Download - Physiotherapy in Obstetrics & Gynaecology By MOHD. JAVED MPT(ORTHO)-1ST YR. APOLLO COLLEGE, DURG C.G
Obstetrics concerns itself with pregnancy, labour, delivary &the care
of the mother after child birth
Gynaecology is the study of disease associated with women which in effect means condition involving the female
genital tract.
Physiotherapy in obstetrics condition
From the moment of conception pregnancy profoundly alters the women physiology.
There is change in all body system to fulfill the requirement of the body.
Therapeutic exercises may be prescribed to pregnant women for several reasons:
Primary conditioning unrelated to pregnancy.
Impairments related to physiological changes of pregnancy, such as back pain ,faulty posture, or leg cramps.
Physical &physiological benefits.
Preventive measures
Physiological changes during pregnancy
Pregnancy wt. gain - 9.70 to 14.55 kg.
Changes in reproductive system.
Urinary system -kidney increases by 1cm.
Changes in pulmonary system.
CVS.
Physiological changes during pregnancy
Musculoskeletal system. a. Stretching of abdominal muscles
b. Decrease in ligamentous tensile strength.
c. Hyper mobility of joints due to
ligamentous laxity.
d. Pelvic floor drops as much as 2.5 cm.
Mechanical changes.
a. COG shifts upwards & forwards.
b. posture –
*shoulder girdle becomes rounded, *scapular protraction, upper
*limb internal rotation.
*increase in cervical lordosis.
*knee hyperextension.
*increase in lumber lordosis.
c. balance – pt. walks with wider BOS.
Prenatal Exercise:
Potential impairments of pregnancy
Development of faulty posture
Upper & lower extremities stress
Altered circulation, varicose vein LL edema
Pelvic floor stress
Abdominal muscle stretch & diastasis recti
Inadequate relaxation skills necessary for labour & delivery
Development of musculosketal pathologies
GOALS
1.Improve posture & correct body mechanics
2.Upper & lower extremities strengthening
PLAN OF CARE
1.Train & strengthen postural muscle
2. Teach correct body mechanics in all position
2. strengthening ex. of UL & LL
3. Prepare for circulatory compromise
4. Improve awareness & control of pelvic floor musculature
5. Maintain abdominal muscle
function & correct diastesis
recti
6. Provide information about
preg. & associated problem
7. Improve relaxation skill
3. Stockings, stretching ex.
4. Pelvic floor muscle strengthen
5. Abd. Muscle strengthen ex.
6. Prenatal & postnatal information
7. Relaxation tech.
Physical examination is must prior to engaging a pt. in an Exercise Programme.
Each person should be individually evaluated for preexisting Musculo -skeletal problems, posture & fitness level
Exercise regularly, at least thrice a week
Avoid ballistic movements & rapid change in directions. include warm-up & cool down session
avoid an anaerobic pace.
strenuous activities should be avoided.
avoid prolong period of standing specially in third trimester.
adequate caloric intake, increase to 300 kcal./day for ex. during preg. & 500 kcal./day for ex. during lactation.
low resistance & high repetitions ex. is recommended, avoid valsalva maneuvers.
stop ex. if any unusual symptoms occur.
1. ABSOLUTE CONTRAINDICATIONS
Preg. Induced HTN BP >140/90 mmhg.
Diagnosed heart disease IHD,RHD,CHF.
Premature rupture of membrane.
Placental abruption.
History of preterm delivery.
Recurrent miscarriage.
Persistent vaginal bleeding.
Fetal distress.
IUGR.
Incomplete cervix
Thrombophlebitis &pulmonary embolism.
Pre-eclampsia
polyhydraminos / oligohydraminos
Acute infection
2.RELATIVE CONTRAINDICATIONS
Diabetes
Anemia's or other blood disorders
Thyroid disorder
Dialated cervix
Extreme obesity / underweight
Breech presentation during third trimester
Multiple gastation
Ex. induced asthma
Peripheral vascular disease
Pain of any kind.
General rhythmic activities to warm-up.
Gentle selective stretching
Aerobic activities for CVS conditioning
UL &LL strengthening ex.
Abdominal ex
Pelvic floor ex.
Relaxation /cool down activities
Educational information [if any] & postpartum ex.
Education.
Postural exercise.
Abdominal exercise
Stabilization exercise
Pelvic motion training & strengthening.
Modified UL & LL strengthening.
Perineum &adductor flexibility.
Relaxation &breathing exercise
STRETCHING EXERCISES
Upper neck extensors & scalenes
Scapular protractors, shoulder internal rotators & levetor scapulae
Low back extensors
Hip adductors [caution do not over stretch in
women with pelvic instability]
Ankle planter flexor.
Strengthening Exercise .
Upper neck flexors lower neck &upper thoracic extensors
Scapular retractors &depressor
Shoulder external rotators
Hip & knee extensors
Ankle dorsi flexors
ABDOMINAL EXERCISES: -
1. Corrective ex. for diastesis recti Head lift
Head lift with pelvic tilt
Head Lift
2. Trunk curls
3. Leg sliding
Hook lying with posterior pelvic tilt
Maintain pelvic tilt as the feet slide along the floor away from the body
Leg Sliding
Stabilization Exercises.
These ex are progression for developing dynamic control of the pelvis &LL .
These may be performed throughout the pregnancy & postpartum period.
caution – the women to maintain a relaxed breathing pattern & exhale during the exertion phase of each ex.
Alternate hip & knee extension with one leg stationary on a mat.
Progression is alternate hip & knee extension &flexion with both LL moving.
Pelvic floor exercises: -
Isometric ex. / kegals ex.
Pt position – any position
Instruction - to tighten the pelvic floor as if
attempting to stop urine, &hold for 3 to 5 sec.
This ex is valuable in treating leaky bladder.
Modified Upper Limb & Lower Limb Exercise.
1. Modified push ups /standing pushups
2. Hip extension
a. supine bridging
b. All four leg raising
Quadruple position with posterior pelvic tilt
Leg is raised only until it is in line with the trunk
a.
b.
3. Modified squatting
These are used
To strengthen the hip &knee extensor.
Stretch the peroneal area.
a. Supported squatting using a chair or wall.
b. Wall slide.
PERINEUM & ADDUCTOR FLEXIBILITY
Self stretching
1. Women's position supine or side lying .
instruct to abduct the hip &pull the knees towards the sides of her chest & hold the position for as long as comfortable.
2. Sitting – have the women sit on a short stool with the hips abducted & feets flat on the floor.
RELAXATION & BREATHING EX
Relaxation & Breathing exercise. Are given with the following objectives
1. To obtain rest during preg.
2. To help the mother regain normal health afterwards by preventing unnecessary fatigue
3. Most common method of relaxation is MITCHELLS METHOD.
4. Patient position in kneeling forward on to one’s arm on a cushion placed on a seat of a chair.
5. In this position wt. of the fetus lies on the anterior abdominal wall & pelvic floor relaxes
6. In this position pt. take deep diaphragmatic breathing.
7. Other methods of relaxation are
a. mental imagery.
b. muscle setting – “Jacobson’s Method”
PREPERATION FOR LABOURPREPERATION FOR LABOUR
A prog. of labour training consist of
1. Body awareness & labour/ positioning during labour.
2. Relaxation during labour.
3. Breathing during labour.
4. Massage during labour.
Positioning During LabourPositioning During Labour
1st stage of labour –In this stage uterus anteverts
Forwards leaning facilitates ante version
Woman should be encouraged To change position during first stage of labour
Positions attended during 1st stage are
Sitting with head &shoulder resting on a table.
Standing leaning against a wall either facing or with back support.
Stride sitting across a chair resting the head & arms on the back.
On all four on floor supported by partner, standing, resting head on his shoulder.
KEGALS EX. DURING 1ST STAGE OF LABOUR
These are labour inducing exercise.
In 1st half an hour –supine to sitting every 5 min.
In 2nd half an hour – do supine to sitting every 4 min.
2. POSITIONING DURING 2ND STAGE OF LABOUR.
Commonly used positions are
Lithotomy
Dorsal (recumbent)
Lateral & semirecument
RELAXATION DURING LABOUR
Once the labour begins, the of contraction of the uterus progress.
Relaxation during contraction becomes more demanding.
Provide the women with suggested tech. to assist in relaxation.
1.Moral support from family members.
2.Seek comfortable position including lying on pillows, gentle motions such as pelvic rocking.
3.Slow breathing with each contraction.
4.Visual imagery.
5. During transition there is often an urge to push . Use quick blowing tech. using the cheeks during push.
6. Local heat/ cold application.
7. Gentle touch provides relaxation.
BREATHING DURING LABOUR
according to Williams & Booth (1985)
1st stage
Easy breathing- a little slower & deeper then usual.
Transitional stageBreathing to prevent pushing “fairly deep breathing” to move the diaphragm up &down together with a sharp blow out through relaxed lip
2nd stage
1 or 2 deep breaths in & out, then hold making the diaphragm “piston go down” repeat when breath runs out, after a gulp of air.
BREATHING & PUSHING
ask the mother to place her index finger over epigastrium, take a breath in & feel the expansion in this area.
fix the ribs & increase the intrathoracic pressure,
with inspiration bear down & diaphragm will then act as a piston directed downwards towards the fundus.
place the other hand on the waist feel it expand sideways & become aware of the forward bulging of the lower abd.muscle & the relaxation of the pelvic floor.”open the door for the birth of baby”
Relaxation of the jaws should explain to the patient.
The direction of the push is downward under the pubic bone.
Breath hold for only 6-7sec. To minimize any adverse effect on the fetus due to a prolonged pushing maneuver.
several pushes may be necessary during contraction. b/w contraction sigh out, rest & relax.
MASSAGE DURING LABOUR
It is helpful in pain relief during labour.
soothing effect of massage activates “gate closing” mechanism at spinal level.
tissue manipulation stimulates the release of endogeneous opiates.
massage is applied over-
1. BACK MASSAGEBACK MASSAGE
2. ABDOMINAL MASSAGE2. ABDOMINAL MASSAGE
3. LEG MASSAGE3. LEG MASSAGE
4. PERINEAL MASSAGE4. PERINEAL MASSAGE
BACK MASSAGEBACK MASSAGE
1. It is helpful in prolong 1st stage of labour or when the fetus is in the occipito post. Position.
2. Back pain experienced in lumbosacral region.
3. Stationary kneading is applied slowly & deeply to the painful area.
4. Effleurage from sacrococcygeal area up & over the iliac creast
5. Longitudinal stocking from occiput to coccyx.
6. Kneading with clenched fist directly over the SI joint for severe pain.
ABDOMINAL MASSAGEABDOMINAL MASSAGE
1. Pain experienced over the lower half of the abdomen in the suprapubic region.
2. light finger stroking over the site of pain.
LEG MASSAGELEG MASSAGE
1. Occasionally labour pain may be perceived in the thighs & cramps in the calf or foot.
2. effleurage or kneading relieve pain.
PERINEAL MASSAGEPERINEAL MASSAGE
1. It is done in 2nd stage of labour to encourage stretching of skin & muscle to prevent tearing/ episiotomy.
EXERCISES THAT ARE NOT SAFE DURING EXERCISES THAT ARE NOT SAFE DURING PREGNANCYPREGNANCY
Bilateral SLR.
“Fire hydrant” ex.- this should be avoided by any women who has pre existing SI joint symptoms.
Unilateral wt. bearing activities.
Several activities that have potential for high velocity impact may cause abdominal trauma should be avoided.1.horse riding & driving.
2. Heavy wt. lifting.
3. Ice skating, etc.
1. Ex. Can be started as soon as after delivery as
the women feels able to ex.
2. All prenatal ex. Can be performed safely in
postpartum period.
3. Before starting ex. Proper assessment of
position & consistency of the fundus of the
uterus should be done.
4. Assessment of perineum & lochia.
5. Monitoring of lower limb edema, varicosities.
6. Care & advise on breast feeding & baby care.
POSTNATAL EXERCISES
1. Initial postnatal exercises.
2. Early postnatal ex. - Include proper
positioning.
INITIAL POSTNATAL EX.
Breathing Ex.
Leg exercise
Abdominal exercise
Pelvic tilting exercise
Deep breathing for circulatory & relaxing effect
Foot ankle leg exercise
In crook line position combined with expiration
Crook lying position
Tilt- Relax-Tilt – Relax Exercise
CESAREAN CHILDBIRTH
It is an operative procedure whereby the fetuses after the end of 28th wk. are delivered through an incision on the abdominal &uterine wall.
Impairments /Problem Due To Cs
1. Risk of pneumonia
2. Postsurgical pain.
3. Risk of adhesion.
4. Formation at incisional site.
5. Risk of vascular complication.
6. Faulty posture.
7. Pelvic floor dysfunction.
8. Abdominal weakness
GOAL
1.Improve pulmonary function & decrease the risk of pneumonia
2.Decrease incisional pain associated with coughing
3. Prevent postsurgical adhision formation
4.Prevent postsurgical vascular complication
PLAN OF CARE
Breathing ex. Coughing &huffing.
2. Postnatal TENS support incision with hands when coughing.
3. Friction massage & scar mobilisation.
4.Active leg ex. ,early ambulation
5.Correct posture & protected activities of daily living
6. Prevent pelvic floor dysfunction
7. Develop abdominal strength
5.Postural instruction &positioning for ADL
6. Pelvic floor ex.
7. Abdominal ex.
.1. Exercises
All prenatal ex. Should be done.
The women should be instructed to begin preventive ex. As soon as possible during recovery period.
Ankle pumping activities &early ambulation to prevent venous stasis.
Pelvic floor ex. Kegals ex. &pelvic tilting ex.
Abdominal ex. Should be progressed more slowly.
Deep diaphragmatic breathing
Women should wait at least 6 to 8 wk before resuming vigrous ex.
2. 2. COUGHING & HUFFINGCOUGHING & HUFFING huffing is a forceful outward breath using the diaphragm rather then abdominal to push air out of lungs.The abdominals are pulled up &in rather then pushed out causing decreased abdominal pressure & less strain on the incision.Support the incision with pillows or hands during cuffing or huffing.& say “HA” forcefully while pulling in abdominal muscle.
3. EX TO RELIEVE INTESTINAL GES PAINS3. EX TO RELIEVE INTESTINAL GES PAINS Abd. Massage or kneading while lying on the left side.Pelvic tilting ex.
4.SCAR MOBILISATION4.SCAR MOBILISATION
HIGH RISK PREGNANCY
A pregnancy that is complicated by disease or problem that put the mother or fetus at risk for illness or death . Condition may be preexisting be induced by pregnancy or an abnormal physiological reaction during preg.
The goal of medical intervention is to prevent preterm delivery, usually through use of bed rest, restriction of activity &medications when appropriate.
GOAL
1. Decrease stiffness
2. Maintain muscle length & bulk to improve circulation.
3. Improve proprioception
4. Improve posture within available limits.
5. Stress management & enhance relaxation .
6. Enhance postpartem recovery.
PLAN OF CARE
1. Positioning instruction ,joint motion at available ROM.
2. Stretching & strengthening ex. Within limits imposed by physician.
3. Movement activities for many body parts as possible.
4. modified posture instruction.
5. relaxation tech.
6. Ex instruction &home program for postpartum period.
EX. PROGRAM FOR HIGH RISK PREGNANCY
1.1. POSITIONING INSTRUCTIONPOSITIONING INSTRUCTION
Left side lying position to prevent vena cava
compression, enhance COP & lower extrimity
edema.
Pillow to support body parts & enhance relaxation.
Supine position for short period with wedge placed
under the rt. Hip to decrease IVC compression.
2.2. ROM INSTRUCTIONROM INSTRUCTION
slow active full ROM of all the joints.
Teach movement in gravity eleminated position.
3. SUGGESTED EX. SUGGESTED EX. Lying
- supine or side lying with alternate knee to chest . - ankle pumping . - shoulder , elbow , fing. Flex. & extn. , reach to
ceiling, arm circle. - unilateral SLR in supine & side lying position. - bilateral active ROM in diagonal pattern for UL &
LL -pelvic tilt, bridging, isometrics for pelvic floor
muscle.Sitting [may not be allowed]
- all UL joint movement in available ROM. -cervical movement in available ROM.
4. RELAXATION TECHNIQUE RELAXATION TECHNIQUE
5. BED MOBILITY & TRANSFER ACTIVITIESBED MOBILITY & TRANSFER ACTIVITIES
moving up down side to side in bed.
rolling
supine to sitting assisted by arms.
66.PREPRATION FOR LABOUR.PREPRATION FOR LABOUR
Relaxation tech.
Modified squatting supine, sitting or side lying with knee to chest.
Breathing
PATOHLOGY
1. diastesis recti
2. Lower back pain & pelvic pain.
3. SI dysfunctioN
PT MANAGEMENT
1.Modified abdominal muscle
ex. With crossed hand
over the abdomen.
2.In acute condition bed rest
do’s or don’t
gentle heat & massage
pelvic tilting in croock lying
TENS if indicated
3. Modified ex. For SI pain
4. Nerve compression
syndrome
-Carple tunnle syndrome
-Brachial pluxus pain
-Meralgia paraesthetica
-Posterior tibial nerve
compress
5.Circulatory problem
varicose vein of leg
vulval varicose vein
leg cramps
-thrombosis &
-
thromboembolism
4. Splinting
ice packs
elevation of the limb
TENS
5. –prolonged standing avoided
ankle ex. ,calf stretching
- raising foot end of standing should bed.
deep kneading massage
- stocking & breathing ex.
6. Stress incontinence
7. Postural backache
8. coccydynia
6. pelvic floor ex
7. postural correction
8. Ice packs ,heat, US,
TENS,
use of rubber ring to relieve pressure in sitting.
INDICATIONS PT MANAGEMENT
1. INFECTIONS 1. in acute phase
-vulvitis -chemtherapy.
-vaginitis in chronic phase
- cervicitis pulsed or cont SWD
- salphingitis
- PID
2. CYST & NEW GROWTH 2. pulsed SWD /US for
softning of painful abd.
adhesion.
3..STRESS INCONTINENCE 3. pelvic floor ex.
4.GENITAL PROLAPSE 4. pelvic floor strength
-cystocele, urethrocele, - ening ex.
-rectocele, enterocele,
- uterine prolapse
5. MENSTRUAL DISORDER 5. primary type
-primary / spasmodic type pain coping strategies- sec. /congestive - dysmennoria relaxation & breathing
tech. & TENS
6. BACKACHE & ABD. 6. TENS
PAIN