Physiotherapy in Obstetrics & Gynecology

OBSTETRICS AND GYNAECOLOGY 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.

Importance of pelvic floor Provide support for the pelvic organs and their contents Withstand increases in intra-abdominal pressure Contribute to stabilization of the spine/pelvis Maintain continence at the urethral and anal sphincters reproductive function

Effect of Childbirth on the Pelvic Floor Neurological compromise Muscular impairment Episiotomy (second degree perineal tear)

Pelvic floor dysfuntion Prolapse Urinary or faecal incontinence Pain and hypertonus Specific exercises: Kegel’s exercise Contract relax (hold for 3-5 seconds) Quick contractions (15-20 reps) Elevator exercise

Interventions for pelvic floor Patient education Neuromuscular re-education Biofeedback

Changes during pregnancy Musculoskeletal system Stretching of abdominal muscles Decrease in ligamentous tensile strength. Hyper mobility of joints due to ligamentous laxity. 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 Guidelines for Exercise Instruction

Contraindications to exercise

Precautions

Suggested sequence for Exercises

Postural Exercises Stretching 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

Strengthening of External Rotators Corner Press Out

ABDOMINAL EXERCISES Head Lift 1. Corrective ex. for diastesis recti 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

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 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 1. Patient position in kneeling forward on to one’s arm on a cushion placed on a seat of a chair. 2. In this position wt. of the fetus lies on the anterior abdominal wall & pelvic floor relaxes 3. In this position pt. take deep diaphragmatic breathing. 4. Other methods of relaxation are a. mental imagery. b. muscle settings

POST NATAL EXERCISES 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 Monitoring of lower limb edema, varicosities. Care & advise on breast feeding & baby care.

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 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

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 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 Correction for diastasis recti

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