Physical Therapy for Women's Health - 4th Year Students SVU

4. -Antenatal care (ANC) can be defined as the
care provided by skilled health-care professionals to
pregnant women in order to ensure the best health
conditions for both mother and baby during pregnancy.
The components of ANC nay include the following : risk
identification, prevention and management of pregnancy-
related or concurrent diseases, health education and health
promotion.
-Antenatal care (ANC) reduces maternal & fetal
morbidity and mortality both directly, through detection
and treatment of pregnancy-related complications, and
indirectly, through the identification of women at increased
risk of developing complications during labor and delivery.

5. -The principles of ANC for women with
uncomplicated pregnancies are:
*To provide advice, education, reassurance and
support.
*To provide effective screening during the
pregnancy.
*To address and treat the minor problems of
pregnancy

6. The main objectives of antenatal care are:
1)Maintenance of health of mother during pregnancy.
2)Identification of high-risk cases and appropriate management.
3)Detection of malpresentations, malpositions and disproportion that influence labor decision.
4)Decrease maternal and infant mortality and morbidity and prevention of complications.
5)Remove the stress and worries of the mother regarding the delivery process.
6)Teach the mother about childcare, nutrition, hygiene and warning sings .
7)Advice about family planning.

7. -Diagnosis of pregnancy requires a multifaceted approach
using 3 main diagnostic tools, These are:
1) History and physical examination:
*Personal, Present, Past, Family and Obstetric history.
*General, Abdominal, Auscultation of fetal heart sounds
and local examination if needed.
2) Laboratory evaluation:
*Serum B-hCG are positive if more than 50 mIU/ml at the 1st day
of the missed period and it is superior to urine pregnancy test.
3) Ultrasonography:
*Diagnosis of pregnancy as early as 5 weeks by TVS and
6 weeks by TAS and it can determine placental location and amniotic fluid volume.

8. -Frequency of antenatal visits:
*Every month during the first 6 months.
*Every 2 weeks during the 7th and 8th months.
*Every week during the last month.
*More frequent visits are indicated in high-risk pregnancy.
-The Preconception visit:
*for health education and risk assessment , advices regarding the avoidance of harmful and
teratogenic factors (alcohol, smoking and drugs) and control of chronic medical disorders.
-The First Antenatal visit:
This visit should occur as soon as the woman thinks she is pregnant, no later than the fourth
month of pregnancy.
*Naegele's rule is a standard way of calculating the due date for a pregnancy when
assuming a gestational age of 280 days (40 weeks) at childbirth.
*Naegele’s rule estimates the expected date of delivery (EDD) = Date of first day of Last
Menstrual Period + 9 Calendar Months + 7 days.

9. -Complete history is taken.
-A physical examination is done by a midwife, nurse,
physiotherapist or obstetrician ,who:
*Measures height and weight
*Measures blood pressure
*Examines the entire body
-Certain tests are done using samples of:
*Blood (blood group, Rh typing, Glucose and Hb%) &Urine.
-Certain medicines may be given, including:
*Iron tablets (to prevent anaemia)
*Anti-malaria tablets
*An injection to prevent tetanus
-Appropriate health education and counselling is provided ,
depending on the stage of pregnancy
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10. -LATER VISITS:
At least 3 or 4 additional visits should be made .
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-A short physical examination is done that includes:
*Auscultation of the fetal heart sounds
*Checking weight gain
*Measuring blood pressure
*Assessment of the fundal level and lower limb edema
*Checking on the lie of the baby
-Appropriate health education and counselling dedivorp si
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depending on the stage of pregnancy
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health and history (the advice may change during the
pregnancy, based on whether problems are treated, or new ones develop(

11. Warning Signs of possible pregnancy complications?
-Certain signs should be reported to the healthcare provider right away
during any stage of the pregnancy. These include the following:
*Bleeding or leaking fluid from the vagina
*Dizziness or Blurred vision
*Frequent, severe, and/or constant headaches
*Regular menstrual like colicky Contractions,
before 37 weeks that happen every 10 minutes or more
*Decrease in baby's movements after 28 weeks
*Excessive vomiting and diarrhea
*Fever or painful urination
*Marked Swelling of face, fingers, and feet
*Muscular convulsions

13. Guidelines for Exercises:
*Following instructions of healthcare team providers.
*Encourage complete bladder emptying before exercise to
reduce stress on pelvic floor.
*Drinking a lot of fluids before ,during and after exercises.
*Wearing lose comfortable clothing and supportive shoes.
*Exercising in well ventilated area with enough rest intervals.
*Starting with proper warm up and cool down.
*Avoidance of overwork & contact sports.
*Limit activities in which single-leg weight bearing, in
addition to possible loss of balance, these activities can promote
sacroiliac or pubic symphysis discomfort.
*Avoid overstretching especially hamstrings and hip adductors.
*Termination of exercises when needed.

14. Effects of Sedentary Lifestyle During Pregnancy
*Significant health risk of deep venous thrombosis which threatens
the lives of the infant and mother.
*Can lead to obesity which may contributes to these complications:-
-More likely to suffer spontaneous abortions.
-Higher risk of neural tube defects which include cleft palate,
spina bifida and hydrocephalus.
-At risk for gestational diabetes, preeclampsia, sleep apnea, macrosomia,
preterm birth and even stillbirth (the higher the women's BMI, the greater the risk).

15. What are the benefits of exercise during pregnancy?
*Reduces back pain
*Eases constipation and more relaxation
*May decrease the risk of gestational diabetes,
preeclampsia and cesarean delivery
*Promotes healthy weight gain during pregnancy
*Improves overall general health
*Enhance cardiopulmonary fitness

16. Role of physiotherapist during pregnancy
1)Assess and identify any neuromusculoskeletal problems:
that may be associated with pregnancy such as:
*Mechanical Back pain and sciatica
*Pelvic floor dysfunctions
*Rectus diastasis
*Sacroiliac joint dysfunctions
*Osteitis pubis
*Carpal tunnel syndrome
*Dequervain tenosynovitis
*Chondromalacia patellae
*Cervicogenic headache
*Hamstring strain
*Thoracic outlet syndrome

17. 2) Advise on postural correction and ergonomic consideration:
*Lifting, Bending and Carrying
1. Bend the hips and knees to lower the body, avoid stooping forward
the spine, to lift weights then use hip and knee extensors to stand up.
2. Avoid holding breath and slightly put one-foot in front of the other.
3. Get as close to the object as possible and carry approximately equal weights on both hands.
4. Always keep the back as straight as possible.
5. Avoid twisting the spine while carrying a load.
6. Contract the transversus abdominis and pelvic floor muscles.

18. Using kneeling chair is very important during sitting to avoid pressure on
enlarged uterus

19. 3) Treat any neuromusculoskeletal problems: that may be associated with pregnancy
such as:
*Back Pain, sciatica, Sacroiliac and Symphysis pubis dysfunctions:
-Grade 1&2 modified PA mobilization from side lying position or
sitting with upper limbs supported on treatment table with lower
limbs apart to avoid abdominal pressure, But
Manipulation is contraindicated during pregnancy. “Given the hormonal and
the coagulability status of peripartum and postpartum individuals, it is possible that SMT is a
contraindication to the musculoskeletal complaints associated with pregnancy”
(Stuber et al., 2012).
-Myofascial release techniques
-Postural correction techniques

20. -Posterior Pelvic rocking exercises
-Hot packs for 15-30 min.
-Sciatic N. mobilization from side lying
-Core stability exercises
-Maternal pregnancy supporting belt
-Kinesiotaping
-Gentle stretching& strengthening exercises
-Muscle energy techniques from side lying

22. *Pelvic floor Training:
- Kegel exercises
- Cyriax method
- Cross sitting positioning
-
- Pelvic floor training with wall squat
-
-Avoid electrical stimulation on the
pelvic floor during pregnancy.

23. *Rectus diastasis rehabilitation:
1) Kinesio tape
2) Core stability exercises:
- TA breathing
- Side plank
- Side lying leg lift
- Dead bug crunches
- Scissor kicks
- Heel slides

25. Exercises NOT suitable for Diastasis recti
1) All frontal planks
2) All crunches
3) Push ups
4) Sit ups
5) Twisting movements
6) Quadruped exercises

26. Safe abdominal exercises during pregnancy
(Without Diastasis Recti)
-Sitting knee lift
-Hip hiking
-Side lying crunches
-Core breath
-Standing pelvic tilt
-Seated ball stability hold
-Side plank
-Standing crunches
-Standing bicycles
-Bird dog

27. Safety Measures While Performing Abdominal Exercises
during Pregnancy
*During the first trimester, static exercises for a longer time by
increasing the number of repetitions in a comfortable manner.
*In the second and third trimesters, reduction of the intensity of exercises and avoid
any exercises that put pressure on abdominal area or involve abrupt movements.
*Do not do exercises in a supine or crock lying position after
the first trimester and if these positions are desirable to pregnant
woman, the therapist should put a towel under the Rt pelvis.
*Also, before beginning Abdominal exercises, assessment of diastasis recti is very
critical as some positions may not be suitable in this case.

28. *Carpal tunnel syndrome, Chondromalacia patella and De quervain’s tenosynovitis:
1) Therapeutic ultrasound
2) Low level laser therapy (LLLT)
3) Deep transverse friction (DTF)
4) Stretching and nerve gliding techniques
5) Gradual strengthening exercises
6) Kinesio tape and orthotics
7) Ergonomic consideration

29. *Upper & Lower crossed syndromes:
1)Postural correction exercises
2)Gentle stretching exercises
3)Gradual strengthening exercises
4)Muscle energy techniques (METs)
5)Kinesio tape
6)Ergonomic consideration

30. *Balance Problems and Risk of Fall:
-Pregnancy involves a series of changes to the soft tissues and joints, as well as to posture
and gait.
-Postural balance is best described as the ability to maintain the
body’s center of gravity (COG) within the area of support provided
by the feet (Base of Support).
1)Modified Strengthening exercises: for hip extensors,
hip abductors, knee extensors, ankle planter flexors and core muscles
2)Proprioceptive training:
-Tandem walk
-Static and dynamic ball balance exercises

31. 4) Teach methods for controlling stress and tension associated with pregnancy:
-Increase awareness of physiological changes associated with pregnancy and reassurance
through antenatal classes
-Relaxation training
-Positioning
-Breathing exercises
-Yoga

32. 5) Teach positions that may be used for labor:
- Squatting
- Lithotomy
- Prone kneeling (Quadruped)
- Sitting
- Side lying
- Lunging
- Kneeling

33. The Lamaze technique
(The psychoprophylactic method)
-The goal of Lamaze is to build a mother's confidence in her ability to
give birth, through the presentation of classes that help expectant mothers
understand how to cope with pain in ways that both facilitate labor and
promote comfort by providing current and evidence-based information.
-Building confidence, teaching childbirth coping mechanisms,
including relaxation techniques, movement and positions, soft tissue
mobilization, aromatherapy, hot and cold packs, breathing techniques,
the use of a "birth ball", spontaneous pushing, upright positions for
labor, breastfeeding techniques, and keeping mother and baby together
after childbirth.

34. -Each class has a specific curriculum that includes learning about common medical
interventions and pain relief such as an epidural in an evidence based, non-biased manner.
The 6 Healthy Birth Practices of Lamaze
-Practice 1: Let labor begin on its own
-Practice 2: Walk, move around and change positions throughout labor
-Practice 3: Bring a loved husband or doula for continuous support
-Practice 4: Avoid interventions that are not medically necessary
-Practice 5: Avoid giving birth in supine lying and follow the body's urges to push
-Practice 6: Keep mother and baby together – It's best for mother, baby and breastfeeding

35. Model of physical therapy program
for normal pregnant women in Antenatal classes
1) Through the first trimester:
*Instructions about anatomy and physiology of pre pregnant and
pregnant women and giving advice regarding to pregnancy
*Pelvic floor exercises
*Gentle static abdominal exercises
*TENS for hyperemesis gravidarum
2) From 4th to 6th month:
*Monitoring of any abnormal pregnancy signs or symptoms
*Breathing exercises (Deep diaphragmatic)
*Relaxation training
*Pelvic floor exercises
*Postural correction
*Safe core exercises
*Management of different neuromusculoskeletal disorders using safe protocols

36. 3) From 6th to 8th month:
*Breathing exercises (Deep diaphragmatic)
*Relaxation training
*Pelvic floor exercises
*Postural correction
*Safe core exercises
*Management of different neuromusculoskeletal disorders using safe protocols
*Pelvic rocking ( upward and backward)
*Arm exercises and Circulatory exercises
*Reassurance
4) During the 9th month:
*Instructions about onset and stages of labor
*Advice on walking in open fresh environment
*Concentration on Pelvic floor elasticity and strength
*Psych prophylactic method (Lamaze technique)
*Positional training for labor positions
*Breathing exercises (Panting breathing)
*Explanation of role of TENS to relieve labor pain

37. Important advice regarding to pregnancy
1) exercises:
-The pregnant women should avoid vigorous exercises and
highly contact sports.
-Exercises should be prescribed by a specialized physiotherapist
in women’s health and should be guided by safety measures.
2) Travelling:
-Avoid travelling on bumpy roads and for long distance.
-Travelling must be restricted after the 36th week of gestation and if there is history of
habitual abortions, Travelling must be restricted through any gestational age.

38. 2) Sleeping and rest:
-Sleep at least 7-8 hours at night and relax or sleep for 1-2 hours
every afternoon.
-Not less than 6 hours (increased risk for preeclampsia &4.5 times
likely to have cesarean section).
-Not more than 10 hours (increased risk of still birth and prolonged
labor).
-The best pregnant sleeping position is side lying on left.
-Avoid prone lying (risk of intrauterine fetal death ) also, avoid
supine lying (risk of vena cava syndrome, low birth weight and
hemorrhoids).

39. 4) Bowel habits:
-The pregnant women should avoid constipation through:-
-Regular aerobic, pelvic floor exercises, eating fruits and vegetables that
are rich in fibers and drinking 2-3 liters of water to avoid dehydration.
5) Intercourse:
-Intercourse should be avoided during
the first trimester ( fear of abortion).
-Avoid intercourse during the 8-9th month ( fear of ascending infection).
-If there is history of habitual abortions, Intercourse must be restricted through any
gestational age.

40. 6) Nutrition:
-Normal requirements during pregnancy:
About 1,800 calories per day during the first trimester
About 2,200 calories per day during the second trimester
About 2,400 calories per day during the third trimester
-Additional calories should come from nutrient-dense foods
including lean protein, whole grains, low-fat, vegetables and fruit.
-Folic acid (400µg) should be commenced as early as possible (ideally before conception)
to prevent neural tube defects. also, Pregnant women likely have an increased need for
essential omega-3 fatty acids.
-Daily iron requirements are 30 mg to 60 mg of elemental iron, calcium (1000-1500 mg)
and Vitamin D (400-600 IU).

41. Some Allowed Electrophysical Agents
during Pregnancy
-Superficial moist heat is allowed
while cold application should be done with precautions.
-Acupuncture Not Electroacupuncture at forbidden points including: SP6 or LI4
does not induce miscarriage or expulsion of the fetus and is not associated with increased
rates of adverse pregnancy outcome in observational studies of healthy pregnant women.
-Kinesiotaping can be used as a complementary treatment method to achieve effective
control of low back pain and other pregnancy-related neuromusculoskeletal disorders .

42. Transcutaneous Electrical Nerve Stimulation
(TENS)
-TENS is an effective and safe treatment modality for LBP during
Pregnancy, High frequency (Conventional TENS)120 Hz
and duration of 100 µs. improved LBP more effectively than did
exercise and acetaminophen (Keskin et al., 2012).
-High frequency (Conventional TENS) 80 -120 Hz is a safe therapy for low back
and/or pelvic girdle pain in the last trimester of pregnancy with no side effects, low costs
and the possibility of home application (Quittan et al., 2016).
-Avoid Low frequency (Acupuncture like TENS) during pregnancy as it can induce
strong uterine contractions.

43. Some Contraindicated Electrophysical Agents
during Pregnancy
-If the patient is pregnant, the modalities to completely Avoid
(anywhere) are shortwave, pulsed shortwave and microwave therapies.
-Ultrasound and laser therapy are to be avoided locally (so that the applied energy does
not reach the fetus)
-Electrical stimulation modalities as Russian and Interferential Current (IFC) are
generally considered best avoided in the ( lower trunk, lower abdominal and pelvis )
during pregnancy fear of induced uterine contractions.

44. Absolute Contraindications for exercises
during pregnancy
*Eclampsia *Premature labor
*Persistent vaginal bleeding *Ruptured membranes
*Placenta previa after 28 weeks’ gestation *Uncontrolled hypertension
*High-order multiple pregnancy (e.g., triplets) *Uncontrolled thyroid disease
*Incompetent cervix or current cerclage *Uncontrolled type I diabetes
*Other serious cardiovascular, respiratory or systemic disorder

45. Relative Contraindications for exercises
during pregnancy
*Severe anemia *Chronic bronchitis
*Recurrent pregnancy loss *Extreme underweight
*Heavy smoker *Orthopedic limitations
*Poorly controlled hypertension *Poorly controlled seizures
*History of extremely sedentary *Poorly controlled hyperthyroidism
*Twin pregnancy after the 28th week *Intrauterine growth restriction in current pregnancy

46. High-Risk Pregnancy
• Pregnancy Induced Hypertension
• Pre- eclampsia
• Gestational Diabetes
• Multiple Gestations
• Very young (under 17 years old)
• Old maternal age (above 35 years old)
• Sever anemia
• Cardiac disorders
• Bronchial asthma
• Premature Labor
• Premature Rupture of Membranes
• Incompetent Cervix
• Placenta Previa

47. The primary indications for treatment in this patient population are related
to the effects of prolonged bed rest
• The physiologic effects of diminished mobility due to bed rest include:
- General deconditioning
- Muscle atrophy
- Joint stiffness
- Risk for thrombus formation
- Risk for orthostatic hypotension
- Decreased respiratory capacity → shallow breathing patterns
- Constipation
- Increased pressure on areas of bony prominence
• The psychological effects of prolonged bed rest include:
- Diminished sensory stimulation - Limited social interactions
- Altered perception of body image

49. *Physical activity has been shown to increase
blood flow and reduce risk of high blood pressure.
So, there is the potential for exercise to help prevent
pregnant women developing preeclampsia.
*Physical activity during pregnancy was also associated with reductions in gestational
diabetes mellitus risk. Women who engaged in physical activity during both time periods
experienced a 69% reduced risk.
*Regular gradual controlled aerobic exercises are particularly good exercise for pregnant
women with bronchial asthma such as : Yoga & swimming also diaphragmatic breathing
exercises& Buteyko techniques may relieve asthma symptoms. Using quick-relief medicine
10 minutes before exercise may help in toleration of a recommended exercise program.
Role of physical therapy in some high-risk pregnancy conditions

50. Evaluation / Assessment:
•The primary goal when working with this patient population is to provide them with an
individualized plan of care which minimizes deconditioning, decreases potential for formation
of deep venous thrombosis (DVT), and provides the patient with an element of control in her
care without increasing potential for early delivery.
•Secondary goals include serving as a resource for the patient and provide emotional support.
Potential impairments in this patient
population may include:
-Impaired emotional responses
-Impaired integument integrity
-Impaired range of motion & Impaired pain control
-Impaired strength & Impaired muscle tone
-Impaired aerobic capacity/endurance
-Impaired circulation and venous return

51. The rehabilitation prognosis may be
modified by any of the following factors:
-Nature of the pathology
-Ongoing medical treatments
-Presence of co-morbidities
-Social barriers that impact ability to return to
previous situation & care for self and infant
-Psychological status
Therapeutic Exercises:
-Instruct the patient in general active-assisted or active exercises with progression to
include all four extremities.
-Do not perform isometric exercises, including isometric quadriceps, gluteal, or Kegel
(pelvic floor) exercises. Do not perform any primary abdominal exercises. Avoid Valsalva
maneuver. All have potential to increase pelvic floor pressure.

52. -Individualize these exercises to each patient’s needs and abilities (e.g., For a patient with
multiple high-risk factors, start with only the distal leg exercises and progress slowly).
-Provide patient with the written exercise sheet
designated for the high-risk pregnancy population.
-For initial visit, patient should perform 5 repetitions of each appropriate exercise under
direct supervision by a specialized physical therapist. Patient should not perform more
than one additional set of 5 repetitions later that day.
-A follow-up visit the day after initial evaluation is necessary to assess patient tolerance for
exercise (e.g., no increased bleeding, no increased contractions, and no increased leakage of
amniotic fluid).
-Assess patient’s ability to continue exercises independently.

53. -Exercises for the upper extremities can also be progressed from active-assisted
to active-free to light resisted using small weights (not to exceed 3 lbs).
-Do not increase to more than 10 repetitions within
one session. Do not increase the number of sessions to
more than 3 per day. Do not make more than one change
in the exercise program per visit.
-Relaxation, Breathing and allowed electrophysical agents may be used for
relieving symptoms.
Vital Sign Monitoring:
-Monitor heart rate and blood pressure as appropriate,
especially with patients with pregnancy-induced
hypertension or pre-eclampsia.

54. Suggested Plan of Care and PT Interventions for
High-Risk Pregnant Women