Physiotherapy in Obstetrics & Gynaecology. By MOHD 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 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 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 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……….

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

Strengthening exercise Stretching exercise Includes:- Strengthening exercise Stretching exercise Posture 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. Modified push ups /standing pushups 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

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.

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 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.

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

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

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.

These are labour inducing exercise. 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 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.

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”

The direction of the push is downward under the pubic bone. 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 MASSAGE 2. ABDOMINAL MASSAGE 3. LEG MASSAGE 4. PERINEAL MASSAGE

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.

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.

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

Ex. Can be started as soon as after delivery as 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 Initial postnatal exercises. 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. sitting standing feeding others lying

CESAREAN CHILDBIRTH Postsurgical pain. Risk of adhesion. 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

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. 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.

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.

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.

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.

moving up down side to side in bed. 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

PREGNANCY INDUCED PATHOLOGY

1.Modified abdominal muscle ex. With crossed hand over the abdomen. 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 -vulvitis -chemtherapy. 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.

-cystocele, urethrocele, - ening ex. -rectocele, enterocele, 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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