Antenatal and Intrapartum Physiotherapy Techniques; Flashcards
Terminology
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)
What are the modes of delivery?
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
Perineal Trauma Classification and characteristics
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
Vaginal Delivery and Physiotherapy - Acute Care
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
Caesarean Delivery (LSCS) - Acute care
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
What is Trial of Void (TOV) and when to use:
- After IDC removed – Ax bladder function
- 6 hours to void (400mls) with x2 voids
- IDC removed between 6am and 7am
If Failed TOV: Physiotherapy Intervention
- Running water
- Shower
- Supra-pubic pressure
- Education on TOV
- Defecation position
- Don’t panic or strain
- Hydration levels
What are the Long-Term Goals: Vaginal/LSCS Inpatient Physiotherapy
- 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:
What are the appropriate activity guidelines post Vaginal/LSCS Inpatient Physiotherapy
- 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
What are the risks post Vaginal/LSCS Inpatient Physiotherapy?
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)
What is LAM?
Levator Ani Muscle Injury: Avulsion of the puborectalis from inferior pubic rami/os pubis in vaginally parous women. Can be uni- or bi-lateral
Risk factors of LAM?
o Risk factors
Forceps
Maternal age >40 years on first delivery
Prolonged 2nd stage labour
3rd and 4th degree perineal tears
Diagnosis of LAM?
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
What is acute care and Follow up care of 3rd and 4th Degree Perineal Trauma?
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 +
What are the long term risks of LAM?
o Long-Term Risk Factors
LAM injury (associated)
Fecal incontinence
Fecal urgency
Flatus
Deficient perineum
What is DRAM?
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
What is the management of DRAM?
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?
What is Pelvic Floor Rehabilitation? Cues, Technique and Acute care
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):
What are the causes of Coccyx Pain?
o Physical trauma during birth; pre-existing dysfunction during pregnancy, or previous coccyx injury
o Common with OP presentations/forceps/previous anterior displacement coccyx
What is the management of Coccyx Pain?
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
What are the causes of Severe Pelvic Joint (SIJ) or Symphysis Pubis Pain? What are the tests?
- Causes
o Pre-existing (PR-PGP)
o Labour (vaginal) - Testing
o Trendelenberg
o ASLR
o Palpation over joint
o Good subjective Ax
What is the management of Severe Pelvic Joint (SIJ) or Symphysis Pubis Pain? ACUTE CARE
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
What are the causes of Thoracic Pain?
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
What is the management of Thoracic Pain?
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
What are the causes of Lower Back Pain?
o Flexed posture
o Epidural site (bruising)
o DOMS (labour)
o Exaggerated Lx lordosis
o Pre-existing LBP
What is the management of LBP?
o Ergonomic advice
o Postural stretches
o Bed mobility
o PFM and TrA
o STM/heat
o Support garment
o Gentle passive mobilisation
What are the Returning to Exercise/FItness Programs requirements? Day 0 - Week 2
Pelvic floor, TrA, postural stretches, posture
Gentle walks (pain and heaviness tolerated)
What are the Returning to Exercise/FItness Programs requirements? Week 2 - Week 6
Progress walking
Continue PFM/TrA
Light weight from 4-5 weeks
Monitor for symptoms of UI/heaviness
What are the Returning to Exercise/FItness Programs requirements? Week 6 - Week 12
Progress walking
Continue PFM/TrA
Light weight from 4-5 weeks
Monitor for symptoms of UI/heaviness
Trial high-impact (running, cross-fit)
What are the Returning to Exercise/FItness Programs requirements? Week 12 +
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
