loss of linea alba tension, a dysfunction is established (Benjamin et al., 2014).

Diastasis is not just an aesthetic problem, but a functional one. It can cause lumbopelvic instability, low back pain, pelvic floor dysfunctions, and, in more severe cases, umbilical hernias. Conservative physiotherapy treatment is the first approach. It is imperative to avoid traditional abdominal exercises (such as classic “crunches” or sit-ups), which increase intra-abdominal pressure and can worsen the separation. The rehabilitation protocol is based on the synergistic activation of the transversus abdominis and pelvic floor muscles, motor control exercises, diaphragmatic breathing, and, in some cases, the use of neuromuscular taping or specific support garments, always under the supervision of your doctor or physical therapist.

Scars: cesarean section and episiotomy

Both vaginal delivery and cesarean section can leave scar tissue that requires attention. Episiotomy or spontaneous perineal lacerations can cause persistent pain (dyspareunia), altered sensation, and fascial retractions that impair pelvic floor function. Cesarean section involves an incision that crosses several tissue layers (skin, subcutaneous tissue, muscle fascia, peritoneum, uterus). The formation of scar adhesions can limit tissue gliding, causing chronic pelvic pain, postural alterations in flexion, and visceral dysfunctions.

Physiotherapy treatment of scars begins once clinical wound healing is complete (usually after 4-6 weeks, subject to medical authorization). Scar massage techniques, tissue mobilization, dry cupping, and Tecar therapy (in athermic mode) are used to improve vascularization, promote connective tissue elasticity, and prevent the formation of deep adhesions.

Return to sports activity

The return to physical and sports activity postpartum must be gradual and progressive. There is no universal timeline; recovery depends on pre-pregnancy fitness level, type of delivery, presence of complications, and the new mother’s sleep quality. Initially, light walks and mobility and deep core activation exercises are recommended. High-impact activities (running, jumping, heavy weightlifting) should be avoided in the first 3-6 months, or at least until the complete competence of the pelvic floor and abdominal wall in managing increases in intra-abdominal pressure has been ascertained. A comprehensive functional assessment by a physical therapist is essential before resuming high-intensity sports.

Ergonomics, return to work, and prevention of biomechanical overloads

The daily management of a newborn imposes a significant biomechanical load on the mother’s musculoskeletal system. Breastfeeding, lifting the baby from the crib or stroller, carrying in arms or in a baby carrier, and the countless trunk flexions for diaper changes or bathing represent risk factors for the onset of biomechanical overload conditions. Among these, upper limb tendinopathies stand out, such as De Quervain’s tenosynovitis (inflammation of the thumb and wrist tendons, also known as “mommy’s wrist”), cervicobrachialgia, and low back pain recurrences.

Breastfeeding and correct postures

Ergonomic education is a fundamental component of postpartum rehabilitation. During breastfeeding, whether breast or bottle feeding, it is common to assume anterior closing postures, with anteriorly positioned shoulders, a flexed cervical spine, and dorsal musculature in constant tension. It is advisable to use nursing pillows to bring the baby to breast height, avoiding bending toward the infant. The mother should sit on a chair with good lumbar support, keeping her feet well supported on the floor or on a footrest, and relaxing the shoulders. The physical therapist instructs the patient on stretching exercises for the pectoral and cervical muscles, and strengthening exercises for the interscapular muscles, in order to restore correct postural alignment.

Lifting and carrying the baby: INAIL data and workplace protection

Lifting the newborn must be done respecting the ergonomic principles of the spine: bending the knees, keeping the load close to the body, activating the abdominal and perineal muscles before the effort, and avoiding trunk rotations during lifting. The use of ergonomic baby carriers or wraps is recommended to distribute weight symmetrically on the trunk, reducing stress on the arms and lumbar spine.

Overload prevention assumes even greater importance when addressing the topic of returning to work. According to the data and guidelines of INAIL (the Italian National Institute for Insurance against Accidents at Work) regarding maternity protection in the workplace (Legislative Decree 81/08 and Legislative Decree 151/01), workers during pregnancy and up to seven months after delivery are subject to specific protections against occupational risks. INAIL highlights how manual handling of loads, prolonged standing, vibrations, and awkward postures represent significant risk factors for maternal-fetal health and the onset of musculoskeletal conditions.

Particular attention is directed toward specific professional categories, such as healthcare workers (nurses, healthcare assistants), large-scale retail workers, manufacturing workers, and agricultural sector workers. For these categories, INAIL prescribes abstention from tasks involving load lifting or exposure to vibrations, providing for reassignment to compatible duties. In this context, the physical therapist plays a key role in occupational medicine, providing ergonomic consultation, assessing the postpartum worker’s residual functional capabilities, and structuring specific physical reconditioning programs to facilitate a safe return to work free from injury risk or pain recurrence. It is always recommended to liaise with the company occupational physician and your doctor or physical therapist for an accurate assessment of individual occupational risk.

FAQ – Frequently Asked Questions about physiotherapy in pregnancy and postpartum

Frequently Asked Questions

What is physical therapy in pregnancy and postpartum?

This specialized field of physical therapy focuses on preventing, assessing, and treating musculoskeletal disorders and perineal dysfunctions during pregnancy and the postpartum period. Its aim is to support the body through significant physiological and anatomical changes.

Why is physical therapy important during pregnancy and postpartum?

During this period, hormonal changes, postural adaptations, and weight gain lead to increased ligamentous laxity and altered joint stability. Physical therapy helps manage these changes, addressing compensatory spinal shifts and increased tension on muscles and ligaments.

What are the main goals of physical therapy during the perinatal period?

The primary goal of rehabilitative intervention is to maintain optimal motor function and improve the quality of life for pregnant women and new mothers. It aims to resolve painful symptoms and support the body’s adaptation to profound physiological and biomechanical variations.

Are there any precautions before starting physical therapy during pregnancy or postpartum?

Any rehabilitative pathway or therapeutic exercise program must be undertaken exclusively after careful clinical evaluation. Prior authorization from a doctor or physical therapist is essential to exclude any absolute or relative contraindications.

Sources and Scientific References

1. Pelvic Obstetric & Gynaecological Physiotherapy (POGP). Pregnancy-related Pelvic Girdle Pain: Guidelines for the Management of Pelvic Girdle Pain During Pregnancy and After Birth. POGP, 2015.
2. Liddle SD, Pennick V. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database of Systematic Reviews, 2015.
3. NICE. Antenatal and postnatal mental health: clinical management and service guidance. Clinical guideline [CG192]. National Institute for Health and Care Excellence, 2014.

Sources and Scientific References

1. Romeikienė KE et al. (2021). Pelvic-Floor Dysfunction Prevention in Prepartum and Postpartum Periods. Medicina (Kaunas). 57. DOI | PubMed
2. Diz-Teixeira P et al. (2023). Update on Physiotherapy in Postpartum Urinary Incontinence. A Systematic Review. Arch Esp Urol. 76:29-39. DOI | PubMed
3. Mantilla Toloza SC et al. (2024). Pelvic floor training to prevent stress urinary incontinence: A systematic review. Actas Urol Esp (Engl Ed). 48:319-327. DOI | PubMed
4. Lawson S et al. (2018). Pelvic Floor Physical Therapy and Women’s Health Promotion. J Midwifery Womens Health. 63:410-417. DOI | PubMed
5. Beamish NF et al. (2025). Impact of postpartum exercise on pelvic floor disorders and diastasis recti abdominis: a systematic review and meta-analysis. Br J Sports Med. 59:562-575. DOI | PubMed