Transcript Physiotherapy in obstetrics & gynaecology
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.
Normal anatomy of female pelvis
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.
Exercises in pregnancy
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Prenatal exercises Preparation for labour Postnatal exercises
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
General goals & plan for exercise programs
GOALS PLAN OF CARE 1.Improve posture & correct body mechanics 1.Train & strengthen postural muscle 2. Teach correct body mechanics in all position 2.Upper & lower extremities strengthening 2. strengthening ex. of UL & LL
3. Prepare for circulatory compromise 3. Stockings, stretching ex.
4. Improve awareness & control of pelvic floor musculature 4. Pelvic floor muscle strengthen 5. Maintain abdominal muscle function & correct diastesis 5. Abd. Muscle strengthen ex.
recti 6. Provide information about preg. & associated problem 6 . Prenatal & postnatal information 7. Improve relaxation skill 7. Relaxation tech.
General Guidelines for Exercise Instruction
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.
Contraindications to exercise……….
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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.
Suggested sequence of exercise.
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.
Selected exercise techniques
Postural exercise.
Abdominal exercise Stabilization exercise Pelvic motion training & strengthening.
Modified UL & LL strengthening.
Perineum &adductor flexibility.
Relaxation &breathing exercise
Posture exercise: Includes: Strengthening exercise Stretching 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.
Self Scalen streching Scalens stretching by therapist
Low back extensors stretching Manual Back Stretch
Self Back Stretching
Hip adductor stretching : -
Tailor’s Sitting Position
Strengthening Exercise .
Upper neck flexors lower neck &upper thoracic extensors Scapular retractors &depressor Shoulder external rotators Hip & knee extensors Ankle dorsi flexors
Strengthening of External Rotators Corner Press Out
ABDOMINAL EXERCISES: -
1. Corrective ex. for diastesis recti Head lift Head lift with pelvic tilt Head Lift
2. Trunk curls 3. Leg sliding Leg Sliding Hook lying with posterior pelvic tilt Maintain pelvic tilt as the feet slide along the floor away from the body
4 Quadruped pelvic tilt ex.
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.
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Modified push ups /standing pushups Hip extension a. supine bridging
b. All four leg raising a.
b.
Quadruple position with posterior pelvic tilt Leg is raised only until it is in line with the trunk
3. Modified squatting These are used To strengthen the hip &knee extensor. Stretch the peroneal area.
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Supported squatting using a chair or wall.
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.
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Other methods of relaxation are a. mental imagery.
b. muscle setting – “
Jacobson’s Method
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PREPERATION FOR LABOUR
A prog. of labour training consist of 1.
Body awareness & labour/ positioning during labour.
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Relaxation during labour.
3.
Breathing during labour.
4.
Massage during labour.
Positioning During Labour
1 st 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 1 st 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 1 ST STAGE OF LABOUR These are labour inducing exercise .
In 1 st half an hour –supine to sitting every 5 min.
In 2 nd half an hour min.
– do supine to sitting every 4
2. POSITIONING DURING 2 ND STAGE OF LABOUR.
Commonly used positions are Lithotomy Dorsal (recumbent) Lateral & semirecument
RELAXATION DURING LABOUR O nce 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) 1 st stage Easy breathing- a little slower & deeper then usual.
Transitional stage Breathing to prevent pushing “fairly deep breathing” to move the diaphragm up &down together with a sharp blow out through relaxed lip 2 nd 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”
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elaxation 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 MASSAGE 2. ABDOMINAL MASSAGE 3. LEG MASSAGE 4. PERINEAL MASSAGE
BACK MASSAGE
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It is helpful in prolong 1 st stage of labour or when the fetus is in the occipito post. Position.
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Back pain experienced in lumbosacral region.
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Stationary kneading is applied slowly & deeply to the painful area.
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Effleurage from sacrococcygeal area up & over the iliac creast 5.
Longitudinal stocking from occiput to coccyx.
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Kneading with clenched fist directly over the SI joint for severe pain.
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ABDOMINAL MASSAGE
Pain experienced over the lower half of the abdomen in the suprapubic region.
light finger stroking over the site of pain.
LEG MASSAGE
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Occasionally labour pain may be perceived in the thighs & cramps in the calf or foot.
effleurage or kneading relieve pain.
PERINEAL MASSAGE
1. It is done in 2 nd stage of labour to encourage stretching of skin & muscle to prevent tearing/ episiotomy.
EXERCISES THAT ARE NOT SAFE DURING PREGNANCY
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.
POSTNATAL EXERCISES
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Ex. Can be started as soon as after delivery as the women feels able to ex.
All prenatal ex. Can be performed safely in postpartum period.
Before starting ex. Proper assessment of position & consistency of the fundus of the uterus should be done.
Assessment of perineum & lochia.
Monitoring of lower limb edema, varicosities.
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.
Deep breathing for circulatory & relaxing effect Leg exercise Foot ankle leg exercise Abdominal exercise In crook line position combined with expiration Pelvic tilting exercise Crook lying position Tilt- Relax-Tilt – Relax Exercise
EARLY POSTNATAL EX.
sitting standing feeding others lying
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CESAREAN CHILDBIRTH
It is an operative procedure whereby the fetuses after the end of 28 th wk. are delivered through an incision on the abdominal &uterine wall.
Impairments /Problem Due To Cs
Risk of pneumonia Postsurgical pain.
Risk of adhesion.
Formation at incisional site.
Risk of vascular complication.
Faulty posture.
Pelvic floor dysfunction.
Abdominal weakness
GOAL 1.Improve pulmonary function & decrease the risk of pneumonia 2.Decrease incisional pain associated with coughing PLAN OF CARE Breathing ex. Coughing &huffing.
2. Postnatal TENS support incision with hands when coughing.
3. Friction massage & scar mobilisation.
3. Prevent postsurgical adhision formation 4.Prevent postsurgical vascular complication 4.Active leg ex. ,early ambulation
5.Correct posture & protected activities of daily living 5.Postural instruction &positioning for ADL 6. Pelvic floor ex.
6. Prevent pelvic floor dysfunction 7. Develop abdominal strength 7. Abdominal ex.
SUGGESTED ACTIVITIES FOR THE PT. WITH A CS.
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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.
COUGHING & 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 PAINS
Abd. Massage or kneading while lying on the left side.
Pelvic tilting ex.
4.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.
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GOAL Decrease stiffness Maintain muscle length & bulk to improve circulation.
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Improve proprioception 1.
PLAN OF CARE Positioning instruction ,joint motion at available ROM.
Stretching & strengthening ex. Within limits imposed by physician.
Improve posture within available limits.
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Movement activities for many body parts as possible.
Stress management & enhance relaxation .
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modified posture instruction.
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relaxation tech. Enhance postpartem recovery.
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Ex instruction &home program for postpartum period.
EX. PROGRAM FOR HIGH RISK PREGNANCY
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POSITIONING 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.
ROM INSTRUCTION
slow active full ROM of all the joints.
Teach movement in gravity eleminated position.
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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.
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RELAXATION TECHNIQUE
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BED MOBILITY & TRANSFER ACTIVITIES
moving up down side to side in bed.
rolling supine to sitting assisted by arms .
6.PREPRATION FOR LABOUR
Relaxation tech.
Modified squatting supine, sitting or side lying with knee to chest.
Breathing
PREGNANCY INDUCED PATHOLOGY
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.
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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 4 . Splinting ice packs elevation of the limb TENS Meralgia paraesthetica Posterior tibial nerve compress 5.Circulatory problem 5.
–prolonged standing avoided varicose vein of leg ankle ex. ,calf stretching vulval varicose vein - raising foot end of standing should bed. - thromboembolism - stocking & breathing ex.
6. Stress incontinence 6 . pelvic floor ex 7. Postural backache 8. coccydynia 7 . postural correction 8.
Ice packs ,heat, US, TENS, use of rubber ring to relieve pressure in sitting.
Sitting posture in coccydynia
PHYSIOTHERAPY IN GYNAECOLOGICAL CONDITIONS
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.
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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 6. BACKACHE & ABD . 6 . TENS tech. & TENS PAIN
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