Physiotherapy inObstetrics & Gynaecology

By

MOHD. JAVEDMPT(ORTHO)-1ST YR.APOLLO COLLEGE, DURGC.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

1. Prenatal exercises

2. Preparation for labour

3. 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

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.

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……….

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.

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

Hook lying with posterior pelvic tilt

Maintain pelvic tilt as the feet slide along the floor away from the body

Leg Sliding

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.

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.

POSTNATAL EXERCISES

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

EARLY POSTNATAL EX.

standingsitting

feeding

lying

others

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.

SUGGESTED ACTIVITIES FOR THE PT. WITH A CS.

.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

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.

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.

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.

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

THANKYOU

THANKS