ROLE OF PHYSICAL THERAPY

IN OBSTETRICS &
GYNECOLOGY

Presented By:
Tayyaba Sabahat PT
ROLE OF PHYSICAL THERAPY
IN OBSTETRICS &
GYNECOLOGY
LEARNING OBJECTIVES
 Introduction
 Physical Therapy in Antenatal Care

 Physical Therapy in Postnatal Care

INTRODUCTION
 PHYSICAL THERAPY: therapy for the preservation,
enhancement, or restoration of movement and
physical function impaired or threatened by disease,
injury, or disability that utilizes therapeutic exercise,
physical modalities (such as massage and
electrotherapy), assistive devices, and patient
education and training.

 GYNECOLOGY: a branch of medicine that deals with

the diseases and routine physical care of the
reproductive system of women.

 OBSTETRICS: a branch of medical science that deals

with pregnancy, childbirth, and the postpartum
period.
 Antenatal Period
(pregnancy)

.
.

OBSTETRICS Labor
(parturition/childbirth)

Postnatal Period
(postpartum)
ANTENATAL CARE
 DEFINITION: periodic, regular and supervised
examination of a women during pregnancy is
called antenatal care.
Supervision should be regular and
periodic nature in accordance with the need of
individual.
PELVIC FLOOR ANATOMY
Muscle Layer Structure
 Superficial (outlet)
Ischiocavernosus
Bulbocavernosus
Superficial transverse
perineal
External anal sphincter

 Urogenital diaphragm (perineal membrane)

Deep transverse perineal
Compressor urethrae
Urethrovaginal sphincter
 Pelvic diaphragm (primary muscular support)
Levator ani
■ Pubococcygeus
■ Puborectalis
■ Iliococcygeus
Coccygeus
FUNCTION OF PELVIC FLOOR
MUSCULATURE
 Provide support for the pelvic organs and their contents.
 Contribute to stabilization of spine/pelvis.
 Withstand increases in intra-abdominal pressure.
 Maintain continence at the urethral and anal sphincters.
 Reproductive Function.
CHANGES IN ORGAN SYSTEMS
 Uterus:
1. Increases 5-6times in size,
2. 3000-4000times in capacity
3. 20times in weight by the end of pregnancy.
 Urinary System:
1. Kidneys increase in length by 1cm.
2. Ureters enter into bladder at perpendicular angle
3. results in reflux of urine out of bladder and back into ureter developing UTI’s
because of urinary stasis.
 Pulmonary system:
1. Upper Respiratory Hypersecretion .
2. Ribs flare up and out.
3. Antero-posterior and transverse diameter each increase by 2cm.
4. Total chest circumference increases.
5. Diaphragm is elevated by 4cm.
6. 15%-20% increase in oxygen consumption causes hyperventilation.
7. Dyspnea is present with mild exercise as early as 20 weaks into pregnancy.
. Cardiovascular System:
1. Blood volume progressively increases.
2. Plasma increase is greater than RBC’s Increase leading to
“physiological anemia” of pregnancy.
3. Venous pressure in lower extremities increases during
standing.
4. Pressure in inferior vena cava rises in late pregnancy
specially in supine position leading to “sypmtomatic
supine hypotensive syndrome”.
5. Blood pressure rises early in 1st trimester, reaches it’s
lowest level midway through pregnancy and then rises
gradually from mid-pregnancy.
6. Heart size increases.
7. Heart is elevated from it’s prepragnant position.
8. Heart rhythm disturbs.
9. Heart rate increases.
10. Cardiac Output increases 30%-60% significantly in the
left side-lying position.
.
 Musculoskeletal System:
1. Abdominal muscles particularly both sides of rectus muscle as well
as linea alba became stretched to their point of elastic limitby the
end of pregnancy.
2. Thus decreases their efficiency of contraction.
3. Pelvic floor drops as much as 2.5cm.
4. The thoracolumbar fascia is lengthened via its connection to the
abdominal wall, which diminishes its ability to support and
stabilize the trunk effectively.
5. Joint hypermobility occurs as a result of ligamentous laxity and
may predispose the patient to injury, especially in the weight-
bearing joints of the back, pelvis, and lower extremities.
 Thermoregulatory System
1. During pregnancy, basal metabolic rate and heat production
increase.
2. An additional intake of 300 calories per day is needed to meet the
basic metabolic needs of pregnancy.
3. In pregnant women, normal fasting blood glucose levels are lower
than in nonpregnant women.
.
 Changes in Posture and Balance
 Center of Gravity
The center of gravity shifts upward and forward.
This requires postural compensations to maintain balance and
stability.
1. The lumbar and cervical lordosis increase
2. The shoulder girdle and upper back become rounded
3. upper extremity internal rotation because of breast
enlargement;
4. Tightness of the pectoral muscles
5. The sub-occipital muscles respond to maintain appropriate
eye level and to moderate forward head posture

Changes in posture do not automatically correct after childbirth,

and the pregnant posture may become habitual. In addition,
many child care activities contribute to persistent postural faults
and asymmetry.
.
 Balance
With the increased weight and redistribution of body
mass, there are compensations to maintain balance.
1. The pregnant woman usually walks with a wider
base of support & increased external rotation at the
hips.
2. This change in stance, along with growth of the
baby, makes ADLs progressively more challenging.
3. Activities requiring fine balance and rapid changes
in direction, such as aerobic dancing and bicycle
riding, may become inadvisable, especially during
the third trimester.
POTENTIAL STRUCTURAL AND FUNCTIONAL
IMPAIRMENTS WITH RELATIVE INTERVENTIONS
 Faulty postures
1. Stretch, train, and strengthen postural muscles
2. Posture awareness training
3. Proprioception activities
4. Posture reinforcement

 Poor body mechanics

1. Learn safe body mechanics
2. Body mechanics in sitting, standing, lifting, and lying as
well as transitions from one position to another
3. Positioning options for labor and delivery

 Varicose veins and Lower Extremity edema

1. Use of elastic support stockings
2. Stretching exercises
3. Resistive exercises to appropriate muscles
. Abdominal muscle stretch, trauma, and diastasis recti.
1. Monitor diastasis recti.
2. Diastasis recti exercises
3. Safe abdominal-strengthening exercises with diastasis recti
protection

 Potential decrease in cardiovascular fitness

1. Safe progression of aerobic exercises

 Lack of knowledge of body changes and safe exercises to use during

pregnancy
1. Patient/family instruction
2. Refer to other disciplines as indicated
3. Relaxation and breathing techniques
4. Education about potential problems of pregnancy
5. Teach prevention techniques and appropriate erxercises

 Lack of physical preparation (strength, endurance, relaxation)

necessary for labor and delivery
1. Strengthen muscles needed in labor and delivery, and train
responses
2. Teach comfort measures for labor and delivery
GUIDELINES FOR MANAGING THE
PREGNANT WOMAN
 Examination. Individually examine each woman before participation to
screen for preexisting musculoskeletal problems, posture, and fitness level.

 Education. Educate your patients

 increased uterine cramping may occur with moderate activity; this is
acceptable as long as the cramping stops when the activity is completed.

 Do not exceed 5 minutes of supine positioning at any one time after the 1st
trimester of pregnancy to avoid vena cava compression by the uterus.

 Avoid motionless standing.

 For supine exercise, place a small wedge or rolled towel under the right hip to
lessen the effects of uterine compression on abdominal vessels and to improve
cardiac output. The wedge turns the patient slightly toward the left This
modification is also helpful during physical therapy evaluation and treatment
when the patient is positioned supine.
 ■ To avoid the effects of orthostatic hypotension, instruct the woman to always
rise slowly when moving from lying down or sitting to standing positions.
 ■ Discourage breath-holding
 Break frequently for fluid replenishment ( risk of dehydration )
.
 Avoid exercising in high temperature or humidity. Increase water intake in
proportion to time spent exercising and as environmental temperature
increases.

 Encourage complete bladder emptying before exercise. A full bladder places

increased stress on an already weakened pelvic floor.

 Include appropriate warm-up and cool-down activities.

 Modify or discontinue any exercise that causes pain.


 Limit activities in which single-leg weight bearing is required, such as standing
leg kicks.

 Stretching/flexibility. Choose stretching exercises that are specific to a single

muscle or muscle group; do not involve several groups at once. Asymmetrical
stretching or stretching multiple muscle groups can promote joint instability.

 Do not allow any joint to be taken beyond its normal physiological range.

 Use caution with hamstring and adductor stretches. Over- stretching of these
muscle groups can increase pelvic instability or hypermobility.
SUGGESTED SEQUENCE FOR EXERCISES
CLASSES
 1.General rhythmic activities to “warm-up”
 2.Gentle selective stretching for postural alignment and for
perineum and adductor flexibility
 3.Aerobic activity for cardiovascular conditioning
(duration/intensity may need to be individualized)
 4.Postural exercises; upper/lower extremity strengthening
and individualized abdominal exercises
 5.Cool-down activities
 6.Pelvic floor exercises
 7.Relaxation techniques
 8.Labor and delivery techniques
 9.Educational information
 10. Postpartum exercise instruction (e.g., when to begin
exercises, how to safely progress, precautions) because the
patient may not be attending a postpartum class. Include
education regarding body mechanics relative to child care
 SELECTED EXERCISE TECHNIQUES
 Posture Exercises
 Selected Stretching and Resistance Exercises During Pregnancy
 Stretching (with Caution)
1. Upper neck extensors and scalenes
2. Scapular protractors, shoulder internal rotators, and levator scapulae
3. Low back extensors
4. Hip flexors, adductors, and hamstrings women with pelvic instabilities
should not overstretch these muscles.
5. Ankle plantarflexors

 Strengthening (Low Intensity with Modifications)

1. Upper neck flexors and lower neck and upper thoracic extensors Scapular
retractors and depressors
2. Shoulder external rotators
3. Trunk flexors particularly lower abdominals; use corrective exercises for
diastasis recti if present
4. Hip extensors
5. Knee extensors
6. Ankle dorsiflexors
 Dynamic Trunk Exercises
.
1. Pelvic Motion Training
2. pelvic tilt exercises
3. pelvic clock

4. Trunk Curls
5. Curl-ups
6. Diagnol curls
 Modified Upper and Lower Extremity
Strengthening
1. Standing Pushups
2. Supine Bridging*
3. Quadruped Leg Raising*
4. Modified Squatting (wall slides)
5. Scapular Retraction
 Perineum and Adductor Flexibilty
(supine/side lying. Abduct the hips, pull knees towards side of chest)
PELVIC FLOOR AWARENESS, TRAINING
AND STRENGTHENING

 Contract-Relax
 Elevator Exercise

 Pelvic Floor Relaxation (elevator exercise + slow

deep brathing relax pelvic floor voluntarily)
RELAXATION AND BREATHING EXERCISES
FOR USE DURING LABOR

 Visual Imagery
1. (concentrate on relaxing image)

 Breathing
1. slow deep breathing,
2. relax abdomens during inspiration,
3. slow rate of breathing to prevent
hyperventilation
UNSAFE POSTURES AND EXERCISES
DURING PREGNANCY
 Bilateral straight-leg raising
 Fire Hydrant Exercise*

 All Four (Quadruped) Hip Extension

 Unilateral Weight-Bearing Activities

PHYSICAL THERAPY IN ANTENATAL CARE
.
.
 Exercise for circulation and cramping

.
POSTNATAL CARE
 DEFINATION:A postpartum period or postnatal period is
the period beginning immediately after the birth of a child
and extending for about six weeks.

 POSTPARTUM PHYSICAL & MENTAL CONDITIONS:

• Muscles and ligaments be softer and more elastic than pre
pregnancy and it will take 4 to 5 months for full recovery to
take place.
• Heavy, edematous, aching legs, swollen feet and ankles.
• Back pain frequently develops following the birth.
• Breasts may become engorged and painful when lactation
begins on the 3rd or 4th postnatal day.
• mother’s attention is fixed on her baby and
she is often hypersensitive to every nuance of its
behaviour.This could potentially be an issue for the
physiotherapist attempting to achieve rehabilitative aims.
 .
Spontaneous
Vaginal Delivery
(SVD)
.

POSTNATAL Spontaneous
PERIOD Vaginal Delivery
(postpartum) with Episiotomy
(SVD e’ Epi)

Cesarean Section
(C-Section)
SUGGESTED ACTIVITIES FOR THE PATIENT
FOLLOWING A CESAREAN SECTION
 Exercises
1. Ankle Pumping, AROM of lower extremity and walking
2. Pelvic floor exercises (keggel Exercises)
3. Deep Breathing and coughing/huffing
4. Abdominal Exercises (diastasis recti correction) progress slowly
5. Posture Correction (chin tucks)
6. Inform the women that she should wait at least 6-8 weeks
before resuming vigorous exercise
 Interventions to Relieve Intestinal Gas Pains
1. Ambulation
2. Abdominal Massage/Kneading
3. Pelvic Tilting/Bridging
 Scar Mobilization
1. Cross-friction Massage
BED EXERCISES FOR HIGH-RISK PREGNANCY

 ■ Patient supine (with wedge under the right hip), semireclined or

side-lying
 ■ Cervical active ROM and chin tucks
 ■ Backward shoulder circles (scapular retraction); reach to ceiling
(protraction)
 ■ Unilateral upper extremity diagonal patterns
 ■ Shoulder, elbow flexion/extension; arm circles in side-lying
 ■ Forearm pronation/supination; wrist flexion/extension, hand
open/close
 ■ Pelvic tilts
 ■ Abdominal exercises (per physician consultation)
 ■ Pelvic floor exercises (per physician consultation)
 ■ Quad and gluteal isometric sets
 ■ Unilateral hip abduction and adduction, internal/external rotation
 ■ Unilateral hip and knee flexion/extension in side-lying
 ■ Ankle pumping, ankle circles, ankle “alphabet”
 ■ Toe flexion/extension