PTH 270: Women's Health

Guidelines for Exercise for the uncomplicated Obstetric Patient (1)

(1)It is recommended. Moderate intensity exercise for both strength and cardiopulmonary benefits for at least 20-30 minutes, most or all days of the week. Examination by a physician prior to beginning an exercise program. PT eval for pre-existing musculoskeletal problems, posture, and fitness level. Exercise levels should not exceed pre-pregnancy levels.

dilation

The cervix opens in stages from 0 cm to completion at 10 cm (4 inches)

brow presentation

The normal position is cervical flexion, brow presentation occurs if the baby is in cervical extension.

pelvic organ prolapse

The support of the muscles, fascia, ligaments is insufficient + increased intra-abdominal pressure = there is a descent of pelvic organs

Round ligaments

runs from uterus to mons pubis, connecting them, functions to maintain the position of the uterus. But it stretches and causes pain (sharp, stabbing pain in abdomen) during pregnancy as the uterus expands

Guidelines for Exercise for the uncomplicated Obstetric Patient (3)

(3)Limit balancing or single-leg weight bearing, such as standing leg lifts; promotes sacroiliac or pubic symphysis discomfort To avoid vena cava compression by the uterus, do not lie supine for more than 5 minute after the 4th month/1st trimester of pregnancy When supine, a small wedge or rolled towel placed under the right hip will lessen the effects of uterine compression on abdominal vessels and improve cardiac output by turning the patient slightly toward the left. Rise from the floor slowly, to avoid the effects of postural hypotension Avoid activities that increase the tendency toward the Valsalva maneuver, leads to undesirable downward forces on the uterus and pelvic floor. Also increases heart rate and BP. The risk of dehydration during exercise is increased in pregnancy. Drink plenty of water. Empty bladder prior to exercise to avoid increased stress on an already weakened pelvic floor. Be sure to warm up and cool down appropriately

relative contraindications

(Clients may participate in exercise under the close supervision of a physician and a therapist as long as no further complications arise. Exercises may require modification.) Systemic infection, chronic bronchitis Musculoskeletal complaints and/or pain resulting in orthopedic limitations Phlebitis Diastasis recti Hx of sedentary lifestyle Extreme morbid obesity or underweight during pregnancy Type 1 Diabetes, hypertension, seizure disoder

first trimester

-First 3 months (Weeks 0-12) Fertilization of the egg, followed by the implantation of fertilized egg in the uterine wall Fetus grows to approx. 2-3 inches and 2 oz.

tx of low back pain during pregnancy

-Proper body mechanics • posture •"back-saving" work techniques •moist heat, cold pack, massage (superficial modalities) -Use of deep heat (US, diathermy), electrical stimulation, and traction is contraindicated during pregnancy.

function of the pelvic floor

-Provide support for the pelvic organs, contributes to stabilization of the spine/pelvis, closure of urethra, vagina and anus, and withstand increases in intra-abdominal pressure (it is a shock absorber) -"The combined action of these muscles creates a superior force and a puckering motion around the sphincters" The layers of muscles form a structure similar to the diaphragm.

labor stage 2

-This stage begins when the cervix is at full dilation and ends with the delivery (expulsion) of the baby. Voluntary contraction ("pushing") of the abdominals and diaphragm are the primary force that expel the fetus Fetus pushed through the cervix and pelvis Contractions occur every 2-3 minutes, last approx. 1 minute each Usually lasts from 2 to 3 hours according to the World Health Organization

ex during pregnancy has been shown to:

-decrease GDM, decrease cesarean birth, decrease in operative vaginal delivery, decrease in postpartum recovery time, and decrease in postpartum depression -In pregnancy, greater self-reported overall physical fitness and cardiorespiratory fitness are associated with less bodily pain, lumbar and sciatic pain, and reduced pain disability

anatomic and physiologic changes d/t pregnancy

25-35 pounds weight gain is recommended Changes in organ systems occur -Recommendations are for an increase of 300 calories per day for the sedentary patient and 500 for the energy needs of pregnancy and exercise.

Babies born before ______ weeks "pre term"

37

Pregnancy lasts an average of ____ weeks and is divided into 3 trimesters

40

Musckuloskeletal system changes

Abdominal muscles and Linea Alba are stretched to their limits Hormones cause increased ligament laxity, decreased ligament strength, resulting in hyper-mobility of joints (esp. in back, pelvis, and LE's) Pelvic floor drops up to 1 inch and may be stretched/torn/incised during birth process

treatment for diastasis recti

All pregnant and postpartum patients should be tested for the presence of diastasis recti prior to performing abdominal exercises. If present, corrective abdominal strengthening exercises should be done (partial curl-ups using cross-hand splinting). Other abdominal exercises should not be done until the separation is less than 2 cm. Cannot be corrected during pregnancy, but the cross hand splinting can be used during pregnancy for prevention.

urinary and fecal incontinence

As a result of neuromuscular or musculoskeletal impairment -Urinary and Fecal Incontinence affects an estimated 25 million people. Over the age of 65: 25% of men. 50% of women. -Strong evidence supports pelvic floor strengthening decreases incontinence.

clinical signs of first trimester

Breasts enlarge Small weight gain (0-3 lbs) Nausea, "morning sickness," fatigue, urinary frequency, heightened emotions

clinical signs of diastasis recti

Develops primarily in third trimester and may continue postpartum Primarily above or at the level of the umbilicus; may occur below Is less common in women with good abdominal tone prior to pregnancy Significance - may contribute to low back pain, as it impairs abdominal muscle strength and as a result pelvic and lumbar stability -Likelihood increases as pregnancy progresses. Also occurs outside of pregnancy, in men and women -Significance cont. - potential for herniation, decreased fetal protection, difficulty with supine to sit.

changes in thermoregulatory system

Basal metabolic rate and heat production increase May cause overheating of fetus and dehydration during aerobic activity -Normal temperature while pregnant is .2 to .4 degrees higher. So, avoid overheating. No saunas or hot tubs. Exercise in only climate controlled areas. Staying hydrated also prevents overheating.

do not do these exercises during pregnancy

Bilateral SLR "Fire Hydrant" exercise Quadruped hip hyperextension Unilateral weight-bearing exercises

changes in cardiovascular system

Blood volume increases Heart size increases HR increases 10-20 bpm Cardiac Output increases Aorta and vena cava compressed by uterus in supine Veins are distended (esp. in LE's) BP usually decreases (in some women, hypertension may develop during the third trimester) Hypotension may occur when supine or rising from supine Side lying on left side relieves pressure on abdominal blood vessels and increases cardiac output -Blood pressure typically is lower despite the increased blood volume because of venous distensiblity. BP is decreased until ~midpoint of pregnancy then slowly returns to pre-pregnancy levels ~6 weeks after delivery -Supine = pressure on inferior vena cava = decreased cardiac output = hypotension. -Left Sidelying = less pressure on your liver (right side), improved circulation to the fetus, less pressure on kidneys and intestines improving digestion and decreasing kidney issues (edema)

maternal clinical signs third trimester

Contractions occurring regularly Urinary frequency Back pain & Round Ligament Pain LE edema and fatigue SOB Constipation

c-section outpatient

Correct diastasis recti Strengthen abdominal muscles Correct pelvic asymmetry Mobilize scar tissue Improve overall fitness Instruct in support groups

postural changes

COG shifts forward and up (due to increased size of uterus and breasts) Balance is affected by COG changes. BOS widens, resulting in waddling gait Increased cervical and lumbar lordosis Rounding of shoulders/upper back with scapular protraction and shoulder internal rotation due to increased breast size Genu Recurvatum to shift weight posteriorly toward heels to counteract the more anterior COG

labor stage one

Cervix fully effaces and dilates due to uterine contractions With frequent, strong uterine contractions the fetus is pushed downward, forcing the cervix to open Occurs over 8-12 hours -usually doesn't last more than 10-12 hours with an average being 4 hours. (WHO) -Last longer with first birth compared to subsequent births.

pain and overactivity of pelvic floor musculature

Chronic pain as a result of trauma to pelvic floor Overactivity, associated with muscle spasms, guarding, anxiety regarding movement.

low back pain

Commonly occurs due to postural changes of pregnancy increased ligamentous laxity decreased abdominal muscle function Physically fit mothers generally have less back pain during pregnancy. Typically, back pain resolves following pregnancy, as a result of the cause of low back pain no longer being present. -High Incidence - 50-80% of pregnant women report low back pain

sacroiliac pain

Commonly occurs due to ligamentous laxity and postural changes. Symptoms: Pain in posterior pelvis; stabbing deep into the buttocks distal and lateral to L-5/S-1. May radiate into the posterior thigh or knee but not into the foot. Increases with prolonged sitting, standing, or walking; climbing stairs or turning in bed; unilateral standing or twisting activities.

pt tx for in patient c-section

Decrease incisional pain Prevent respiratory and circulatory complications, prevent post-surgical vascular or gastrointestinal complications Reduce gas pains with massage and exercise Strengthen Pelvic Floor muscles Correct posture and body mechanics -Support incision with a pillow if coughing/moving "Women who have had a cesarean section may still require pelvic floor rehabilitation." Pelvic floor dysfunction may still be present, despite C-section. Just as with a vaginal delivery, pelvic floor strengthening should be resumed as soon after birth as possible.

Absolute Contraindications to Aerobic Exercise during Pregnancy

Early dilation of the cervix (incompetent cervix) Vaginal bleeding of any amount Placenta previa: placenta is located on the uterus in a position where it may detach before the baby is delivered. Rupture of membranes: loss of amniotic fluid prior to the onset of labor. Premature labor: S & S of labor beginning prior to the 37th week of pregnancy. Maternal heart disease Pre-eclampsia: pregnancy induced hypertension Multiple Gestation with high risk of early delivery

Cephalo-pelvic disproportion

Either the baby's head is too big or the pelvis is too small

varicose veins tx

Elastic support stockings Elevate LE's as often as possible Exercise

labor stage 3

Expulsion of the placenta as it detaches from the uterine wall Occurs 5-30 minutes after the baby is delivered Uterine contraction and shrinkage continues to occur for 3-6 weeks after delivery

treating SI pain

External stabilization Log rolling and positioning using pillows to maintain alignment should be practiced. Avoid! Single leg weight bearing and asymmetrical exercises. Teach pelvic floor exercise, stabilization exercises, transverse abdominis

reproductive system changes

Increase in size of uterus by: 5-6x in size Starts out 2"x 4", ends 10"x 14" 20x in weight Uterus expands into abdomen, displacing abdominal organs Each muscle cell in the uterus increases 10x in length (smooth muscle)

varicose veins etiology

Increased uterine weight Venous stasis in LE's Increased venous distensibility

urinary system changes

Kidneys increase in size Bladder is pushed down and forward, changing the angle at which the ureters enter the bladder This may result in urinary stasis, which may lead to UTI's Pressure on bladder = urinary frequency Kidneys increase 1 inch in length. Kidneys grow secondary to increased blood volume Hormonal changes also result in increased urinary stasis, further increasing the risk of UTIs

what happens when pelvic organs prolapse?

Low back and abdominal pain, difficulties with bowel and bladder elimination. Constipation, urinary leakage, constant urge to urinate

second trimester

Months 4 - 6.5 (Weeks 13-26) Fetus grows to 7-9 inches and 1-2 pounds Fetus is very active Morning sickness, fatigue and emotional lability usually go away and the mother feels good The mother can feel the fetus moving now at around ~20 weeks.

third trimester

Months 6.5 - 9 (Weeks 27-40) Fetus grows to 16-19 inches and approx. 5-10 pounds

pelvic floor dysfunction etiology

Muscle and soft tissue laxity/weakness Other causes: hx of hysterectomy, straining from constipation, obesity, chronic coughing.

postpartum ex guidelines

Pelvic floor strengthening initiated as soon as possible, correction of diastasis recti, and gradual increasing of intensity of aerobic and strengthening exercises.

reasons to d/c ex

Persistent pain; chest, pelvis, low back Vaginal bleeding/leaking of amniotic fluid Shortness of breath, esp. before exercise -Painful uterine contractions that Irregular heart beat Tachycardia Dizziness, faintness Hypertension Severe back or pubic pain Difficulty walking/maintaining balance

test for diastasis recti

Position patient hook-lying. Partial sit up (spine of the scapula leaves the floor) The therapist places the fingers of one hand horizontally across the midline of the abdomen at the umbilicus. If a separation exists, fingers sink into the gap. Diastasis measured by the # of fingers that will fit between the rectus muscle bellies. A diastasis can also present as a longitudinal bulge along the linea alba. This test should also be done above and below the level of the umbilicus.

c-section procedures

Prep Anesthesia - general or local Incisions (Horizontal or Vertical) Incisions through uterus Pull out baby, then placenta Incision is closed, with sutures; staples or steri-strips may be present

fire hydrant can cause

SI pain

diastasis recti

Separation of rectus abdominis muscle in the mid-line at the linea alba due to hormonal weakening of connective tissue, biomechanical changes during pregnancy or intra-abdominal stress during pregnancy or labor -Caused by the linea alba stretching laterally, not torn, just stretched

trauma post child birth

Stretching and compression of nerves, or Extreme stretching or tearing of tissues - tearing may occur during childbirth with a large baby or forceps delivery. -Childbirth is clearly the most significant risk factor for female pelvic floor impairments" "The process labor...can produce significant trauma to the pelvic floor" - Increased risk with larger babies, multiple deliveries, prolonged labor, mothers over 30, use of forceps during delivery.

Guidelines for Exercise for the uncomplicated Obstetric Patient (2)

Stretching exercises should be specific to a single muscle or muscle group and should not involve several groups at once - promotes joint instability. Ballistic movements should be avoided, as should contact sports, anything with a high risk of falling or "hot" yoga. No joint should be taken beyond its normal physiologic range. Hamstring and adductor stretches should be used with caution. Overstretching of these muscle groups can increase pelvic instability or hypermobility.

pulmonary system changes

Subcostal angle increases as ribs flare up and out Total chest circumference increases 2-3 inches Diaphragm is elevated ~1.5 inches Tidal volume (depth of respiration) increases, RR stays the same = hyperventilation Hyperventilation meets increased oxygen demands of the presence of a fetus May experience dyspnea with moderate to maximal exertion/exercise -15-20% increase in oxygen is required, resulting in a state of hyperventilation. -The pregnant woman reaches a maximum exercise capacity at a lower work level because of the increased oxygen requirement of exercise

tx for pelvic floor dysfunction

Superficial ice/heat to relieve pain TENS (Transcutaneous electrical nerve stimulation) to reduce pain and promote relaxation Biofeedback or Surface Electromyography to increase motor control and strength

reasons for having a C-section

a.Cephalo-pelvic disproportion b.Fetal distress c.Brow or face presentation d.Breech presentation e.Transverse presentation f.Prolapsed umbilical cord g.Placenta previa h.Active herpes or gonorrhea infection i.Failure to progress or dysfunctional labor j.Elective

pelvic floor musculature can be voluntarily contracted by:

cueing the patient to tighten the muscles as if they are attempting to hold in a BM or gas, or hold in or stop the flow of urine.

bilateral SLR can cause

diastasis recti

hypertonicity

due to pain, improper healing or surgical repair, or scarring

sx of LBP during pregnancy

dull and aching pain increases with muscle fatigue and static postures generally increases throughout the course of the day relieved with rest or change of position

GM pelvic floor ex:

hips elevated higher than the heart or hooklying or sidelying. Against gravity would be standing or seated.

Temperature regulation is highly dependent on _____________ and _______________ _________________. During exercise, pregnant women should stay well hydrated, wear loose-fitting clothing, and avoid high heat and humidity to protect against heat stress, particularly during the first trimester. Although exposure to heat from sources such as hot tubs, saunas, or fever has been associated with an increased risk of neural tube defects, exercise would not be expected to increase core body temperature into the range of concern. At least one study found no association between exercise and neural tube defects.

hydration environmental conditions

Episiotomy

intentional incision made in perineum to enlarge vaginal opening and prevent tearing

unilateral exercises can cause

irritate SI joint, possible balance safety issues

pelvic floor dysfunction

is a broad category of multiple "dysfunctions" encompassing bowel, bladder and sexual dysfunctions in men and women, including: -Pelvic Organ Prolapse, Urinary Incontinence, Fecal Incontinence, Pain, Overactivity of Pelvic Floor Musculature

stress incontinence

loss of urine with increased abdominal pressure: sneezing, coughing, any strenuous activity (sit to stand).

quadruped can cause

only safe if performed like Figure 21.12 on 1007, with posterior pelvic tilt, stopping before hip hyperextension occurs

common errors in pelvic floor therex:

patients will hold their breath and recruit the wrong muscles (abdominals, hip adductors, glutes) and not the pelvic floor muscles. Like the device above, it gives resistance for hip adduction, that ain't pelvic floor. It is recommended to put these exercises in a pelvic floor program as well. Hip IR and ER as well as stabilization exercises (the 1000 variations of planks and isometric abdominal work)

The _______ ________ is a multilayered collection of muscles spanning between the boney landmarks of the pubis and the coccyx, forming the inferior support for the pelvic organs and their contents

pelvic floor

failure to progress

terminology for a labor that is not producing. >20 hours

effacement

the cervix thins/flattens from 2 inches to the thickness of paper

prolapsed umbilical cord

the umbilical cord comes out before or with the baby, theres not enough room for both, the umbilical cord is compressed, cutting off blood supply to the baby.

kegel exercises

to improve muscle control, improve muscle tone and strength, increase circulation and promote relaxation