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
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
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 5. Abd. Muscle strengthen
ex.
function & correct diastesis
recti
6. Provide information about 6. Prenatal & postnatal
information
preg. & associated problem
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……….
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
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.
1.
2.
Modified push ups /standing pushups
Hip extension
a. supine bridging
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
3. Modified squatting
These are used
To strengthen the hip &knee extensor.
Stretch the peroneal area.
a.
b.
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.
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
1.
Body awareness & labour/ positioning during
labour.
2.
Relaxation during labour.
3.
Breathing during labour.
4.
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.
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”
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 over1. BACK MASSAGE
2. ABDOMINAL MASSAGE
3. LEG MASSAGE
4. PERINEAL MASSAGE
BACK 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 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 MASSAGE
1.
Occasionally labour pain may be perceived in the
thighs & cramps in the calf or foot.
2.
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
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.
2.
Initial postnatal exercises.
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
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.
2.
3.
4.
5.
6.
7.
8.
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
5.Postural instruction
&positioning for ADL
6. Pelvic floor ex.
6. Prevent pelvic floor
dysfunction
7. Abdominal ex.
7. Develop abdominal
strength
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
PLAN OF CARE
1.
Decrease stiffness
1.
Positioning instruction
,joint motion at available
ROM.
2.
Maintain muscle length &
bulk to improve
circulation.
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.
3.
4.
5.
6.
Improve proprioception
Improve posture within
available limits.
Stress management &
enhance relaxation .
Enhance postpartem
recovery.
6.
Ex instruction &home
program for postpartum
period.
EX. PROGRAM FOR HIGH RISK PREGNANCY
1.
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.
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.
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
PATOHLOGY
1. diastesis recti
PT MANAGEMENT
1.Modified abdominal muscle
ex. With crossed hand
over the abdomen.
2. Lower back pain & pelvic
pain.
2.In acute condition bed rest
do’s or don’t
gentle heat & massage
pelvic tilting in croock lying
TENS if indicated
3. SI dysfunctioN
3. Modified ex. For SI pain
4. Nerve compression
syndrome
-
Carple tunnle syndrome
-
Brachial pluxus pain
-
Meralgia paraesthetica
4. Splinting
ice packs
elevation of the limb
TENS
Posterior tibial nerve
compress
-
5.Circulatory problem
varicose vein of leg
vulval varicose vein
leg cramps
-thrombosis &
- thromboembolism
5. –prolonged standing
avoided
ankle ex. ,calf stretching
- raising foot end of standing
should bed.
deep kneading massage
- stocking & breathing ex.
6. Stress incontinence
6. pelvic floor ex
7. Postural backache
7. postural correction
8. coccydynia
8. Ice packs ,heat, US,
TENS,
use of rubber ring to
relieve pressure in
sitting.
Sitting posture in coccydynia
PHYSIOTHERAPY IN GYNAECOLOGICAL
CONDITIONS
INDICATIONS
1. INFECTIONS
-vulvitis
-vaginitis
- cervicitis
- salphingitis
- PID
2. CYST & NEW GROWTH
PT MANAGEMENT
1. in acute phase
-chemtherapy.
in chronic phase
pulsed or cont SWD
2. pulsed SWD /US for
softning of painful abd.
adhesion.
3..STRESS INCONTINENCE 3. pelvic floor ex.
4.GENITAL PROLAPSE
4. pelvic floor strength
- ening ex.
-cystocele, urethrocele,
-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
THANKS