Maternal health presentation Role of physiotherapy in Gynaecology and obstetrics Role of physiotherapy in maternal health Antenatal and postnatal care

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Maternal Health

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Topics Covered
Anatomy,
Physiological changes in pregnancy and peuperium.
Musculoskeletal changes and other discomforts of pregnancy.
Antenatal period.
Physiology of labour and Coping with labour.
Postnatal period.
Pelvic floor dysfunction in Perinatal period and its physiotherapy
management.

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Anatomy
The Pelvis:
• A protective shield for important pelvic contents.
• Consist of two innominate bones, sacrum to which coccyx
attach.
• Inlet: level of sacral promontory and superior aspects of
pelvic bones.
• Outlet: pubic arch, ischial spines, sacrotuberous ligaments
and the coccyx
• Space enclosed within inlet and outlet is called true pelvis

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1. Gynaecoid: most common shape, almost
round.55% of women
2. Android or male: heart shaped.20%
women
3. Anthropoid: oval, longer
anteroposteriorly.20% women
4. Platypelloid: longer transversely.5%
women
Narrow suprapubic arch is associated with
consequential prolonged labour and
postpartum anal incontinence.

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Diameters of Gynaecoid true pelvis.
A/P (cm) Oblique(cm) Trans(cm)
Inlet 28 30.5 33
Midcavity 30.5 30.5 30.5
Outlet 33 30.5 28

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Pelvic floor and muscles of pelvis:

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Pelvic trampoline - pelvic floor.
Layers of pelvic floor from deep to
superficial:
1. Endopelvic fascia: fibromuscular tissue
composed of collagen, elastin, smooth
muscle fibres.
• Connects pelvic organs to pelvic side
walls.
• Major ligaments: cardinal (transverse
cervical) and uterosacral

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2. Levator ani muscles: also called
pelvic diaphragm.
• Three muscles are classified
under it,
a) puborectalis
b) pubococcygeus
c) iliococygeus
Supplied by perineal branch of
pudendal nerve. (S2-S4)

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3. Perineal membrane:
also called urogenital
diaphragm.
provides lateral attachments
for perineal body and
supports urethra.
4. External genital
muscles:
a) ischiocavernosus
b) bulbocavernosus
c) transverse perineal
muscles

10. 5) External genitalia and skin.
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Chief function of pelvic floor:
• Support abdominal and pelvic viscera
• Maintain continence of urine and faeces
• Allow voiding, defaecation, sexual activity and
childbirth.

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• Deepest group : transversus abdominis,lies
internally to internal and external oblique muscles.
all three insert into broad aponeurosis,which is
reinforced by two rectus abdominis muscles.
• PFMs are part of abdominal capsule along with
deeper muscles of abdomen, spine, diaphragm.
The abdominal muscles

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Reproductive tract

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1. Ovaries
• Two pinkish grey structures with the
size and shape of almonds,
consisting of thousands of primary
follicles.
• Produce ova and secretes
oestrogens and progesterone.
• At ovulation,ovum is directed to
fallopian tube by fimbriae.

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• After ovulation follicle collapses and
become corpus luteum which
secretes oestrogens and
progesterone.
• If fertilization occurs,it enlarges and
remain active for 4months. If the
ovum does not fertilize,it shrivels in 10
days.

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2. Fallopian tubes
• Outer end of tube is funnel shaped
and fimbriated.

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• Conception occurs at the junction of
distal third and proximal two-thirds of
the tube.
• Capacitation: tubal secretions contain
essential ingrediants to condition
sperm and ovum for fertilization.
• Ectopic pregnancy: implantation in
tube.

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3. Uterus :
• Consists of fundus, body,
isthmus (develops into
lower segment during
pregnancy) and cervix.
• Shape: inverted pear.
• In nulliparous measures
9cm long, 6cm wide and
4cm thick. Weighs 50g.

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• Myometrium has three muscle
layers:
a) Inner circular layer: pulls open
lower segment and cervix in
labour.
b) Middle oblique layer: involved in
expulsive contractions of labour
and clamping off bleeding vessels
after placental delivery.
c) Outer longitudinal layer: pushes
foetus down into the more passive
lower segment in labour.

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• Cervix :
Forms a fusiform or spindle shaped
canal at the junction of main body of
uterus and vagina.
Distal two-third protrudes into and
form vault of vagina-lowest portion is
called external os.

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4. Vagina :
• About 7.5cm long, passes upwards
backwards and meet longest axis of
uterus at about 90 degrees.
• Consist of layer of smooth muscle
whose fibres are placed longitudinally
and circularly.
• It is positioned posteriorly to urethra
and base of bladder and anteriorly to
rectum.

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• Urethra embedded in anterior vaginal
wall is vulnerable to trauma during
childbirth, pelvic surgery and
occasionally during intercourse.

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Physiological changes in pregnancy
Pregnancy brings changes in following systems of
body,
1. Endocrine system
2. Reproductive system
3. Cardiovascular system
4. Respiratory system
5. Immune system
6. Breasts

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7. Skin
8. Gastrointestinal system
9. Nervous system
10. Urinary system
11. Musculoskeletal system

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Endocrine system
• Hormones of major importance to us are:
progesterone, oestrogen, relaxin.
• Progesterone: first produced by corpus luteum for
10wks then by placenta in entire pregnancy.
Oestrogens: produced same as progesterone.

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• Relaxin:
Produced as early as 2wks of
gestation, highest in 1st trimester and
then drops by 20% to remain steady.

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Effect of progesterone,
1. Reduction in tone of smooth muscle,
• Reduced Peristaltic activity in
stomach
• Constipation
• Reduced uterine muscle tone
• Detruser muscle tone reduced
• Urine stasis due to dilatation of
ureters: urinary infection

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• Urethral tone reduced : stress
incontinence
• In blood vessels: lowered diastolic
pressure.
2. Increase in temperature (0.5 to 1C)
3. Reduction in alveolar and arterial
Pco2 tension, hyperventilation.

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4. Development of breasts milk
producing glands.
5. Increased storage of fat.

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Effects of oestrogens:
1. Increase in growth of uterus and
breasts ducts.
2. Increase in level of prolactin for
lactation.
3. Assist maternal calcium metabolism
4. Increase water retention.

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Effects of relaxin:
1. Gradual replacement of collagen in
target tissues, increase in its water
content.
2. Inhibition of myometrial activity till
28wks.
3. Towards end of pregnancy, soften
the cervix.
4. Relaxation of pelvic floor muscles.
5. Ligament laxity

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Reproductive system
• Amenorrhoea: first sign of pregnancy
• Change in the colour of cervix within few days of
conception.
• Dilatation of cervix.
• Growing uterus rises to become an abdominal
organ at about 12wks gestation.

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Average fundal heights,

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• At term, weight of the uterine tissue :
1000gm and can hold 5000ml which
in non-pregnant women is 6ml.
• Braxton Hicks contractions:
• False labour or prelabour: sequences
of contractions of variable lengths
(20secs to 4min)

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Cardiovascular system
Undergoes great changes during pregnancy,
Cardiac output
• Changes in cardiac output (SV * HR) includes,
40% increase persisting throughout pregnancy.
• Heart rate increase by 15 beats/min
• Blood flow increase approx 500ml/min.

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Blood pressure
• Little change in systolic pressure,
decrease in diastolic pressure.
• Preganancy Induced
Hypertension(PIH): when systolic
increases more than 30mmHg or
diastolic more than 15 mmHg.

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Supine hypotension
• Reason
• Moving the women into sidelying
gives relief
Venous blood pressure
• Rise in lower limbs:
• May result in varicosities,oedema.

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Peripheral vasodilatation
• Occurs because of effect of
progesterone.
• Epistaxis, haemangioma, palmar
erythma, vascular spiders may occur

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Blood volume
• Plasma volume increase by 50%
• Red cell mass by 20-30%
• Thus total blood volume increase by
40%,from 4L to 5.5L.
• Physiological anaemia.

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Heart and myocardial contractility
• Apex shifts more lateral and higher
than normal:
• ECG changes may mimic IHD.

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Respiratory system
• Increased congestion in lung
capillaries
• R.R goes high slightly, from 15 to 18.
• Tidal vol increase by 40%
• Towards term diaphragm is displaced
up by 4cm.
• More diaphragmatic breathing

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• Relaxin softens costochondral
junction: women sometimes complain
of costal margin ache or rib ache.

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Immune system
• Depressed immunity
• Prone to diseases like pnuemococcal pnuemonia,
influenza, poliomyelitis.
Predisposes to reactivation of latent virus like CMV
or herpes.

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• Baby is protected against
transplacental and postnatal
infections by passive antibodies i.e.
IgG by placental transfer,gaining
passive immunity.

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Breasts
• Tenderness and tingling may be experienced
around 2-4wks.
• Weighs 400-800gms.
• At about 8weeks,Montgomerry tubercles appear –
secrete sebum

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• As early as 12th week, little serous
fluid expressed from nipple.
• By 16th week, colostrum is expressed.
• Human milk ‘comes in’ about 3rd or 4th
postpartum day.

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Skin
Pigmentation
• Linea nigra
• Darkening of areola
• Increase in colouring of vulva
• Chloasma on face
Striae gravidarum
• On abdomen, breasts, buttocks, thighs in
varying degrees.
• Cause: rupture of dermis

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• Marks are permanent. Change from
blue/red to small silvery lines.
• Some women genetically susceptible.
• Also association with hypermobile
joints.

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Gastrointestinal system
• Morning sickness
• Triggered by food odours
• Hyperemesis gravidarum: HCG
human chorionic gonadotrophin
• Gut muscules become hypotonic,
motility decreases.
• Prolonged gastric emptying time.
• Delay in the large bowel movements,
Constipation.

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• Gastric reflux or heart burn
• Softening and hyperemia of gums.
• Pregnancy involves energy
expenditure of about 1000kJ/day.
• Average weight gain: 10 to 12 kg

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Nervous system
• Mood lability, anxiety, insomnia, nightmares, food
fads and aversion,
• Decrease in brain size in pregnancy
• unusual pressure on nerves: carpal tunnel
syndrome.

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• Paraesthesia in hand due to traction
on nerves.

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Urinary system
• Presence of HCG in urine: basis of pregnency
tests.
• Increase in blood supply to urinary tract.
• Increase in the size and weight of kidneys and
dilatation of renal pelvis.
• Urinary tract infections: hypotonic musculature of
ureters.

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• Increased urinary output.
• Changes in tubular resorption can
lead to gestational diabetes.
• Bladder weakness - puts pressure on
your bladder
• frequency of urination in early as well
as late pregnancy.
• Towards term, possibility of urge and
stress incontinence.

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Musculoskeletal system
• Generalized joint laxity: hormonally mediated.
• Returns to pre-pregnant state in 6 months
postpartum
• Postural changes.
• Diastesis recti

56. Hormonal
Changes
Increase in
body
weight
Increase in the
abdominal size
due to growing
uterus

57. Increase in joint laxity & joint
ranges
Increased water retention 
oedema & nerve compressions
Drop in the pelvic floor  Pelvic
floor dysfunction
Painful muscle cramps
Pregnancy associated
osteoporosis (PAO)

58. Diastesis Recti
Diastesis pubis

59. POSTURAL
CHANGES
•
Increase in the
abdominal size
COG shifts
anteriorly
Counter-
balanced by:
* Increase of lumbosacral angle
* Increase of lumbar lordosis and
thoracic kyphosis
* Bending forward over the
enlarging uterus
Protraction of the
shoulders
&
Hyperextension of the
knee

62. GAIT
Wide
BOS
Loss of
Balance
Waddling

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Physiological changes during Puerperium
Puerperium: period of 6 to 8 wks following delivery.
Process by which this occurs is called ‘involution’
Decline of placental hormones production level.
Endocrine system:
it takes time for changes in this system to occur.

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Effect of relaxin maintained for 12
weeks.
Cardiovascular system:
Returns to normal in two weeks.
Skin changes:
Chloasma and linea nigra takes time to
fade.
Respiratory system:
Returns to normal soon after delivery.

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Oxygen saturation come up to 98% day
after delivery; during labour which
had reduced to 87%.
Uterus:
• Uterus reduces in size by 3 process:
1. Uterine contractions continue after
delivery.
suckling by baby

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‘After pains’: throbbing or cramping
kind of pain of moderate to severe
intensity.
2.Actual reduction in uterine tissue:
3.For 2 to 3 weeks, woman experience
discharge of lochia: consist of blood
and necrotic tissue of decidua.

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• Sign of involuting uterus: can be
palpated.
On 1st postpartum day: above
umbilicus
By 6 days: midway
By 10 days: dissapeared down behind
symphysis

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Lactation
• Prolactin, produced by anterior pituitary steadily
rises throughout pregnancy.
Effect inhibited by placental hormones.
• On 3rd to 4th postpartum day,it is free to act.
• Milk is produced by glandular cells and stored in
alveoli.

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• Suckling reflex stimulates posterior
pituitary to release oxytocin: causes
myoepithelial cells around alveoli to
contract.
• ‘let-down’ or milk ejection reflex:
• Recommendation by RCM(2002):
regarding breast feeding.

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Back and pelvic girdle pain
• First episode of pain:between 4th and 7th months in
majority.
• Radiated to buttocks and thigh, occasionally down the legs
as sciatica.
• Made worse by standing, sitting, forward bending, lifting –
when combined with twisting.

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• Pain can also be felt in posterior
pelvis,deep in gluteal region.
• Stabbing pain in buttocks distal and
lateral to L5 S1 area,with or without
radiation to posterior thigh,not in foot.
• Pain can be provoked by Posterior
pelvic pain provocation test.
• Mechanical cause is not clear
although it may be related to
sacroiliac joint.

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Prevention of back pain:
Principles of back care:
• Lying: additional support in form of
pillows.
Long periods supine lying should be
discouraged after first trimester.

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• Rolling:
maintain adduction at hips and flexion
at knees.
a) turn head in direction of travel:
fascilitate upper trunk.
b) folding arms across the chest with
top arm leading: fascilitate middle
trunk.
c) slightly flexing outside knee and
laying it on inside leg: fascilitate lower
trunk.

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• Sitting:
on chair, follow the criteria:
• Standing and walking:
Avoid for prolonged period.
Transfer weight from one foot to
other.
Avoid trunk on hip flexion, twisting.
Move up and down spine.

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Getting something from floor, women
should be properly advised:
• Lifting:
held close to the centre of mass.
divide in two hands eg: shopping
bags.

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• Treatment:
Gentle heat and massage.
TENS if pain continues.
Exercise programme, to maintain
results.
Corsets for lumbar spine.

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Sacroiliac joint dysfunction
Treatment:
‘gapping’ of the joint,enabling it to return to more
normal approximation is effective.
• Technique 1:affected knee flexed and flexed knee
across the body
• Technique 2: affected hip and knee flexed, pull left
knee towards a point lateral to left shoulder.

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• Technique 3:sit or stand with hip knee flexed, foot
up on chair and rock forward
• Technique 4: lying, longitudinal leg pull.
• Technique 5 lying, hips at 90 degrees,lower legs
supported on table. Thigh press against the firm
surface.

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Symphysis pubis dysfunction
• Pain type: burning or bruised
may radiate suprapubically or medial aspect of
thigh.
• Difficulty activities:
Getting in and out of car, changing position in bed,
dressing, walking.

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Treatment
• Rest. Avoid single leg standing.
• Pelvic support
• Gentle isometric contraction of hip
adductors, in sitting.

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Thoracic spine pain
• As a result of rib cage expansion.
• Mechanical effect on costochondral joint.
• May be linked with costal margin pain and
intercostal neuralgia.

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Treatment :
• Mobilisation.
• Posture correction
• Rib lifting techniques:
• Hot water bottle or ice pack

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Diastasis of rectus abdominis
Seperation of rectus abdominis in midline.
Any seperation of larger than 2cms is considered
significant.
May occur as a result of hormonal influence on
connective tissue.
Factors having strong causal relationship with
degree of diastasis:

84. Diastasis recti examination
Treatment- curl up
Head lift curl up
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Pregnancy associated osteoporosis
• May be underdiagnosed.
• Symptoms experienced by women were,
a) Backache sometimes radiating around chest
wall.
b) Hip/groin pain
c) Vertebral fractures.

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Nerve compression syndromes
Carpal tunnel syndrome:
there is higher incidence of about 50%.
• Treatment:
Ice packs.
Resting with elevation
Wrist and hand exercises.
Ultrasound

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Brachial plexus pain:
treatment: exercises, stretching, elevation
Meralgia paraesthetica: (lateral femoral
cutaneous nerve entrapement)
TENS is helpful
Posterior tibial nerve compression:
Treatment: elevation, foot ankle exs, ice
packs, ultarsound

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Circulatory disorders:
Varicose veins in legs:
Treatment:
a) Avoid standing for prolonged periods
b) Vigorous foot exercise
c) Brisk walking
d) Elevation
e) Support tights or elastic stockings

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Vulval varicose veins:
Rare, Painful and stretching like
• Treatment:
Rest with foot of bed raised
Keeping sanitory pad.
PFM contractions
Avoid prolonged standing.
Avoid constipation

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Haemorroids:
Straining can cause ballooning of
veins in and around anus
• Treatment:
PFM exercises
Ice pack for pain relief
Teaching defaecation techniques.
Dietary advice.

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Muscle cramp:
could be due to: calcium deficiency,
ischemia, nerve root pressure, fluid
retention with reduced activity towards
term.
Treatment:
• Calf stretches
• Knee extension with dorsiflexion
• Massage
• Vigorous foot exercises
• Prebedtime brisk walk and warm bath

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Other problems
Chondromalacia patellae:
avoid full squat
Restless leg syndrome:
unpleasant creeping like sensation
associated with fatigue, anxiety or stress.

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Uterine ligament pain:
sudden sharp stabs of lower
abdominal pain or constant dull ache.
often unilateral.
Treatment:
• Warmth or cold
• Massaging or stroking

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Heartburn:
Treatment:
• Eat little and often
• Avoid food that increase symptoms
• Raise head end of bed
• Consult doctor to have suitable
antacids

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Morning sickness:
Treatment:
• Acupressure:
between flexor carpi radialis and
palmaris longus
• TENS : 120hz 150 m/s to web space
between thumb and forefinger on right
arm
• Eating ginger, biscuits esp before
rising

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Antenatal class aims
Educate couple about physical, emotional changes
of pregnancy, labour and peuperium
Explain importance of antenatal care
Prepare mother to cope with process of labour
Value of exercise in pregnancy is controversial as
both benefits and risks have been hypothesized.

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Risks: what the literature says?
Pregnancy and neonatal outcome:
1. Regular aerobics and running has beneficial effect on
course and outcome of labour.foetal stress was also less.
2. Maternal exs reduced duration of second stage of labour.
3. Exercisers tend to weigh less,deliver smaller babies than
nonexercisers.

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Maternal risks:
1. Greater risk of musculoskeletal
trauma due to hormone relaxin.
Associated Postural changes.
but with good exercises and advice
these can be reduced.
2. Increase demands on
cardiovascular system already
altered by pregnancy.

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3. Hypoglycemia may arise which could
lead to foetal hypoglycemia.
4. Thermoregulation: hyperthermia can
cause teratogenic effects to foetus.
39.2 C is threshold for neural defects.
5. Respiratory changes: increase in
minute ventilation by almost 50%.
Increase in oxygen uptake with
increase in oxygen consumption of
10%-20%

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Foetal risks:
1. Vigorous exercise have shown
increase in foetal heart rate by 5-15
beats.
Exercise intensity upto 70% of
maternal aerobic power does not
affect foetal heart rate.
2. Alderman et al 1998 found,moderate
exercise for 2hrs per week was
associated with reduced risk of large
birth weight babies.

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Regular activity in first two trimesters
may be associated with reduced risk
of caeserean in primiparous.

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Guidelines for exercises:
1. Consult with medical caregiver
2. Gradually increase exs if previously sedentary
3. Exercise regularly 3/week
4. Maximum H. R. should not exceed 140-150 b/min

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5. Moderate exs not more than 20 mins
6. Avoid overheating and exercising in
hot climate
7.Maintain adequate fluid intake.
8. Donot exercise with febrile illness
9. Avoid exercising in supine after 4
months.
10. Avoid contact sports after 16 weeks.

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Contraindication
Cardiovascular, respiratory and renal diseases
Diabetes
Thyroid disease
h/o miscarriage, premature labour, cervical in
competence
Vaginal bleeding
hypertension

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Multiple pregnancies
Abnormal placntal position
Sudden pain
Decreased foetal movements
Anaemia
Breech presentationin 3rd trimester

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Preclass assessment:
Should consist of,
1. History: obstetric (gestation, miscarriages)
2. Any other medical problems
3. Current and previous level of activity
4. Musculoskeletal problems
5. Abdominal strength, presence of diastasis

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6. Posture
7. Doctor’s permission to exercise.

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Structure of pregnancy class
Some classes can be of low impact aerobic class
with component of cardiovascular work
Some can be of stretches,slow controlled
movements with relaxation training and breath
awareness.
Incorporate ergonomic principles for back care and
changing positions.

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Example of a class format:
• Introduction – emphasize safety and
correct posture.
• Monitor resting pulse
• Warm up 10 mins
• Modified cardiovascular component
20mins
• Monitor pulse and water break

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• Gentle cool down
• Specific strengthening, stability, toning and balance
work
• Stretches
• Relaxation
• Encourage fluid intake
• Question / discussion time

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Introduction to the class
Physiotherapist should introduce herself and
outline the structure of the class.
Warning signs and symptoms:
1. Tachycardia
2. Palpitations
3. Shortness of breath
4. dizziness

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5. Faintness
6. Vaginal fluid loss
7. Pain
Responsible for her own body and
report any discomfort.
Reinforce the importance of drawing
in when changing the posture during
class.

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Warm-up:
• Purpose of the warm up period:
increase the circulation and enhance
neural and connective tissue function
(Bruker and Kahn,1994)
• Reduce the likelihood of injury.
• Implication in antenatal class:
Stroke vol. declines in third trimester.
Causes pooling of blood in lower
limbs and pelvis.(Morton,1985)

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There was decrease in 15% cardiac
output in standing during 3rd trimester.
Modified cardiovascular section:
• Maintain the previous fitness level.
• Increase the heart rate and
respiratory rate for workout acc. to the
norms.
• Avoid sudden changes of
direction,jumping motions or high
level balance work.

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• At the conclusion, women should take
pulse while keeping lower limbs
moving.

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Break:
Drink water to maintain adequate
hydration.
Cool down:
sustain activity of lower limbs.
Pulse rate measured.

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Strengthening, stability and toning
exercises:
should be gentle and encourage
mental and physical relaxation.
Emphasize the muscles that become
weak and stretch due to adaptations.

118. Lengthening of tight soft tissue structures:
• Dangerous exercise is partnered
streches.as this decrease the control of the
woman to stretch safely.
• Lengthen slowly and not upto the extremes.
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Relaxation:
Most enjoyable section of exs.
Different approaches to teach relaxation.
Can be taught in fully supported sidelying or
supported sitting.
Class conclusion:
Time allocated in addressing individual
concern.

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Exercises in antenatal classes:
Posture exercises:
muscles that require stretching and strenthening
are:
• Stretching (with caution)
1. upper neck extensors and scalenes
2. Scapular protractors, shd int rotators, levator
scapulae
3. Low back extensors

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4. Hip flexors, adductors and
hamstrings
5. Plantarflexors.
strenthening (low intensity):
1. Upper neck flexors, lower neck and
upper thoracic extensors
2. Scapular retractors and depressors
3. Shd external rotators, biceps triceps
4. abdominals

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5. Hip extensors
6. Knee extensors
7. Ankle dorsiflexors.
Small hand weights (0.5 to 1kg) can be
used for upper limb strenthening.

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Exercises for diastasis:
Exs should be used only after
seperation is corrected 2cm or less.
1. Head lift: hook lying,
2. Head lift with pelvic tilt: hook lying,

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Abdominal muscle exercises:
1. Pelvic tilt exercise:
Quadruped,
Practice the same in sidelying and
standing.
2. Leg sliding:
Hook lying with pelvis posteriorly
tilted,

125. Maternal health 125
3. Trunk curls:
a) Curl up and curl down:
b) Diagonal curl

126. Maternal health 126
Pelvic motion training:
helpful in postural back pain, improving proprioceptive
awareness as well as lumbar,pelvic and hip mobility.
• ‘The pelvic clock’:
• Hook lying, Visualize face of clock on lower abdomen with
umbilicus at 12o’clock and pubic symphysis at 6.
• Have her begin with gentle movements from 12 to 6 o’clock (the
basic pelvic tilt exercise).
• Then ask her to move from 3 o’clock (weight shifted to left hip)
to 9 o’clock (weight shifted to the right hip).
• Then move in a clockwise manner from 12 to 3 to 6 to 9 and
then back to 12 o’clock.

127. Pelvic Clock Progressions
• Use the visual imagery of cutting the face of the
clock in half so that there is a right side and a left
side, or a top half and a bottom half.
• Have the woman move her pelvis through the arc
on the one side and back through the middle of the
clock, and then move the pelvis through the
opposite side and back through the middle.
• Initially, the woman may notice asymmetry when
comparing the halves; this will improve with time.
• Clock wise and couter clock wise
Maternal health 127

128. Maternal health 128
Modified upper and lower extremity strengthening:
As the abdomen enlarges, it becomes impossible to comfortably assume
the prone position. Exercises that are usually performed in the prone
position must be modified.
1. Standing push ups:
2. Supine bridging: Hook lying, posterior pelvic tilt,
3. Quadruped leg raising:
• Posterior pelvic tilt + leg raising
• Discontinue if there is stress on sacroiliac joints.
if woman cannot stabilize the pelvis, have her just slide one leg
posteriorly and return.

129. Maternal health 129
Modified squatting:
• Strengthen hip and knee extensors
and also help to stretch perineal area.
• Standing with back supported, feet
shoulder width apart,
• Women with knee problem: partial
squat.

130. Maternal health 130
• For optimal success with squatting during
stage 2 of labor, increase duration of squat
gradually to 60 to 90 secs.
5. Scapular retraction:
In sitting or standing.

131. Maternal health 131
Perineum and adductor flexibilty:
Self stretching:
a) Supine or sidelying.
Instruct the patient to abduct the
hips and pull the knees toward the
sides of her chest. Hold the position.
b) Sitting on a short stool.
Hips abducted as far as possible,
feet flat on floor.

132. Maternal health 132
Pelvic floor awareness, training
and strengthening:
• Begin with empty bladder.
• Gravity assisted positioning: hips
higher than heart such as supported
bridge, if there is extreme weakness
and proprioceptive deficits.
• Positional change introduced as
strength and awareness improve.
(supine, side lying, quadruped, sitting
and standing.)

133. Maternal health 133
Contract-relax:
Tighten the pelvic floor as if stopping
urine flow.
Hold for 3 to 5 secs and relax.
Repeat 10 times.
watch for any substitution with
gluteals, abdominals or hip adductors.
Watch for Valsalva, ask woman to
count loud.

134. Maternal health 134
Quick contractions: perform quick
repeated contractions of pelvic floor
with normal breathing rate.
15 to 20 repetitions per set.
this is a type2 fibre response,
important to develop to withstand
pressure from above eg:
coughing,sneezing.

135. Maternal health 135
‘Elevator exercise’
instruct imagining an elevator.
as the elevator goes from one floor to
other,she contracts pelvic floor a little
more.
increase the difficulty by asking the
woman to relax the muscles
gradually, as if descending elevator.
it requires eccentric contraction.

136. Maternal health 136
Pelvic floor relaxation:
after contracting, instruct her to relax
completely,total voluntary release.
Elevator imagery can be used.
Its relaxation is closely linked with
breathing and facial muscle
relaxation.
important in stage 2 and vaginal
delivery.

137. Maternal health 137
Relaxation and breathing:
requires awareness of stress and
muscle tension.
1. Mitchell method:
It utilizes knowledge of typical
stressful posture and reciprocal
relaxation of muscle.
One group relaxes as opposing
group contracts.

138. Maternal health 138
For eg: for hunched shoulders- Pull
your shoulders towards your feet.
Stop.
Proprioceptive receptors in joints and
muscle tendons record resulting
position of ease and this is relayed to
and registerd in cerebellum.

139. Maternal health 139
2. Contrast method:
given by Edmund Jacobson.
Involves alternately contracting and
relaxing muscle group progressively.
To develop recognition of difference
between tension and relaxation.
3. Visual imagery:
Encourage the person to think in pictures
as opposed to words.

140. Maternal health 140
Ask the patient to imagine pleasant
image such as beach, mountain.
Suggest her to focus on the same
image throughout pregnancy so that
can be called up on during labor for
relaxation.
4. Touch and massage:
Soothing stroking, effleurage or
kneading to appropriate areas may
have good effect.

141. Maternal health 141
5. Breathing:
Outward breath is the relaxation phase
of respiratory cycle.
This fact can be used to enhance
relaxation.

142. Maternal health 142
Unsafe postures and exercises during
pregnancy
Knee chest position with buttocks elevated above
heart level.
Not to assume this position for 6wks postpartum
Bilateral SLR
‘Fire hydrant’ exercise:
Patient on hand and knees. One hip abducted and
externally rotated at the same time.
Stress S.I joint and lumbar spine

143. LABOUR
Maternal health 143

144. Maternal health 144
Physiolgy of labour
Physiological changes in mother and foetus during labour:
a) Maternal respiratory:
increase in ventilation, decrease PCO2.
b) Maternal cardiovascular:
increase 10mmHg systolic BP.
increase 5-10mmHg diastolic BP.
c) Maternal gastrointestinal:
decrease motility and absorption.
nausea/ vomiting- dehydration

145. Maternal health 145
d) Foetal cardiovascular
Sometimes there is slight fall in H.R.
Due to cord compression, cord stretch or foetal head
pressure, H.R. recovers at end of contraction

146. Maternal health 146
Stages of labour:
1. Stage 1:
• From onset of labour till full dilatation of cervix.
• It accounts for about half of the duration of
labour.
• 12-16 hours in primigravidae
• 6-8 hours in multipara.
• Dilatation of cervix occur at rate of 1cm/hour.

147. Maternal health 147
Pain in stage 1:
Pain pathway: nerves from uterus and cervix enter
primarily to T11 and 12, secondary to T10 and L1.
Distribution of pain:
over large area, lower abdomen and small area of
back.
Later more intense including thigh and perineal area.

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Pain is due to:
a) Diatation of cervix
b) Contarction and distention of uterine
muscles
c) Pressure on surrounding sensitive
structures.

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Stage 2:
Duration: shorter in multipara, upto 2 hours in
primiparae.
2 phases of second stage:
a) Phase of descent:
It is extension of 1st stage where head is high
and there is no distension of perinium.
Vigorous pushing at this time may introduce
metabolic disturbances hence should be
discouraged till the baby is well placed for
delivery.

150. Maternal health 150
2. Perineal phase:
Phase of stretching and bulging of
perinium through which head will
pass.
Presenting part is now low in birth canal
and can be visualised at vulva.
Hence expulsion efforts can now be
encouraged.
Pain pathways in stage 2: nerves from
cervix and pelvic floor pass to sacral
segments S2,S3,S4.

151. Maternal health 151
Stage 3:
From birth of baby untill delivery of placenta.
Contractions are less painful and less
frequent.

152. Physiotherapy during labour
Maternal health 152

153. Coping with Labour
Relaxation techniques
Positions
Breathing techniques
Massage
Pain relief
Maternal health 153

154. Maternal health 154
Relaxation
Two reasons for relaxation in labour,
1. To prevent mother from getting unduly
tired,thereby causing nervous fatigue.
2. To help mother control her thoughts and feelings
or emotions.

155. Maternal health 155
Jackobson Method:
Mitchell method:
Touch relaxation:
In this concept, where women relaxes to the
touch of her partner.
Imagery

156. Maternal health 156
Breathing for labour
Our bodies receive more oxygen when the
breathing is slow and deep.
Once the technique is learned, it can be
incorporated to relaxation practice.

157. Maternal health 157
Breathing and contractions
3 phases of contraction,
Preparatory phase
Action phase
Recovery phase.

158. Maternal health 158
First stage:
Deep, slow easy breathing- pausing between
expiration and inspiration- may be all that some
women use in first stage.
Imagine a feather or candle in front and breath in
such a way that it barely move.

159. Maternal health 159
Transition phase:
Pain may be well intense.
Woman feel desperation, anxiety.
Reassure with positive response that the 2nd stage
is not far away.
To cope with it, women should be encouraged to
sigh out softly.
Many women worry about making noise during
labour. They should be encouraged to use their
voices to express difficulty.

160. Maternal health 160
Stage two:
Pain of the 1st stage recedes and all becomes
purposeful effort with stage two.
Desire to bear down usually come in waves,
perhaps 3 or 4 emptying urges per contraction.
.

161. Maternal health 161
Breathing and pushing
Woman should be trained to breathe in and slowly
out on exertion.
once trained, it will become instinctive and she
would be able to maintain push and at the same
time breathes in.
Each push last for about 5 to 10 secs.
Each contraction demands 3 to 4 pushes.

162. Maternal health 162
Positions in labour
Because of the anteversion of uterus during first
stage contractions, many women find the need to
lean forward on some sort of support.
Different postures should be demonstrated and
practised in antenatal classes.

163. Maternal health 163

164. Maternal health 164

165. Maternal health 165
Massage in labour
Stroking, effleurage and kneading activates gate
closing mechanism at spinal level.
Tissue manipulation (Deep sacral kneading)
possibly stimulate release of endogenous opiates.
Backpain- 1st stage- lumbosacral region

166. Maternal health 166
Massage to the back:
1. Stationary kneading, either single
handed or reinforced, applied slowly
deeply to painful area.
2. Double handed kneading, with
loosely clenched fists, directly over
S.I joint. Hand held tennis balls can
be used.
3. Effleurage from sacrococcygeal
area, up and above the iliac crests
4. Slow rhythmical longitudinal stroking,
from occiput to coccyx, single or double
handed.

167. Maternal health 167
Massage to abdomen:
Pain usually experienced on lower half
of abdomen.
a) Light finger stroking or brushing
from one ASIS to other.
b) Double handed stroking ascending
either side of midline and across
iliac crest.

168. Maternal health 168
Massage to the legs:
Labour pain may percieve in thighs and
cramps in calf or foot.
Effluerage or kneading may help
Perineal massage:
It encourage stretching of skin and
muscle and thus prevent tearing or
episiotomy.

169. Maternal health 169
Technique:
A natural oil can be used.
Index and middle fingers of one hand
are put about 5cms into vagina.
Rhythmic ‘U’ or sling type movement
upwards along the side of vagina with
downward pressure, stretches the
perinium from side to side.
As elasticity improves, three or four
fingers can be used.

170. Maternal health 170
Pain Relief in Labour

171. Maternal health 171
TENS
Mode of stimulation:
a) Burst train TENS:
• Stimulates A beta and A delta fibres to inhibit C
mediated pain sensations presynaptically at spinal
segmantal level.
b) Brief intense TENS:

172. Maternal health 172
Best used for short periods of time
(10-15 min) because of fatigue in
nerves from intense stimulation.
Two modes are used for specific
instance of labour.
Burst train TENS is used all time during
labour to relieve dull aching type of
labour pain.
Brief intense TENS for pain increased
during contractions.

173. Maternal health 173
Press button mechanism is available
in obstetric TENS machine, to switch
between these two modes.
Placement of electrodes:
One pair of electrodes covering either
side of spinous process of T10-L1
Other pair covering either side of S2-S4

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Safety limits:
fetus was at most risk if,
a) Electrodes were placed abdominally
b) Thin woman, with only 1 inch abdominal
fat
c) Foetus occipitoposterior

175. Maternal health 175
Postnatal Physiotherapy

176. Maternal health 176
Symptoms to look out for include:
• Diastasis rectii
• Inability to voluntary contract pelvic
floor
• Perineal pain / discomfort
• Symphysis pubis pain
• Back pain

177. Maternal health 177
Exercise:
• Encourage to be mobile, which would
reduce circulatory and respiratory
dysfunction.
• Pelvic floor muscle exercises for
strengthening and pain relief.
Will also speed healing by reducing
edema and encouraging good
circulation.

178. Maternal health 178
Two essential early advices are:
a) Contract the PFM every time the intra-abdominal
pressure is increased.
b) Support sutures by applying pressure to the perineum
when defeacation is attempted.
Principles of muscle reeducation should be followed
when exercising abdominal muscles.
• i.e progressing from static to dynamic.
• with different starting positions.
• Static abdominal contractions followed by pelvic tilting
can aid relief in ‘after-pains’ or backache.

179. Maternal health 179
Early postnatal class:
Participants may be sitting, standing or lying.
1. Sitting:
• Well supported back.
• Exercises in sitting for posture, abdominals,
PFM.
2. Standing :
• Stable base of support.
• Appropriate footwear.
• Exercises in standing for posture and
abdominals. This can reduce abdominal girth
upto 12cms.

180. Maternal health 180
3. Lying :
• Pillows and wedges for support.
• Teach checking and correction of diastasis rectii.
• Raise awareness regarding at risk movements.
• Exercises: abdominals, pelvic floor, postural.

181. Maternal health 181
Relaxation:
• It reduces tension and maternal
fatigue.
• Skill for relaxation fascilitate ‘let down’
reflex for breast feeding.

182. Maternal health 182
Teaching ergonomic principles:
1. Sitting:
• Thighs should be fully supported
• Feet flat on floor
• Weights evenly distributed on both
buttocks.
• Trunk fully supported maintaining
natural curves.

183. Maternal health 183
2. Standing:
• Feet slightly apart and angled
slightly.
• Weight evenly distributed.
• ‘soft’ knees.
• Shoulder relaxed.
• Arms held loosely
• Maintain natural curves
• Head in midline.

184. Maternal health 184
Kneel sitting:
• Bilateral: may be cushion at back of
the knees.
Half kneel sitting:
• Unilateral- sitting on one heel, other
hip forward flexed with feet on the
floor.

185. Maternal health 185
3. Lying :
• Fully supported with pillows.
• Legs not crossed.
4. Kneeling :
• Knees hip width apart.
• Knees directly under hips, may be on cushion
• Maintain natural spinal curves.

186. Maternal health 186
5. Feeding:
• New mother may feed baby
8 or more times in a day.
• Hence ergonomic principles
should be followed to avoid
musculoskeletal discomfort.
a) Sitting on chair
b) Long sitting
c) Sidelying

187. Maternal health 187
6. Nappy changing:
Suggested positioning could be:
a) Sitting and changing in lap.
b) Standing and changing on a
surface of appropriate height.
c) Kneeling or half kneel sitting

188. Maternal health 188
Postnatal problems
Perineal dysfunction / pain:
• Problems include bruising, oedema, labial tears,
haematoma, tight stitches, infection, break down of
suturing and haemorrhoids.
• May cause varying degrees of pain.

189. Maternal health 189
Treatment:
1. Pelvic floor muscle exercises:
• Self help technique for pain relief.
• Pumping action
• It activates pain gate mechanism and
may also stimulate production of
endogenous opiates.
• Pain is maximum in first contraction,
then decreases with repetition.

190. Maternal health 190
2. Functional activity:
• Pain relief can occur rapidly with
appropriate positioning for activities like
feeding, relaxation and sleep.

191. Maternal health 191
3. Ice:
• Its pain relieving effect is well documented.
• The technique is cheapest.
• Following are suitable techniques:
1. Crushed ice, wrapped in damp disposable
gauze or put into plastic bag, applied for 5-10
minutes.
women in comfortable half lying position.
2. Ice cube massage: by the women herself.
• Dangers of using ice therapy should be warned,
since sensation may be diminished after birth.

192. Maternal health 192
4. Warm baths:
• Relaxed feeling of well being with use of warm bath.
• Warm water can be poured on perineum.
• Eases burning sensation when urinating.

193. Maternal health 193
5. Ultrasound:
• Treatment should commence as soon as possible after
delivery.
• Best position: crook lying or side lying,
Technique:
• Clean the area with cotton wool and warm water.
• Pulsed ultrasound is used for its analgesic effects.
• For initial treatment, dosage: 3MHz, 0.5 W/cm, 2mins per head
sized area of trauma.
• If pain too intense: condom can be used as a water bag
between treatment head and area.
• Couplant is applied to patient’s skin , bag and treatment head.

194. Maternal health
194
6. PEME:
• Its pain relieving and therapeutic effects for
bruising, hemorrhoids, suturing etc.
• Dosage: pulse width- 40- 65 pulses with
repetition of 10-220 pulses per sec.
• Treatment time: twice daily, from 5 to 20 minutes

195. Maternal health 195
Genitourinary dysfunction / pain:
1. Incontinence:
• Close relationship between pelvic
organs.
• Bowel and bladder problems resolved
between 8 and 24 weeks postpartum.
• Strong relationship between first
childbirth and obstetric trauma.

196. Maternal health 196
Faecal incontinence:
• Women with midline episiotomy had
higher risk of foecal incontinence.
• Incontinence can result from damage
to innervation of pelvic floor during 2nd
stage of labour.
• Neuropraxia resolves by 2 months.

197. Maternal health 197
Stress incontinence:
• Caused by distension and weakening
of PFM and connective tissue and
damage to their innervation.
• Kegel suggested 200 contractions per
day.
• Counter bracing during coughing,
sneezing.

198. Maternal health 198
2. Constipation:
• Extremely common after child birth.
Causes:
• Large diastasis rectii, relaxation of smooth
intestinal muscles, diet, iron medications,
fear of perineal pain.
Remedies:
• Abdominal muscle strengthening.
• Perineum support with pad during
defaecation.
• Change in diet.

199. Maternal health 199
3. Urinary retention
• Frequent gentle PFM contraction.
• Having warm shower may be of help.

200. Maternal health 200
4. Urgency:
• Trauma to nerve supply to detruser
and urethral sphincter are possible
causes.
• Frequent PFM contractions can help.
• Contraction of levator ani muscle
directly inhibits sacral micturation
centre and voiding surge can be
controlled.

201. Maternal health 201
Musculaskeletal dysfunction:
1. Diastasis rectii abdominis:
2. Back pain:
• 67% had back pain directly after
delivery and 37% still had it 18
months later.
• Ergonomic principles followed.

202. Maternal health 202
3. Thoracic pain:
• Relieved with active exercises and
hot or ice packs.

203. Maternal health 203
4. Coccydynia:
• Due to damaged ligaments or aggravation of
previous injury.
• Ultrasound, ice or hot packs, TENS, IFT can
help.
• In sitting, cushion can assist comfort.
• Prone lying is comfortable.

204. Maternal health 204
5. Symphysis pubis pain:
• It may have occurred antenatally or
follow a traumatic delivery.
• Depending on pain severity, advice
bed rest for 24-48 hours with
analgesia.
• Full assistance with baby.
• Gradual mobilisation with walking aids
if required.

205. Maternal health 205
Advice and treatment:
• Avoid non essential weight bearing,
abduction of legs, one leg standing,
twisting lifting.
• Teach proper functional activities like
knees flexed and tightly adducted
when moving in bed.
• Ultrasound and ice may speed
healing.

206. Maternal health 206
6. After pains:
• Practising relaxation and breathing
can help.
• TENS applied over nerve roots
innervating uterus and perineum may
be helpful.

207. Maternal health 207
Circulatory dysfunction:
1. Varicose veins:
2. Oedema:
3. Superficial and deep vein thrombosis:
4. Pulmonary embolism:
5. Haemorrhoids:

208. Maternal health 208
Breast problems:
1. Breast engorgement:
• Ultrasound to the periphery of breast
and then moving towards nipple.
• Warm compresses or crushed ice
packs help in pain relief.
• PEME can help.

209. Maternal health 209
2. Sore and cracked nipples:
• It is suggested that symptoms are
directly related to the position of baby
on breasts.
• Position of baby: facing mother’s body
with neck slightly extended, mouth
well open with lower lip curled down
and nipple extending till palate

210. Maternal health 210
Fatigue:
• Though normal symptom, is
overwhelming in early days.
• Mother usually ‘running’ on adrenaline
high for first 2 or 3 days.
• Had a long or difficult labour.
• Assure her that it is normal
occurrence and can be dealt with rest.

211. Maternal health 211
Advice:
• Rest and sleep when baby sleeps.
• Ask the partner or friend to take baby for
long walk, mother can catch up on sleep.
• Go to bed after early evening feed and
wake up with baby
• Prioratise household duties.

212. Maternal health 212
Psychological symptoms:
Three common manifestations:
1. Maternity blues:
• Occur in first 2 to 3 weeks.
• Mother is weepy, anxious and agitated.
• Sore perineum, uncomfortable breasts, fatigue
aggravate the condition.
• Mother’s response to baby changes.
• 25% of mothers with severe postnatal blues
may develop PND

213. Maternal health 213
2. Puerperal psychosis:
• More severe condition.
• Mother lose contact with reality, have
delusions, mood swings, anxiety,
agitation.
• Suicidal and infanticidal thoughts may
occur.
• High likelihood of recurrence in
following pregnancy.

214. Maternal health 214
3. Postnatal depression:
• Begin early in postpartum period.
• Mother sad, depressed, worry for
herself and baby.
• In severe PND, mother feel suicidal.
• Hormonal, neuroendocrine and even
social factors may play part in above
problems.

215. Sexual problems
• Loss of libido
• Discomfort and pain in perineum
Maternal health 215

216. Maternal health 216
Caesarean section
Between 1997/8 and 2000/01 caesarean rate has
increased from 18.2% to 21.5%.
Surgical approach: transversely through lower
uterine segment- LSCS
Can be elective or emergency.
Performed using spinal or epidural anaesthesia.

217. Maternal health 217
Danish research 1998 shows 86%
women opt for epidural anaesthesia.
Indications for caesarean section:
Elective CS:
CPD
Placenta praevia
Malpresentation (breech, unstable lie)
Previous CS
Active genital herpes

218. Maternal health 218
Pre-eclampsia and eclampsia
Multiple births
Low birth weight
Emergency CS
Obstructed labour
Foetal & maternal distress
Ante partum haemorrhage
Placental abruption

219. Maternal health 219
Prolapsed cord
Failed trial of forceps
Failed trial of previous CS scar.

220. Maternal health 220
Physiotherapy management:
Pre-operative:
Discussions to minimize negative
feelings about surgery. Videos or
pictures can help.
Mobilization tech.: helpful post
operatively should be taught.
Use of Abdominal supports to control
floppy abdomen post-surgically can
be taught.

221. Maternal health 221
Post operative management:
Supervised programme should be started
within first 24hrs.
• Active assisted and active movt of limbs.
• Encourage movt around bed, using crook
lying, bottom lift techniques.
• Encourage deep breathing exs.
• Gentle exs, like crook lying: pelvic rock,
knee rolls from side to side, gluteal
contractions, PFM exs

222. Maternal health 222
Ambulation can be started when
permitted with abdominal support.
Demonstrate in and out of bed and
chair techniques.
Feeding: proper guarding techniques
should be taught.
eg: tucking the baby’s feet under the
arm, positioning pillows to protect
wound.

223. Maternal health 223
Wound healing:
Expose wound to air, keep area dry.
PEME can be used, to relieve pain,
improve circulation and healing.

224. Maternal health 224
Post operative problems:
1. Respiratory problems:
Deep breathing, huffing , coughing
would help.
Support the abdomen with towel binder.
Abdominal and pelvic floor sustained
contractions are encouraged during
expulsive effort.

225. Maternal health 225
2. Excessive abdominal pain:
Following conditions will increase pain
around CS site.
• Wound infection
• Haematoma: therapeutic ultrasound
accelerate resolution.
• Excessive localised oedema
• Nerve entrapment syndrome:
illioinguinal or iliohypogastric nerve
entrapment syndrome:

226. Maternal health 226
3. Wind pain:
Severe intermittent colic type of pain.
• Deep breathing
• Drawing in of abdomen
• Early ambulatuion
• Massage in clockwise direction
along line of colon
• Heating pads.

227. Maternal health 227
4. DVT & PE:
Pelvic surgeries are associated with highest
incidence of DVT( Gray et al 1992)
Prevention:
Application of stockings
Early mobilization
Avoid sitting with knees acutely flexed
Lower limb movements, deep breathing exs

228. Maternal health 228
Treatment:
Anticoagulant therapy.
Antiembolic stocking
5. Back pain:
6. Dependent edema:

229. Maternal health 229
Urinary dysfunction
Lower urinary tract dysfunction:
ICS divides LUTS into 3 main groups:
Storage,voiding and post micturation symptoms.
a) Storage: eg: abnormal bladder sensations,
frequency, urgency and leakage of urine

230. Maternal health 230
b) Voiding: deviation from speedy and
continous flow of urine. Eg: slow or
intermittent stream, hesitancy,
terminal dribble.
c) postmicturation: eg:feeling of
incomplete emptying.

231. Maternal health 231
Common types of urinary incontinence
Main groups of patients referred to physiotherapist are
those with storage symptoms.
1. Extraurethral incontinence:
loss of urine through channels other than urethra.
May be due to congenital abnormality.eg:aberrant ureter
draining into vaginal vault

232. Maternal health 232
Fistula between bladder or urethra and
vagina due to trauma at pelvic
surgery like hysterectomy.
Management: usually require surgery.
2. Detrusor overactivity incontinence:
Symptom: urge incontinence,which is
involuntary leakage of urine
accompanied by or preceded by
urgency

233. Maternal health 233
Sign: overactivity observed at
urodynamic assessment as provoked
detrusor contractions during filling
phase.
Condition: may be neurogenic or
idiopathic,due to infections.
Management:
Removal of cause if possible.
Pharmacotherapy.

234. Maternal health 234
Exercises to strengthen PFM.
Bladder training to regain confidence
Alternative therapy to
pharmacotherapy,is continous E.S
with pulse duration 500microsec at 5-
10 Hz for 20-30mins.

235. Maternal health 235
3. Urodynamic stress incontinence:
Symptom: incontinence when
intraabdominal pressure is raised by
exertion
Sign: involuntary spurt, dribble or
droplet of urine observed to leave
urethra on increase in intraabdominal
pressue. Test should be conducted in
standing also.

236. Maternal health 236
Condition: could be due to incompetent
closure mechanism of urethra.
associated with bladder neck
hypermobility.
detrusor overactivity frequently
coexist.
USI often associated with urgency and
frequency.

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Prolapse of bladder and urethra
possibly due to loss of pinchcock
effect may cause USI.
Weakness can result from any of the
following:
a)Trauma to muscle or adjacent tissues
b) Damage to the nerve supply to
sphincter or levator ani.
c) Weakness from underuse.
d) Stretching from overuse

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Management:
Can be treated conservatively or
surgically.
For conservative treatment, voluntary
contractions of PFM. i.e. intense
rehabilitation
Those with weak PFM,biofeedback with
or without E.S can be used.

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Nocturnal enuresis
Urinary incontinence during sleep.
It affects 15-20% of 5yr old children and upto
2% adults.
Management:
Reward charts, scheduled awkening can be
tried.
Various alarm systems can be used.
Antidiuretic drugs may be prescribed eg:
desmopressin.
PFM contractions,it may have inhibitory effect
on detruser.

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Giggle incontinence:
Generally seen in girls around puberty.
Positive family history.
Caused by detrusor overactivity
induced by laughter (Chandra et al
2002)
Management:
PFM exs regularly.
Develop the habit of contracting these
muscles while giggling.

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Functional incontinence:
Involuntary loss of urine due to deficit in
ability to perform toileting functions
secondary to physical or mental conditions.
Physiotherapist in collaboration with
occupational therapists can help such
patients.
eg: arranging for easily accessible toilets,
solutions for obstacles like heavy doors,
insufficient turning space, etc.
Time voiding technique may help.

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Voiding difficulties:
Causes:
Due to faecal impaction
Large cystocele kinking the urethra.
Urethral dyssynergia, as in multiple
sclerosis.
Neurological damage affecting pelvic
innervation eg: diabetic neuropathy
Detruser atonia as in cauda equina
lesions

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Assessment:
By uroflowmetry.
Management:
Removal of cause.
Faecal impaction can be treated by diet and
bowel training.
Weak detrusor activity can be enhanced by
drugs like bethanechol chloride.
In neurological cases,intermittent self
catheterization may be taught or
suprapubic catheter implanted.

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Physiotherapy assessment methods
Assessment in quite private room.
History of the patient’s condition:
Present and past history.
Two things worth remembering:

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Urinalysis:
Reagent strips.
Within one hour,strip dipped into
specimen of urine.
Change in colour acc to abnormal urine
content.
PTs need official training in reading
strips.

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Frequency / volume chart:
Patient asked to Note the time of the
day and measure vol of urine voided
each time.
From chart it is possible to determine,
• Actual freq of micturation
• Precise degree of nocturia
• Altered diurnal variation
• Total vol voided per 24hrs
• Incidence of urinary accidents.

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Pad test:
Test approved by ICS, takes 1 hour
1. Test started without patient voiding
2. Preweighed perineal pad is put on
and timing begins
3. Patient drinks 500ml of sodium free
liquod within 15 mins
4. Following half hour patient walks,
climbs stairs, perform exs like
standing from sitting, coughing,
running, bending down,etc

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At the end of hour, pad is weighed, any
difference is recorded.
Increase of upto 1gm is considered
normal.

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Paper towel test:
Researched by Miller et al 1998.
Patient holds coloured paper towel
against perinium and coughs 3 times.
Assessment of amount of leakage
measured by weighing or measuring
area of dampness.

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Perineal and vaginal assessment:
RCOG(2002) and ACA(2003) has
published guidelines for intimate
examinations.
PT are strongly advised to study all
these guidelines and undertake
specialist practical training from an
expert.

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Explanation of the examination
procedure and purpose is given to the
woman.
Written consent taken.
Universal precautions should be
taken.
Position of woman: crook lying with
hips abducted and feet apart.

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Internal examination:
1. Observe the perineum:
2. Apply lubricant to gloved index
finger.
3. Gently slide palmar surface of finger
along posterior vaginal wall. Check
for rectocele
4. Ask the patient to ‘draw in strongly
and lift up towards head’
5. Feel the anterior shift.that is
puborectalis. Assess the strength.

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6. Palpate laterally, in region of 3-4 or
8-9 o’clock. Ask the patient to draw in.
medial shift felt is pubococcygeus.
Assess the strength and endurance.
7. Feel the anterior vaginal wall. Check
for cystocoele.
8. Check for superficial perineal
muscles.
Avoid examination during menstruation
and untill postpastum loss has
ceased.

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Manual grading of strength of PFM
contraction:
Six point scale modelled on oxford
scale:
1. Flicker
2. Weak
3. Moderate
4. Good
5. Strong.

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Laycock & Jerwood(2001) validated the
‘PERFECT’ scheme where by:
P: power,
E: endurance’
R: repititions
F: fast
ECT: i.e. ‘every comtraction timed’ to
complete acronym.

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Thirteen ways of confirming PFM
contraction:
1. Vaginal Ex by PT
2. Self- Ex by pt
3. Hand on perinium by PT
4. Hand on perinium by pt
5. Observation by PT
6. Observation by pt
7. perineometer

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8. Stop and start midstream
9. Using Neem healthcare ‘Educator’
10.Using vaginal cones
11.Asking partner at intercourse
12.Manometric and EMG biofeedback
13.Transperineal or labial ultrasound.

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Biofeedback:
For PFM, proprioceptive tech of touch,
stretch, pressure and verbal
encouragement can be used during
digital assessment.
Following may also be available in
assessment:
a) perineometer:
Record changes in activity in region of
vagina.

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Two types:
1) Recording pressure changes
2) Monitoring EMG activity.
Most commonly used is Peritron.

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The Educator
Simple device inserted in vagina.
Voluntary contraction cause indicator to
move downwards.
Upward movt indicates ‘Valsalva
manoevre’

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Computerised manometric and
electromyographic equipment
For manometry: vaginal probe is used
For EMG: two electrodes are mounted
on vaginal probe
Signals are produced and relayed on
VDU.
Can be used in assessment, treatment
and monitor patient progress.

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Quality of life questionares:
King’s health questionare,validated and
specific for urinary incontinence.
Takes 30mins.
ICIQ: international consultation on
incontinence questionnaire in its short
form has just 6 ques and is validated.

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VAS:
10cm line.
One end suggests ‘no leakage’ and
other end ‘always wet’.
Imaging ultrasound scanning of
bladder:
Small portable ultrasound scanner to
scan bladder and calculate volume of
urine.

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Post void residual of less than 100ml is
normal.
It has been used transvaginally with
probe and transperineally or
translabially.

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Electrophysiological tests:
1. Electromyography:
Single needle EMG has been used to
examine peborectalis and external
anal sphincter.
Fine needle inserted and MUAP are
recorded.
Single fiber density: normal FD in
puborectalis and anal sphincter is
1.5

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20 recordings during mild contraction in
various parts of muscle are taken
and mean counted.
2. Motor conduction tests:
a) Pudendal nerve terminal motor
latency:
Intrarectal stimulating and recording
device introduced into anus and
record the response of EAS muscle.

268. Maternal health 268
Latency measured and recorded.
b) Perineal nerve terminal motor latency:
Similar test using catheter mounted recording
electrode in urethra
c) Central motor conduction times:
By stimulating motor cortex,record stimulus
from pelvic floor. Eg:in multiple sclerosis.

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Physiotherapy treatment
For the pts with stress urinary incontinence:
If no VPFMC is possible then biofeedback and ES
should be considered.
If VPFMC is possible then pts should be taught ‘the
knack’
For ES: pulse duration-250 microsec, frequency- 30-
40 Hz, for 10-20 mins.

270. Maternal health 270
Vaginal electrodes is used and pt is told
to join in.
For pts with urge incontinence:
Series of repeated strong PFM,perineal
pressure and encouraged to desist
from going ‘to loo just in case’ to
increase period between voids.
For ES: freq- 5-10 Hz, pulse duration-
500 microsec, for 20-30 mins.

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Teaching PFM contractions:
Teaching points:
1. Visualisation:
2. Language:
3. Starting position:
4. Example of instruction to patient:
instructions for all the three
passages.

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5. Duration and repetition:
Long, strong contractions one after
other with rest of about 4 secs, each
held as long as possible. Record
length of hold and no. of repetitions
Short, sharp quick contractions until
fatigued, no. is recorded.
6. Change of starting posititions:
7. General advice: ‘the knack’

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Biofeedback:
Two types of equipment:
For clinic use and home use.
1. Manometry:
With vaginal pressure probe and
feedback by means of manometer
or visual display.
a) Computerised manometric
equipment:

274. Maternal health 274
Display is shown on VDU screen.
b) Perineometer:
c) Hand held devices: manometric hand
held devices for home.
2. electromyography:
Computerised EMG equipment:
Vaginal electrode is used.
Periform is popular because of its
ellipsoid shape.

275. Maternal health 275
3. other:
a) Vaginal cones:
Progressively weighted cylinders,
ranging from 10 to 100g
Each cone has the nylon string
attached.
Selecting appropriate cone:
Lightest cone inserted in semiquatting
or half lying position.

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Patient stands and walks around, if
retained for 1min, pt progress to next
cone.
Heaviest cone retained for 1min is used
for exs.
Treatment sessions:
Twice a day.
Pt inserts the cone and walks around
for up to 15mins.
Over time, coughing and other activities
introduced.

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Electrical stimulation:
Used for two purpose:
a) To produce muscle contraction
b) To utilise sensory stimulation to
inhibit detrusor overactivity.
IFT, medium freq currents was used
extensively for urinary incontinence.
Incrasing use of biofeedback has made
it less popular.

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Bladder retraining:
Described by Jeffcoate & Francis.
Main aims are:
• Correct faulty habits
• Control urgency
• Prolong periods between voids
• Reduce incontinence episodes
• Reduce daily no. of voids and
increase void vol.
• Build pt’s confidence

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Timed and prompted voiding:
A routine of toileting times is set.

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Bowel and anorectal dysfunction
Two main categories:
a) Difficulty in evacuating faecal material.
Eg:constipation
b) Inability to store faecal material. Eg: diarrhoea,
soiling

281. Maternal health 281
Factors contributing to difficulties in
defaecation:
1. Abnormal defaecation techniques:
Uncoordinated defaecation pattern:
failure of anal relaxation with
lowered levator ani.
Intensive abdominal training may lead
to rigid abdominal wall.
Position of anus at rest:
descending perinium syndrome:

282. Maternal health 282
2. abuse:
Can lead to anismus, paradoxical
puborectalis contraction and pelvic
floor dyssynergia on attempted
defaecation.
3. Eating disorders:
In patients with anorexia nervosa, binge
eaters.
4. Food And drink:

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5. Ignoring call to stool.
6. Irritable bowel syndrome:
Divided into,
Spastic constipation having abdominal
pain
Painless diarrhoea complaining of stool
frequency.

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7. Megacolon and megarectum:
Megacolo: dilated segment with normal
phasic contractility but decreased
tone
Megarectum: incresaed compliance
with maximal tolerable volume.
8. menstruation:
9. Neurological conditions:

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10.Pain with anal fissure:
11.Pregnancy and postpartum:
12.Prolapse:
13.Psychiatric disorders:

286. Maternal health 286
Factors contributing to anal
incontinence:
a) age:
b) Anal sphincter dysfunction:
Childbirth: physical damage to ext or int
anal sphincter, due to perineal tear
extending upto anus.
Surgery:
Accidents:

287. Trauma: to the anal sphincters, tears,
episiotomy, traction on pudendal
nerve during childbirth.
Habitual chronic straining at stool:
can cause descending perineal
syndrome.
Maternal health 287

288. Physiotherapy assessment of faecal
incontinence:
1) History
Bowel habit diary should be adviced
prior to starting treatment.
Food diary should also be adviced.
Any past history of obs, gynaec, urinary
symptoms, drugs, psychological.
Maternal health 288

289. Physical Ex:
Inspection of lower back: may reveal
spina bifida oculta
Abdominal examination:
Neurological assessment:
dermatomes: i.e. S2,S3,S4
Myotomes of lower limbs.
Anorectal Ex: in side lying, with pt’s
prior consent.
Maternal health 289

290. Anorectal Ex:
a) Visual assessment
b) Perineal Ex:
c) Internal Ex:
Introduction:
Puborectalis:
Anal sphincter:
Maternal health 290

291. Investigations:
1. Anorectal manometry:
It includes,
a) Resting anal canal pressure
b) Anal canal squeeze pressure
c) Pressure during cough and
defeacation
d) Sensory threshold in response to
balloon distention
Maternal health 291

292. 2. Colonic transit studies:
Ingestion of radio opaque different
shape and sized markers, followed
by abdominal X-rays on several days
afterwrads. Cannot be done in
pregnancy.
3. Concentric needle EMG:
For EAS and puborectalis
Maternal health 292

293. 4. Defaecating proctogram:
Barium paste is introduced and
evacuation observed during
radiography.
5. Endoanal ultrasonagraphy:
360 degrees rotating transducer
introduced in anal canal, gain image
of both IAS and EAS.
Maternal health 293

294. 6. Pudendal nerve terminal motor
latency:
Special device placed inra-rectally.
Two electrodes: one at tip, one at the
level of anal sphincter.
Activity on anal sphincter is recorded.
Normal: less than 2.2ms
Nerve damage: longer than that.
Maternal health 294

295. 7. Strength duration curve:
Of EAS. Significantly correlates with
other diagnostic measures.
Maternal health 295

296. Treatment
Diet
Bowel retraining:
Toiletting 20-30 mins after meal, to utilize gastrocolic
response.
Four stage holding programme for bowel urgency and
frequency.
Maternal health 296

297. Medications:
Physiotherapy for bowel dysfunction:
1) Effective defeacation techniques:
Proper posture
Breathing patterns: diaphragmatic
Abdominal activity during defaecation:
brace and bulge
Pelvic floor activity during bearing
down: anal relaxation with rectal
support
Maternal health 297

298. 2. Anal sphincter exercise:
Technique: pt sitting on chair
It include strong hold oof maximal
length, longer contractions of half the
maximum hold for endurance and
finally fast contractions.
3. biofeedback:
Via anal pressure probe or EMG
electrodes.
Maternal health 298

299. a) constipation:
Place small electrodes around anal
sphincter at 2 o’clock & 10 o’clock
position.
Ask to observe both contraction and
relaxation of sphincter.
b) Faecal incontinence:
Norton et al 2002 investigated on 4
groups.
Biofeedback and exs help patients with
faecal incontinence.
Maternal health 299

300. 4. Massage for constipation:
Contraindications: cancer of bowel, any
abdominal herniation, recent
abdominal surgery or scarring.
Technique:
5 part tech,
a) Stroking from stomach to groin for
relaxation
b) Effluerage along colon
c) Circular kneeding in same direction
Maternal health 300

301. d) More effleurage
e) Side to side stroking across
abdominal wall.
5. Neuromuscular stimulation:
Anal electrode should be used.
Freq: 35-40 Hz
Pulse duration: 250 microsec.
Maternal health 301

302. 6. Rectal sensitivity training:
Simple device: rectal balloon attached
to a plastic tube with three way tap to
enable air to be introduced is
introduced.
Importance of slow and fast distension.
7. Anal plugs:
Disposable anal plugs are inserted in
upper part of canal. Useful on
occassional basis.
Maternal health 302

303. Maternal health 303