Physiotherapy in Obstetrics & Gynaecology By mohd. Javed mpt(ortho)-1st yr. Apollo college, durg c. G



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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









  • 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



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.





Low back extensors stretching

  • Low back extensors stretching







  • Strengthening Exercise .

  • Upper neck flexors lower neck &upper thoracic extensors

  • Scapular retractors &depressor

  • Shoulder external rotators

  • Hip & knee extensors

  • Ankle dorsi flexors





ABDOMINAL EXERCISES: -

  • 1. Corrective ex. for diastesis recti

  • Head lift

  • Head lift with pelvic tilt



  • 2. Trunk curls

  • 3. 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.

  • Modified push ups /standing pushups

  • Hip extension

  • a. supine bridging



  • b. All four leg raising



  • 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



  • 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)



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 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.





  • 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.



EARLY POSTNATAL EX.



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







  • 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.





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.



  • 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













  • PHYSIOTHERAPY IN GYNAECOLOGICAL CONDITIONS



INDICATIONS PT MANAGEMENT

  • 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




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