Arch Gynecol Obstet (2012) 285:621–627
DOI 10.1007/s00404-011-2037-0
M AT ERNAL-FE T A L M ED I C I N E
EVects of physiotherapy on pain and functional activities
after cesarean delivery
Ãlkim ÇÂtak Karakaya · Ãnci Yüksel · Türkan Akbayrak ·
Funda Demirtürk · Mehmet Gürhan Karakaya ·
Özgür Özyüncü · Sinan Beksaç
Received: 26 June 2011 / Accepted: 25 July 2011 / Published online: 10 August 2011
Springer-Verlag 2011
Abstract
Purpose To investigate the eVects of a physiotherapy program on incision pain and functional activities in the early
post-cesarean period.
Methods Fifty women were evaluated after Cesarean
operation with regard to times of ambulation and return of
bowel activity, intensity of incision pain, diYculty in functional activities and number of analgesics required additional to routine pain control procedure. Twenty-four
women received only routine nursing care, and a physiotherapy program was applied to the study group (n = 26),
additionally.
Results Postoperative ambulation and return of bowel
activity were earlier in the study group (p < 0.05). Incision
pain and diYculty in functional activities decreased signiWcantly within 2 days in both groups, and the values were
lower in the study group (p < 0.05). Study group needed
less medication for pain control (p < 0.05).
Ã. Yüksel · T. Akbayrak
Department of Physiotherapy and Rehabilitation,
Faculty of Health Sciences, Hacettepe University,
06100 Ankara, Turkey
F. Demirtürk
School of Physical Education and Sports,
Gaziosmanpaoa University, Tokat, Turkey
Ã. ÇÂtak Karakaya (&) · M. G. Karakaya
Department of Physiotherapy and Rehabilitation,
Mufla School of Health Sciences, Mufla University,
Mufla, Turkey
e-mail: ilkim74@yahoo.com; ikarakaya@mu.edu.tr
Ö. Özyüncü · S. Beksaç
Maternal and Fetal Perinatology Unit,
Department of Obstetrics and Gynecology,
Hacettepe University Medical Faculty, Ankara, Turkey
Conclusions Findings revealed the eVectiveness of a
physiotherapy program in the early post-cesarean period in
a wider perspective than the current literature, and are
considered to be valuable for increasing the quality and productivity of the postnatal care, therefore improving well-being
after childbirth.
Keywords Connective tissue manipulation · Obstetric
rehabilitation · Physical therapy · Postnatal exercise ·
Transcutaneous electrical nerve stimulation
Introduction
Post-cesarean health problems such as incisional pain,
intestinal problems, mastitis, depression, nausea, vomiting
and anxiety are issues which have been studied prospectively or retrospectively, by many researchers [1–7].
In the literature, physiotherapy studies in the early postcesarean period usually consider the use and eVectiveness
of transcutaneous electrical nerve stimulation (TENS) on
incision pain and the amount of narcotics used for that pain
[2–6]. Smith et al. [6] stated that TENS was more eVective
than placebo TENS in reducing cutaneous, movement-associated post-cesarean incision pain, but not eVective in
reducing analgesic intake. Reynolds et al. [4] also suggested that TENS caused no reduction in narcotic requirements following cesarean section. Navarro Nuñez and
Pacheo Carrasco [3] investigated the eVectiveness of TENS
in comparison with intravenous administration of 1 g of
dipyrone on post-cesarean pain, and pointed out that TENS
was an eVective alternative method in reducing the pain in
the early post-cesarean period.
Additionally, there are some studies which investigated
the eVectiveness of TENS on hypotension after spinal
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622
anesthesia, nausea and vomiting after cesarean section [8, 9].
There is only one study, which presents the results of respiratory physiotherapy on pulmonary functions of women following cesarean delivery under general anesthesia [10].
Therapeutic acupressure is another non-pharmacological
method used for reducing anxiety, pain perception, nausea
and vomiting after cesarean deliveries [1, 11–15].
As mentioned above, subject-related literature is grossly
limited with TENS, and there is lack of information about
the use and eVectiveness of physiotherapy applications in
the early post-cesarean period. To test the hypotheses that
physiotherapy facilitates the recovery in the early postcesarean period, this study was planned to investigate the
eVects of physiotherapy applications on post-cesarean
ambulation time, return of bowel activity, incision pain,
need of analgesics and diYculty during functional activities, and therefore, to provide a wider perspective of obstetrical physiotherapy applications to the related literature.
Materials and methods
Women who underwent cesarean delivery under general
anesthesia due to obstetric indications (repeat cesarean
delivery, pelvic abnormalities that preclude engagement,
malpresentation of the fetus, dystocia and elective cesarean) at a University Hospital in Ankara, between December
2004 and May 2005 were involved in this study. The study
sample consisted of women who were followed and operated by the same obstetrician (SB). Exclusion criteria for
the study were; having multiple births, deliveries with operative complications, cesarean sections with spinal or epidural anesthesia, and using patient controlled anesthesia
(PCA). All eligible patients were informed and written consents were obtained before the study according to the principles outlined in the Declaration of Helsinki. None of the
subjects refused to participate, and 50 women completed
the study which was approved by the Institutional Ethical
Committee and registered to ClinicalTrials.gov.
In this prospectively designed, controlled and assessor
blinded trial, subjects were assigned into study or control
groups, according to the date they gave birth (even/odd
days). Neither the assessor nor the department staV (including the obstetrician) was aware of the randomization technique. Subjects in the study group (n = 26) received
physiotherapy applications in the early post-cesarean
period, and the control group (n = 24) did not receive any
applications other than routine nursing care.
Cesarean section technique and routine care of the patients
All subjects were operated by the same obstetrician (SB)
and lower segment transverse incision technique was used
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Arch Gynecol Obstet (2012) 285:621–627
for the cesarean section. After delivery, patients were transferred to their rooms within the obstetric ward. Vital signs
(heart rate, blood pressure and breathing rate) and body
temperatures were assessed regularly. Patients were not
allowed to feed orally before bowel movements had started.
For post-operative pain control in the Wrst 24 h, meperidine
(50 mg, 4 £ 1) and non-steroid anti-inXammatory medicine
(4 £ 1) were administered intravenously. If required by the
patient, additional analgesics or anti-inXammatory medications were also administered by the nurses, who were
blinded to the group assignment. Patients were encouraged
for early ambulation after delivery if they were not hypotensive and uterine bleeding was under control. Initially,
they ambulated 10–15 m inside their rooms, and the intensity increased in hours and days. Patients were usually discharged within 48–72 h in uncomplicated cases.
Assessments
Age (years), height (m), weight (kg) and body mass index
(kg/m2) values (at the end of pregnancy) were recorded as
physical characteristics. Number of pregnancies, parity,
abortus, dilatation and curettage (D&C), cesarean section
(last one included) and duration of gestation (day) were
recorded as obstetrical history.
Subjects were interviewed in relation with their health
problems before and during pregnancy in order to determine inter-group diVerences. Health problems were then
classiWed for statistical analyses as systemic (hypertension,
thyroid dysfunction, diabetes mellitus, anti-phospholipids
syndrome, factor V Leiden mutation), musculoskeletal
(back and low back pain), neurologic problems (headache,
disc hernia), urinary incontinence and constipation.
Time from transfer to obstetric department room to Wrst
ambulation after cesarean was calculated for statistical
analyses. Also the presence of pre-syncopal symptoms during the Wrst ambulation was recorded.
The patients were asked to record time of breaking gas
and defecation in order to calculate the time passed since
they were transferred to the room.
Intensity of incision pain was evaluated by horizontal
0–10 cm visual analogue scales (VASs), which were
reported to be sensitive to pharmacological and nonpharmacological procedures that alter the experience of
pain [1]. Patients marked the point best describing the
intensity of their pain in resting on VAS (0 = no pain,
10 = unbearable pain).
In order to evaluate the diYculty during functional
activities (turning in bed, coming into sitting/standing
positions, and walking) three separate 0–10 cm VASs
(0 = no diYculty, 10 = unable to perform the activity)
were marked by the patients, and the total score was
recorded (0–30 points).
Arch Gynecol Obstet (2012) 285:621–627
Intensity of incision pain and amount of diYculty in
functional activities were evaluated daily before the physiotherapy program in the study group.
Length of staying at the hospital and number of analgesic/anti-inXammatory medication additional to the standard
pain control procedure were recorded, and also cases were
observed for any adverse eVects which may be due to the
physiotherapy applications.
Physiotherapy program
Applications for respiratory functions
These applications were included in the physiotherapy
program, since they are not among standards of care for
post-cesarean patients in our country. Thoracic expansion
exercises were included in the program because of their
eVects on expansion of lungs and complete exchange of gases,
elimination of waste products, abdominal muscle tonus,
blood circulation, secretions, and relaxation [16, 17]. Also
huYng technique—an easier, less painful and more eVective method than coughing,—was taught to the subjects
[16].
Applications for blood circulation
Bending, stretching and circumXexion of feet at the ankles,
leg bracing, knee bending and straightening exercises were
included in the physiotherapy program to improve circulation, reduce edema, prevent possible post-operational circulatory problems, hasten recovery from the anesthetics and
prepare the patient for the eVort required in Wrst getting out
of the bed [16].
Thoracic expansion and active lower limb exercises
were performed every hour when the patients were awake,
with Wve repetitions in the operation day. After that day,
exercises were done with ten repetitions, three times a day.
Applications for incision pain
TENS with frequency of 120 Hz and pulse width of 60 s
was used for 30 min in every session. Self-adhesive electrodes were placed on each side of the incision, and current
intensity was increased up to the sensation of strong tingling, without causing contraction and uncomfortable feeling [16, 18, 19].
Applications for intestinal activity
Connective tissue manipulation (CTM) to the sacral and
lumbar regions was applied daily, as soon as the subjects
could come into sitting position, and lasted approximately
5 min in each session. CTM, in which localized and spe-
623
ciWc strokes are applied by the third Wngertip to make
traction between skin and tissues underneath, was
included in the program because of its eVects on pain and
visceral dysfunction (decreased intestinal motility in this
study) via stimulating segmental and supra-segmental
reXexes [20–22]. SpeciWc strokes used in this study
included: strokes to the sacrum, iliac crests, sacroiliac
joints, lumbar paravertebral region and subcostal region,
as explained by Tappan [22]. Posterior pelvic tilt exercises were also included in the program to contract
abdominal muscles, stimulate intestinal activity and prevent or control gas pain [16]. Exercises were performed
three times a day, with ten repetitions, within the limits of
pain.
Other
In order to retrain postural awareness, improve straight posture and prevent possible postnatal musculoskeletal pain
problems, subjects of the study group were educated about
proper use of body mechanics during baby caring and daily
activities. Also exercises were given to improve posture,
each with 5–10 repetitions, minimum three times a day,
especially after breastfeeding [16, 23]. Women were
informed about the anatomy, functions and importance of
the pelvic Xoor, and exercises were recommended with ten
repetitions for both slow and fast twitch muscle Wbers, during each breastfeeding. They were also recommended to
contract their pelvic Xoor during activities increasing intraabdominal pressure (such as laughing, sneezing and coughing) [16, 23, 24]. These education and recommendations
were given to the control group before discharge. Physiotherapy program was carried out by the same physiotherapist (ÃÇK).
Statistical analyses
Descriptive variables were presented as percentages.
Inter-group and intra-group analyses of quantitative variables were performed by Student t-test. Chi-square test
was used for inter-group comparison of the qualitative
data. Intra-group time-dependent changes were investigated by one-way ANOVA in repeated measurements,
and in order to Wnd out the superiority of the groups, variables belonging to each measurement time, was compared
by independent samples t-test. Relation of diVerent variables was investigated by Pearson correlation analyses.
All quantitative evaluations were performed from the
operation to the discharge day. However, since the time of
discharge varied between subjects, data of Wrst 3 days
(operation day, postoperative Wrst and second day) were
included in the statistical analyses, since were common in
all subjects.
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624
Table 1 Physical characteristics and obstetrical history of the
subjects
Arch Gynecol Obstet (2012) 285:621–627
Study group (X § SD)
Control group (X § SD)
t
¡0.219
p
Physical characteristics
Age (years)
30.46 § 5.69
30.83 § 6.32
Height (m)
1.63 § 0.06
1.63 § 0.05
0.414
0.828
0.681
Body weight (kg)
77.62 § 11.43
77.48 § 11.45
0.042
0.967
Body mass index (kg/m2)
29.18 § 4.18
29.50 § 5.22
¡0.233
0.816
Gravida (n)
2.23 § 0.91
2.67 § 1.13
¡1.510
0.138
Parity (n)
1.62 § 0.75
2.17 § 1.05
¡2.147
0.037*
Abortus (n)
0.50 § 0.81
0.29 § 0.62
1.011
D&C (n)
0.50 § 0.65
0.42 § 0.58
0.476
0.636
Cesarean section (n)
1.23 § 0.51
1.46 § 0.83
¡1.172
0.247
Duration of gestation (day)
261.73 § 8.73
257.75 § 21.29
0.877
0.385
Obstetrical history
*p < 0.05
Table 2 Health problems of the
subjects before and during pregnancy
0.317
Study group,n (%)
Control group, n (%)
2
p
Systemic problems
4 (15)
3 (13)
0.086
0.769
Musculoskeletal problems
11 (42)
7 (29)
0.935
0.333
Neurologic problems
8 (31)
8 (33)
0.038
0.846
Constipation
9 (35)
12 (50)
1.213
0.271
Urinary incontinence
0 (0)
1 (4)
1.105
0.293
Before pregnancy
During pregnancy
Systemic problems
8 (31)
10 (42)
0.643
0.423
Musculoskeletal problems
17 (65)
16 (67)
0.009
0.924
Neurologic problems
11 (42)
8 (33)
0.427
0.514
Constipation
11 (42)
16 (67)
2.981
0.084
Urinary incontinence
4 (15)
5 (21)
0.251
0.616
Results
The mean age of the subjects was 30.64 § 5.94 with a
range of 19–42 years. There was no diVerence between
groups when compared for age, height, weight and body
mass index (p > 0.05) (Table 1). Obstetric history parameters of the groups were similar (p > 0.05) except parity,
which was higher in the control group (p < 0.05) (Table 1).
Likewise, number of subjects having health problems
before and during pregnancy was similar in both groups
(p > 0.05) (Table 2).
Time to Wrst ambulation after delivery in the study and
the control groups were 6:18 (h:min) and 8:1 (h:min),
respectively, indicating that women who received physiotherapy ambulated earlier (t = ¡2.532, p = 0.015). During
Wrst ambulation, two (7.7%) subjects from the study and
Wve (20.8%) subjects from the control groups experienced
pre-syncopal symptoms (2 = 1.790, p = 0.181).
123
Inter-group comparison analysis revealed that time of
breaking gas and defecating were earlier in the study group
(p < 0.05) (Table 3).
Initial incision pain intensity was similar between groups
(p > 0.05). However, it was lower in the study group in the
postoperative Wrst and second day (p < 0.05) (Table 3).
Incision pain decreased signiWcantly from the operation to
the postoperative second day, in both groups (F = 16.868,
p = 0.000 in the study group, and F = 3.794, p = 0.041 in
the control group).
The number of analgesic/inXammatory medications
needed additional to the standard pain control procedure
was 5.04 § 0.96 in the study, and 5.79 § 0.78 in the control groups (t = ¡3.034, p = 0.004).
Groups had similar amount of diYculty during functional activities in the operation and postoperative second
day (p > 0.05). However, control group had more diYculty
in the postoperative Wrst day (p < 0.05) (Table 3). Values
Arch Gynecol Obstet (2012) 285:621–627
Table 3 Return of intestinal
functions after cesarean delivery, intensity of incision pain
and amount of diYculty in performing daily activities
625
Study group
Control group
X § SD
X § SD
Breaking gas (h:min)
21:00 § 9:40
Defecation (h:min)
42:42 § 15:52
Operation day
t
p
27:40 § 10:35
¡2.326
0.024*
57:16 § 18:11
¡3.024
0.004*
6.12 § 2.68
6.68 § 3.15
¡0.689
0.494
Post-operative Wrst day
3.62 § 1.73
5.32 § 2.80
¡2.612
0.012*
Post-operative second day
3.52 § 1.94
5.14 § 2.80
¡2.391
0.021*
Return of intestinal functions
Intensity of incision pain (0–10 cm)
DiYculty in daily activities (0–30 cm)
*p < 0.05
Operation day
21.02 § 5.98
24.13 § 5.88
¡1.851
0.070
Post-operative Wrst day
15.68 § 6.40
20.29 § 6.31
¡2.562
0.014*
Post-operative second day
14.15 § 6.93
15.80 § 7.24
¡0.827
0.412
decreased signiWcantly from the operation to the postoperative second day (F = 22.998, p = 0.000 in the study group,
and F = 22.390, p = 0.000 in the control group).
Intensity of incision pain and amount of diYculty in
functional activities were positively correlated for each
measurement time (r = 0.426, p = 0.002 in the operation
day, r = 0.534, p = 0.000 in the post-operative Wrst day,
r = 0.528, p = 0.000 in the post-operative second day).
During the physiotherapy program, no adverse eVects
were observed in the study group.
Discussion
The results supported our hypothesis, and indicated eVectiveness of physiotherapy on incision pain and functional
activities in the early post-cesarean period. Also, the need
for analgesic medication was lower and return of intestinal
functions and ambulation was earlier in the study group.
Groups were homogeneous in of physical characteristics, obstetrical history (except parity, which was higher in
the control group) and health problems before and during
pregnancy. All subjects had a companion while staying at
the hospital. Therefore it may be interpreted that all of them
received similar amount of help in case of need during
functional activities and while caring for the baby.
In this study, women who received physiotherapy program could ambulate earlier than the control group. Lower
extremity exercises and respiratory exercises were shown
to help avoiding the eVects of anesthetics, preparing the
subjects for the eVort for ambulation and improving blood
circulation [16, 17, 25]. Therefore, it can be considered that
physiotherapy applications may have provided desired circumstances for ambulation (no hypotension and excessive
uterine bleeding, and being desirous for ambulating) earlier
than routine nursing care.
Although not statistically signiWcant, it was remarkable
that the number of subjects who had pre-syncopal symptoms during Wrst ambulation in the control group (20%),
was approximately threefold of the study group (7%). This
parameter needs to be investigated in further studies,
involving higher number of subjects.
Breaking gas and defecation—indicators of bowel activity,—were experienced earlier in the study group, although
diet programs of the groups were not diVerent. Supportive
eVects of pelvic exercises providing passive movement of
the intestines and stimulation eVects of CTM on segmental
and cutaneo-visceral reXexes shortly after application were
previously presented in studies of Noble and Holey and
Lawler [16, 26]. Therefore, it can be suggested that pelvic
exercises and CTM played a role in early onset of bowel
functions in the study group. Also, earlier ambulation of the
subjects in the study may be an additional explanatory factor.
Several researchers have investigated the eVects of
percutaneous electrical stimulation (PES) and TENS on
post-cesarean pain in comparison with placebo or pharmacological methods, and found out successful results [2, 3, 6,
27, 28]. However, the results of studies concerning the
eVect of TENS on narcotic use after cesarean are conXicting [2, 4, 6].
In this study, the intensity of incision pain decreased signiWcantly from the operation to the post-operative second
day in both groups. Although the values of the groups were
similar in the operation day, following measurements indicated lower intensities of pain in the study group. Therefore, in parallel to the literature, TENS was considered to
be eVective in reducing incision pain after cesarean section.
Methods such as continuous epidural analgesia or PCA,
which are being used in the post-cesarean pain control,
have various adverse eVects, are expensive, require trained
personnel or equipment, and restrict safe and comfortable
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626
movement of the patient [29]. TENS, which was used in
this study with the aim of pain control, is an inexpensive
method, is easy to use for a physiotherapist, and may be
carried on the patient, and therefore does not restrict the
movements of the patient.
Also, breathing exercises may have contributed to this
result, since they have eVects such as improving circulation
and healing, and helping relaxation, by causing a mild muscular activity in the abdominal area [16, 17]. In view of the
studies explaining the acting mechanism and eVects of
CTM, it may be questioned if this method may also have
played a role in decreasing the intensity of incision pain,
since stimulation of the mechanoreceptors by CTM may
also close the ‘pain gate’ via pre and post-synaptic inhibition [21, 22, 30].
Reduced need of medication for pain control in the study
group was also considered to be parallel to the lower pain
intensities of these subjects. This Wnding supports the study
results of Hollinger [2], who indicated that TENS was
eVective in reducing the need of analgesia after cesarean,
and also in decreasing the amount of medication.
DiYculty in functional activities decreased signiWcantly
from the operation day to the post-operative second day
in both groups, and was lower in the study group in the
post-operative Wrst day. This result was also thought to be
parallel to the decreased intensity of incision pain, and may
indicate that the recovery of the study group was more
rapid than the control group.
Although the length of staying at the hospital was
recorded for each patient, eVectiveness of the physiotherapy program on this parameter could not be investigated in
this study, because mothers were permitted to stay at the
hospital until the pediatrics department gave discharge
decision for the babies. This parameter may be investigated
in further studies involving subjects whose discharge was
not delayed because of the health status of their babies.
Also, eVectiveness of diVerent frequency, pulse rate,
pulse width modulations and duration of TENS applications can be investigated in further comparative studies, and
also with other pharmacological or non-pharmacological
pain control procedures.
EVects of applications for postural alignment and pelvic
Xoor were not included in this study, since they were not
expected to appear in such a short time and were not within
the scope of early post-cesarean period. Further studies
with longer follow-up periods may be planned to investigate the eVectiveness of these applications.
As mentioned in “Introduction”, literature samples
regarding physiotherapy applications in the early postcesarean period are mainly related to the eVectiveness of
TENS on incision pain. The current study includes additional parameters (diYculty in functional activities, time of
ambulation, return of bowel activity and analgesic medication
123
Arch Gynecol Obstet (2012) 285:621–627
need), and various physiotherapy applications directed to
these parameters, thus investigates and points out the eVectiveness of physiotherapy in a wider perspective. Clinical
methods used in this study have many contributing and
overlapping eVects to each other. Therefore, the Wndings
may not be directly related to the speciWc eVects of the
methods, and may be considered as results of an integrative
approach.
Randomization per day, which was used in this study,
may not seem to be a state-of-the-art randomization technique, since it is easily understandable by probands and
evaluators, and may lead to bias. As mentioned in “Materials and methods”, this was a single-blinded study, so this
suspense may be valid for the evaluator. However, data
investigated in this study based on either subjective recordings by the participants or records from patient Wles. Therefore, for the randomization technique used in this study,
probability of leading to bias is considered to be minimal.
Lack of a placebo group may be a limitation for this study,
since a time-equivalent intervention (such as talking with a
caregiver) was not applied to the control group. Therefore,
some concern may arise about the genuine physiotherapy
eVect or eVect based on the fact that women in the study
group were more intensely cared for, irrespective of what
has been done in terms of physiotherapy.
The results of this research are considered to be valuable
for obstetricians, physiotherapists and other health professionals who plan and carry out the postnatal health care programs, to increase the quality and productivity of these
programs, therefore to improve well-being of the women
after childbirth. However, they need to be supported by further studies, including higher number of subjects and free
from current limitations, in order to strengthen the evidence.
Acknowledgments The authors thank the nurses and trainees of
Hacettepe University Hospitals, Department of Obstetrics and Gynecology, for their valuable cooperation and help for the study. This
study presents major Wndings of the doctoral thesis by the Wrst author,
and was supported by ScientiWc Research Unit of Hacettepe University
(Project number: 05 T02 102 003).
ConXict of interest
None.
References
1. Chen HM, Chang FY, Hsu CT (2005) EVect of acupressure on
nausea, vomiting, anxiety and pain among post-cesarean section
women in Taiwan. Kaohsiung J Med Sci 21:341–350
2. Hollinger JL (1986) Transcutaneous electrical nerve stimulation
after cesarean birth. Phys Ther 66:36–38
3. Navarro Nuñez C, Pacheco Carrasco M (2000) Transcutaneous
electrical nerve stimulation to reduce pain after cesarean section.
Ginecol Obstet Mex 68:60–63
4. Reynolds RA, Gladstone N, Ansari AH (1987) Transcutaneous
electrical nerve stimulation for reducing narcotic use after cesarean section. J Reprod Med 32:843–846
Arch Gynecol Obstet (2012) 285:621–627
5. Riley JE (1982) The impact of transcutaneous electrical nerve
stimulation on the postcesarean patient. JOGN Nurs 11:325–329
6. Smith CM, Guralnic MS, Gelfond MM et al (1986) The eVects of
transcutaneous electrical nerve stimulation on post-cesarean pain.
Pain 27:181–193
7. Thompson JF, Roberts CL, Currie M et al (2002) Prevalence and
persistence of health problems after childbirth: associations with
parity and method of birth. Birth 29:83–94
8. Arai YC, Kato N, Matsura M et al (2008) Transcutaneous electrical nerve stimulation at the PC-5 and PC-6 acupoints reduced the
severity of hypotension after spinal anaesthesia in patients undergoing cesarean section. Br J Anaesth 100:78–81
9. Habib AS, Itchon-Ramos N, Phillips-Bute BG et al (2006) Transcutaneous acupoint electrical stimulation with the ReliefBand for
the prevention of nausea and vomiting during and after cesarean
delivery under spinal anesthesia. Anesth Analg 102:581–584
10. Kaplan B, Rabinerson D, Neri A (1994) The eVect of respiratory
physiotherapy on the pulmonary function of women following
cesarean section under general anesthesia. Int J Gynaecol Obstet
47:177–178
11. Harmon D, Ryan M, Kelly A et al (2000) Acupressure and prevention of nausea and vomiting during and after spinal anaesthesia for
cesarean section. Br J Anaesth 84:463–467
12. Ho CM, Hseu SS, Tsai SK et al (1996) EVect of P-6 acupressure
on prevention of nausea and vomiting after epidural morphine for
post-cesarean section pain relief. Acta Anaesthesiol Scand
40:372–375
13. Ho CM, Tsai HJ, Chan KH et al (2006) P6 acupressure does not
prevent emesis during spinal anaesthesia for cesarean delivery.
Anesth Analg 102:900–903
14. Stein DJ, Birnbach DJ, Danzer BI et al (1997) Acupressure versus
intravenous metoclopramide to prevent nausea and vomiting during spinal anesthesia for cesarean section. Anesth Analg 84:342–
345
15. Youngs PJ (2000) Acupressure and prevention of nausea and vomiting. Br J Anaesth 85:807–808
16. Noble E (2003) Essential exercises for the childbearing year, 4th
edn. New Life Images, USA
627
17. Polden M, Mantle J (1994) Physiotherapy in obstetrics and gynecology. Butterworth-Heinemann, Oxford, pp 222–280
18. Barr JO (1999) Transcutaneous electrical nerve stimulation for
pain management. In: Nelson RM, Hayes KW, Currier DP (eds)
Clinical electrotherapy, 3rd edn. Appleton & Lange, StamfordConnecticut, pp 291–354
19. Johnson M (2002) Transcutaneous electrical nerve stimulation. In:
Kitchen S (ed) Electrotherapy: evidence based practice, 11th edn.
Churchill Livingstone, Toronto-Canada, pp 259–286
20. Goats GC, Keir KAI (1991) Connective tissue massage. Br J
Sports Med 25:131–133
21. Holey EA (2000) Connective tissue massage: a bridge between
complementary and orthodox approaches. J Bodywork Mov Ther
4:72–80
22. Tappan F (1988) Healing massage techniques: holistic, classic and
emerging methods. Appleton & Lange, California
23. Wilder E (1988) Obstetric and gynaecologic physical therapy.
Churchill Livingstone, USA
24. Johnson ST (2000) From incontinence to conWdence. Am J Nurs
100:69–74
25. Sochart DH, Hardinge K (1999) The relationship of foot and ankle
movements to venous return in the lower limb. J Bone Joint Surg
Br 81:700–704
26. Holey LA, Lawler HL (1995) The eVects of classical massage and
connective tissue manipulation on bowel function. Br J Ther Rehabil 2:627–631
27. Evron S, Schenker JG, Olshwang D et al (1981) Postoperative
analgesia by percutaneous electrical stimulation in gynecology
and obstetrics. Eur J Obstet Gynecol Reprod Biol 12:305–313
28. Rakel B, Frantz R (2003) EVectiveness of transcutaneous electrical nerve stimulation on postoperative pain with movement. J Pain
4:455–464
29. Jakobi P, Solt I, Tamir A et al (2002) Over-the-counter oral analgesia for postcesarean pain. Am J Obstet Gynecol 187:1066–1069
30. Kaada B, Torsteinbø O (1989) Increase of plasma beta-endorphins
in connective tissue massage. Gen Pharmacol 20:487–489
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