Physiotherapy%20in%20Obstetrics%20

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Physiotherapy inObstetrics Gynaecology By
MOHD. JAVEDMPT(ORTHO)-1ST YR.APOLLO COLLEGE,
DURGC.G.
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• 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.

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Normal anatomy of female pelvis
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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.

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• 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

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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.

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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.

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• 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.

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Exercises in pregnancy

1. Prenatal exercises
2. Preparation for labour
3. Postnatal exercises

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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

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• General goals plan for exercise programs

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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
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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.
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General Guidelines for Exercise Instruction
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• 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.

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• 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.

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• Contraindications to exercise.

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• ABSOLUTE CONTRAINDICATIONS
• Preg. Induced HTN BP gt140/90 mmhg.
• Diagnosed heart disease IHD,RHD,CHF.
• Premature rupture of membrane.
• Placental abruption.
• History of preterm delivery.
• Recurrent miscarriage.

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• Persistent vaginal bleeding.
• Fetal distress.
• IUGR.
• Incomplete cervix
• Thrombophlebitis pulmonary embolism.
• Pre-eclampsia
• polyhydraminos / oligohydraminos
• Acute infection

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• 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.

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• Suggested sequence of exercise.

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• 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.

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• Selected exercise techniques

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• Postural exercise.
• Abdominal exercise
• Stabilization exercise
• Pelvic motion training strengthening.
• Modified UL LL strengthening.
• Perineum adductor flexibility.
• Relaxation breathing exercise

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Posture exercise

• Includes-
• Strengthening exercise
• Stretching exercise

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• 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.

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Self Scalen streching
Scalens stretching by therapist
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• Low back extensors stretching

Manual Back Stretch
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Self Back Stretching
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Hip adductor stretching -
Tailors Sitting Position
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• Strengthening Exercise .
• Upper neck flexors lower neck upper thoracic
  extensors
• Scapular retractors depressor
• Shoulder external rotators
• Hip knee extensors
• Ankle dorsi flexors

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Strengthening of External Rotators
Corner Press Out
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ABDOMINAL EXERCISES -

• 1. Corrective ex. for diastesis recti
• Head lift
• Head lift with pelvic tilt

Head Lift
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• 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
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• 4 Quadruped pelvic tilt ex.

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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.

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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.

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Modified Upper Limb Lower Limb Exercise.

• Modified push ups /standing pushups
• Hip extension
• a. supine bridging

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• b. All four leg raising

a.
Quadruple position with posterior pelvic tilt
b.
Leg is raised only until it is in line with the
trunk
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• 3. Modified squatting
• These are used
• To strengthen the hip knee extensor.
• Stretch the peroneal area.
• Supported squatting using a chair or wall.
• Wall slide.

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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.

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RELAXATION BREATHING EX

• Relaxation Breathing exercise.
• Are given with the following objectives
• To obtain rest during preg.
• To help the mother regain normal health
  afterwards by preventing unnecessary fatigue
• Most common method of relaxation is MITCHELLS
  METHOD.

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• 4. Patient position in kneeling forward on to
  ones 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 Jacobsons
  Method

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PREPERATION FOR LABOUR

• A prog. of labour training consist of
• Body awareness labour/ positioning during
  labour.
• Relaxation during labour.
• Breathing during labour.
• Massage during labour.

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Positioning 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
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• 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.

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• 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.

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• 2. POSITIONING DURING 2ND STAGE OF LABOUR.
• Commonly used positions are
• Lithotomy
• Dorsal (recumbent)
• Lateral semirecument

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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.

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• 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.

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BREATHING DURING LABOUR

• according to Williams Booth (1985)

1st 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 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.
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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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• 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.

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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

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• BACK MASSAGE
• It is helpful in prolong 1st stage of labour or
  when the fetus is in the occipito post. Position.
• Back pain experienced in lumbosacral region.
• Stationary kneading is applied slowly deeply
  to the painful area.
• Effleurage from sacrococcygeal area up over
  the iliac creast
• Longitudinal stocking from occiput to coccyx.
• 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
• 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 2nd stage of labour to encourage
  stretching of skin muscle to prevent tearing/
  episiotomy.

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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.
  
  
  

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• POSTNATAL EXERCISES

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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.

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• POSTNATAL EXERCISES
• Initial postnatal exercises.
• Early postnatal ex. - Include proper positioning.

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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
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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 28th 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

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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
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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.
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• 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.

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• 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

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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. Improve proprioception Improve posture within available limits. Stress management enhance relaxation . Enhance postpartem recovery. PLAN OF CARE Positioning instruction ,joint motion at available ROM. Stretching strengthening ex. Within limits imposed by physician. Movement activities for many body parts as possible. modified posture instruction. relaxation tech. Ex instruction home program for postpartum period.
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EX. PROGRAM FOR HIGH RISK PREGNANCY

• 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.
• ROM INSTRUCTION
• slow active full ROM of all the joints.
• Teach movement in gravity eleminated position.

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• 3. 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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• 4. RELAXATION TECHNIQUE
• 5. 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

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• PREGNANCY INDUCED PATHOLOGY

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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 dos or dont gentle heat massage pelvic tilting in croock lying TENS if indicated 3. Modified ex. For SI pain
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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.
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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.
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Sitting posture in coccydynia
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• PHYSIOTHERAPY IN GYNAECOLOGICAL CONDITIONS

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• 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.

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• 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

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