Antenatal and Intrapartum Physiotherapy Techniques;

Question 1

Terminology

Answer 1

LSCS - Caesarean BS – Birth Suite
SCD – Spontaneous Vaginal Delivery BF – Breastfeeding
NVD – Normal Vaginal Delivery
OA – Occiput Anterior
VE – Vacuum Extraction
OP – Occiput Posterior
Kiwi – Vacuum Extraction (brand)
SROM – Spontaneous Rupture of Membranes
NBF – Neville Barnes Forceps
AROM – Artificial Rupture of Membranes
IOL – Induction of Labour
VBAC – Vaginal Delivery after CS

DRAM – Diastasis Rectus Abdominal Muscle
GBS – Group Beta Streptococcus
BSL – Blood Sugar Levels
NICU – Neo Natal Intensive Care Unit
GDM – Gestational Diabetes Mellitus SCN – Special Care Nursery
IUD – Intra Uterine Death
PIH – Pregnancy Induced Hypertension
D&C – Dilation and Curettage Gravida – # of pregnancies
MROP – Manual Removal of Placenta Parity - # of times woman has delivered a foetus
FHR – Fetal Heart Rate (e.g. G1P0)

Question 2

What are the modes of delivery?

Answer 2

o Caesarean (spinal anaesthetic or GA)
 Emergency (Em LSCS)
 Elective (El LSCS)

o Vaginal Delivery
 Spontaneous vaginal delivery (SVD) – No forceps of vacuum
 Induction of labour (IOL) – medical intervention; risk of AROM
 Instrumental vaginal birth – forceps or vacuum

Question 3

Perineal Trauma Classification and characteristics

Answer 3

1st Degree tear
- Injury to skin or vaginal epithelium only
- Can be repaired or not repaired depending on the severity

2nd Degree tear
- Injury to the perineum involving perineal muscles but not the EAS
- Always repaired in birth suite (BS)

3rd Degree tear
- 3a (<50% EAS)
- 3b (>50% EAS)
- 3c (entire thickness of EAS)
- Always requiring repair (BS vs OT)

4th Degree tear - rare
- Injury to perineum involving EAS and IAS and anal epithelium
- Always repairs in OT

Episiotomy
- Surgical incision made between vagina and anus (perineum) – commonly mediolateral
- Used when high likelihood of severe perineal trauma, soft tissue dystocia, accelerate birth
- Repaired in BS

Question 4

Vaginal Delivery and Physiotherapy - Acute Care

Answer 4

o Perineal Ice 10-15 minutes every 2-3 hours (in lying)
o Limit prolonged sitting (increases peri swelling)
o Rest lying flat every 1-2 hours in hospital (first 48 hours)
o Gentle PFM contraction stimulate circulation to control swelling; 10 x 2 second holds
o Compression shape-wear pants/medical compression
o Passive support of perineum when coughing, sneezing, emptying bowels
o Minimise intra-abdominal pressure straining for bowels, lifting
o Appropriate underwear reduce friction
o Perineal support underwear/garments
o Good hygiene
o Pain relief Panadol, Brufen
o No haemorrhoid rings or rolled towels
o Side-lying or sitting on soft surfaces encouraged
o Treatment for acute MSK pain
o DRAM assessment and management
o Epidural headache vs MSK pain
o Bladder and bowel advice

Question 5

Caesarean Delivery (LSCS) - Acute care

Answer 5

o Chest physiotherapy if required (rare)
o DVT check
o Lower limb circulation exercises encouraged
o LSCS wound support with cough, sneeze, vomit
o Bed mobility (roll and sit) patients are mostly independent
o Pain relief control Panadol, Brufen, Targin, Endone; NO PCA’s
o Fluid intake
o Bladder dysfunction decreased urge to void, dysfunctional flow, bladder retention, dysuria
o Bowels constipation management if required (generally OK day 2 or 3)
o Bowels bloating and wind (gentle abdominal massage, peppermint tea, mobilise, heat)
o Minimise intra-abdominal pressure straining for bowels, lifting
o Support garments if DRAM (to limit stress on LSCS wound)
o MSK pain Epidural headache vs. MSK pain

Question 6

What is Trial of Void (TOV) and when to use:

Answer 6

• After IDC removed – Ax bladder function
• 6 hours to void (400mls) with x2 voids
• IDC removed between 6am and 7am

Question 7

If Failed TOV: Physiotherapy Intervention

Answer 7

• Running water
• Shower
• Supra-pubic pressure
• Education on TOV
• Defecation position
• Don’t panic or strain
• Hydration levels

Question 8

What are the Long-Term Goals: Vaginal/LSCS Inpatient Physiotherapy

Answer 8

• Pelvic floor program (minimum 6 months) based on this delivery and previous deliveries
• Bladder health/habits
• Bowel health
• Reduce risk of MSK conditions developing
• Posture
• Manage any evidence of DRAM (abdominal support and advice + follow up)
• Appropriate activity guidelines:
• Assess need for outpatient physiotherapy follow up
• Aim is to screen patients for risk of:

Question 9

What are the appropriate activity guidelines post Vaginal/LSCS Inpatient Physiotherapy

Answer 9

• Appropriate activity guidelines:
  o 0-6 weeks – pain/swelling tolerated walking
  o 6-12 weeks – all low impact exercise generally ok
  o 12 weeks and beyond – high impact trial

Question 10

What are the risks post Vaginal/LSCS Inpatient Physiotherapy?

Answer 10

o SUI (stress urinary incontinence)
o Levator ani muscle injury (LAM)
o FI (faecal incontinence)/faecal urgency
o POP (pelvic organ prolapse)
o OAB
o Chronic constipation
o Chronic pelvic pain
o Residual PGP (pelvic girdle pain)

Question 11

What is LAM?

Answer 11

Levator Ani Muscle Injury: Avulsion of the puborectalis from inferior pubic rami/os pubis in vaginally parous women. Can be uni- or bi-lateral

Question 12

Risk factors of LAM?

Answer 12

o Risk factors
 Forceps
 Maternal age >40 years on first delivery
 Prolonged 2nd stage labour
 3rd and 4th degree perineal tears

Question 13

Diagnosis of LAM?

Answer 13

 Difficult to accurately diagnose
 Progression of symptoms is fast identify intrapartum risk factors and refer appropriately
 Start early pelvic floor contraction on the ward or in your clinic

Question 14

What is acute care and Follow up care of 3rd and 4th Degree Perineal Trauma?

Answer 14

ACUTE CARE
 Soft-tissue management/pain management
 Positioning
 Perineal support
 Gentle pelvic floor pulses for circulation (10 x 2 second holds)
 Activity guidelines 0-6 weeks

FOLLOW UP CARE
 Wound healing
 Pelvic floor progression at 6 weeks
 Treating any SUI/OAB/POP
 Think about assessing for LAM injury
 Follow up at 6 weeks and 12 weeks (physio)
 Colorectal (endoanal USS) and 12 weeks
 Activity guidelines 6-12 weeks and 12 weeks +

Question 15

What are the long term risks of LAM?

Answer 15

o Long-Term Risk Factors
 LAM injury (associated)
 Fecal incontinence
 Fecal urgency
 Flatus
 Deficient perineum

Question 16

What is DRAM?

Answer 16

Rectus Abdominus Diastasis Injury
o A condition where the RA muscle separates in the midline at the linea alba.
o Linea alba is a complex connective tissue – connecting the left and right abdominal muscles

Question 17

What is the management of DRAM?

Answer 17

 Assessment on ward (2 finger spaces above umbilicus) after day 2
 Does it affect LSCS wound?
 PFM activation/TrA activation if PFM achieved
 External abdominal support
 Teach patient to monitor throughout activities
 Outpatient follow up at 6 weeks
 Consider surgical repair?

Question 18

What is Pelvic Floor Rehabilitation? Cues, Technique and Acute care

Answer 18

o Cue’s for Pelvic Floor Contraction
“Squeeze and lift”
“Stop the flow of urine”
“pulling up front and middle passage”

o Technique
 Lying with knees bent/side-lying
 Looking for accessory muscle movement
 Can view perineum for lift
 May have access to a RTUS on ward

o Acute Care
 Aim for gentle pelvic floor exercises pain tolerated
o Encourages healing/circulation/reduction in swelling (with ice)
 Pelvic floor (progression):

Question 19

What are the causes of Coccyx Pain?

Answer 19

o Physical trauma during birth; pre-existing dysfunction during pregnancy, or previous coccyx injury
o Common with OP presentations/forceps/previous anterior displacement coccyx

Question 20

What is the management of Coccyx Pain?

Answer 20

o Minimise any weight bearing on coccyx (breastfeeding/seating surfaces)
o Foot stool/coccyx wedge/folded towel
o Side lying most comfortable (pillow between legs)
o Ice (as tolerated)
o Manage constipation
o Oral pain relief in hospital
o Gentle pelvic floor pain guided (remember pubococcygeus attachments)
o Physiotherapy follow-up at 6 weeks
o NSAIDs vs. guided corticosteroid injection (if pain not reducing)
o Relocation (manual) PR of dislocated coccyx

Question 21

What are the causes of Severe Pelvic Joint (SIJ) or Symphysis Pubis Pain? What are the tests?

Answer 21

• Causes
  o Pre-existing (PR-PGP)
  o Labour (vaginal)
• Testing
  o Trendelenberg
  o ASLR
  o Palpation over joint
  o Good subjective Ax

Question 22

What is the management of Severe Pelvic Joint (SIJ) or Symphysis Pubis Pain? ACUTE CARE

Answer 22

o Rest (48-72 hours)
o Ice (especially symphysis pubis)
o Oral pain relief (enable breastfeeding and bed mobility
o Positioning advice:
 Back roll onto side, strong brace, legs must travel with body
 Pillow between legs with side lying
 Avoid 1-leg stance (e.g. stepping into pants
 Limit lumbar rotation
 Aim for bilateral weight bearing
o Pelvic floor/TrA (when able)
o Treat any associated Lx spine pain
o Support garments:
 SIJ belt if SIJ only
 Flexible compression for any symphysis pubis involvement
o Mobility aids (severe, NWB)
 Wheelchair
 Flexible compression for any symphysis pubis involvement

Question 23

What are the causes of Thoracic Pain?

Answer 23

o Delivery position
o Pre-existing
o Poor breastfeeding positions
o Exhaustion
o DDx: epidural headache (severe headache with lying to sit/sensitive to light; no relief with pain relief)
o DDx: thoracic crush fractures (low oestrogen/low BMI/low Vit D/low Calcium) often severe pain at night and pain in supine
o DDx: Mastitis/systemic referral

Question 24

What is the management of Thoracic Pain?

Answer 24

o Mobilisation (sidelying/sitting)
o STM
o Heat
o Taping for biofeedback help settle UT
o Posture advice (chin poke)
o Thoracic stretches (rolled towel, bow and arrow)
o Shoulder girdle stretches (shoulder retraction exercises)
o Exhaustion

Question 25

What are the causes of Lower Back Pain?

Answer 25

o Flexed posture
o Epidural site (bruising)
o DOMS (labour)
o Exaggerated Lx lordosis
o Pre-existing LBP

Question 26

What is the management of LBP?

Answer 26

o Ergonomic advice
o Postural stretches
o Bed mobility
o PFM and TrA
o STM/heat
o Support garment
o Gentle passive mobilisation

Question 27

What are the Returning to Exercise/FItness Programs requirements? Day 0 - Week 2

Answer 27

 Pelvic floor, TrA, postural stretches, posture
 Gentle walks (pain and heaviness tolerated)

Question 28

What are the Returning to Exercise/FItness Programs requirements? Week 2 - Week 6

Answer 28

 Progress walking
 Continue PFM/TrA
 Light weight from 4-5 weeks
 Monitor for symptoms of UI/heaviness

Question 29

What are the Returning to Exercise/FItness Programs requirements? Week 6 - Week 12

Answer 29

 Progress walking
 Continue PFM/TrA
 Light weight from 4-5 weeks
 Monitor for symptoms of UI/heaviness
 Trial high-impact (running, cross-fit)

Question 30

What are the Returning to Exercise/FItness Programs requirements? Week 12 +

Answer 30

 Continue low-impact exercise from 6 weeks (bike, yoga, gym classes)
 Trial high-impact exercise (if PFM/TrA functional) to withstand increased intra-abdominal pressures
 Continue PFM/TrA
 Increase strength and endurance/stability
 Monitor for symptoms of UI/heaviness