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ILP: Obstetrics Physiotherapy Flashcards

1
Q

What are 8 different care providers for pregnancy care?

A
  1. Obstetricians –public and private
  2. GP
  3. Obstetricians and GPs in “Shared Care” arrangements
  4. Midwives –public/private/independent
  5. Physiotherapists
  6. Dieticians
  7. Psychologists
  8. Diabetes educators
  9. Social Workers

(Allied Health Professionals)

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2
Q

What is the aim of pregnancy care?

A

To ensure the health and safety of both mother and baby during pregnancy, labour, delivery and the puerperium.

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3
Q

What are 3 ways we can achieve the aim of pregnancy care (ensure health and safety of both mother and baby)?

A
  1. Identify and where possible modify risk factors for adverse maternal and fetal outcomes
    • Pre-conception, antenatal, labour, delivery, post-partum
  2. Consider the whole clinical and social picture
  3. Multidisciplinary care
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4
Q

What are 8 characteristics of pre-conception care?

A
  1. Ideally counsel as a couple- Health of mother and father
  2. Optimise Physical Health
    • Modify the modifiable
      • Smoking, diet/exercise/weight
    • Optimise medical conditions –more common with AMA
      • Hypertension, Diabetes- Kidney diseases and clotting problems
  3. Genetic counselling/screening- Personal or family history
  4. Natural or assisted reproduction (Such as IVF)
  5. Optimise Mental Health
    • Involvement of psychology/psychiatry
    • Optimise/reduce medications
  6. Pre-pregnancy Supplementation
    • Folic Acid
    • Fe
    • Vitamin D?
  7. Antenatal Screening Bloods
  8. Physiotherapy
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5
Q

What are 2 characteristics of of optimising physical health in pre-conception care?

A
  1. Modify the modifiable
    • Smoking, diet/exercise/weight
  2. Optimise medical conditions –more common with AMA
    • Hypertension, Diabetes
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6
Q

What are 2 characteristics of of optimising mental health in pre-conception care?

A
  1. Involvement of psychology/psychiatry
  2. Optimise/reduce medications
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7
Q

What are 3 pre-pregnancy supplementations?

A
  1. Folic Acid
  2. Fe
  3. Vitamin D?
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8
Q

What is the purpose of folic acid of a pre-pregnancy supplementation?

A

Significantly reduces the risk of neural tube defects as the neural fold forms in the first 13 weeks of pregnancy

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9
Q

What is the purpose of Fe of a pre-pregnancy supplementation?

A

Baby, placenta and uterus develop and draw iron from blood (in iron stores)

  • If mother is Fe deficient, before pregnancy, it is very unlikely that she will replace due to diet –> need supplementary intake
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10
Q

What are the 2 physio assessment and optimisation of pre-existing MSK issues?

A
  1. Back
  2. Pelvis
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11
Q

What are the 3 physio assessment and optimisation of pre-existing pelvic floor issues?

A
  1. Pregnancy Related –SUI, OASIS, perineal trauma
  2. Dyspareunia, vaginismus
  3. Chronic Pelvic Pain
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12
Q

What are 6 things in the initial history of antenatal care?

A
  1. PMHx
  2. PGHx
  3. POHx
  4. PSHx
  5. FHx
  6. PsychHx

Aim to identify risk factors and plan for their management

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13
Q

What are 3 things in the physical examination of antenatal care?

A
  1. BP, Pulse
  2. Cardiovascular and Respiratory systems
  3. Height and weight
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14
Q

What are 2 things in WTU of antenatal care?

A
  1. Proteinuria
  2. Evidence of UTIor asymptomatic bacteriuria
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15
Q

What are 4 First Trimester Investigations in antenatal care?

A
  1. Blood Tests
  2. Urine
  3. Imaging
  4. Screening for aneuploidy
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16
Q

What are 4 characteristics of blood test in First Trimester Investigations in antenatal care?

A
  1. FBE, Group and antibody screen (Reeses’ status), Fe
  2. Infection screen –Hep B/C, HIV, syphilis, rubella, +/-varicella, CMV
  3. Vitamin D, TFT (thyroid)
  4. Others as indicated e.g. U&E, LFT, thrombophilia screen
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17
Q

What are 2 characteristics of urine in First Trimester Investigations in antenatal care?

A
  1. m/c/s
  2. Pr:Cr (Protein: cretin ratio) if obese
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18
Q

What are 3 characteristics of imaging (USS) in First Trimester Investigations in antenatal care?

A
  1. Location (Eg. not fallopian tube development)
  2. Number
  3. Chorionicity if multiple
  4. EDC
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19
Q

What are 2 characteristics of screening for aneuploidy in First Trimester Investigations in antenatal care?

A
  1. FTCS (First trimester combined screening –> scans to look at thickness of mucous folds 11-14 weeks –> 12wks)
  2. NIPT (Non-invasive pre-natal testing –> placental DNA and blood stream
    • Screening tool for chromosome 21 (down syndrome), ,13 or 18)
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20
Q

What are 2 characteristics of Secondary Trimester Investigations in antenatal care?

A
  1. K17-22 –Morphology USS
  2. K26-28 –GTT, FBE, Group and antibody screen
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21
Q

What is one characteristics of Secondary Trimester Investigations in antenatal care?

A

K36 –FBE(Group and antibody screen if Rh neg)

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22
Q

What are 2 other investigations required in antenatal care?

A
  1. Growth USS (macrosomia, IUGR)
  2. TrimesterlyTFT
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23
Q

What is the schedule of visits of antenatal care?

A
  1. 4 weekly to K28
  2. 2 weekly to K36
  3. Weekly until delivery
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24
Q

What does K28 mean?

A

28 weeks into pregnancy

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25
What are 3 important things to do in antenatal care?
1. Ongoing surveillance for maternal and fetal issues 2. Education –pregnancy/labour/breastfeeding- Social and mental health as well 3. Discussion regarding timing and mode of delivery * Obstetric and neonatal issues * Maternal preference * Previous birth history/outcomes/complications
26
What are 7 changes related to weight gain and influence of placental hormones on MSK structures in MSK physiological in pregnancy (antenatal care)?
1. Increased load and forces across joints 2. Increased lordosis of LB, forward flexion of neck, downward motion of shoulders 3. Laxity in anterior and posterior longitudinal ligaments 4. Widening and increased movement in SI and PS 5. Increased in anterior tilt of pelvis 6. Widened gait 7. Vaginal length increase, GHwidening
27
What are 11 physio input for antenatal care?
1. LBP 2. PGP 3. Hip, knee, thigh pain 4. Leg cramps 5. Hand and wrist pain- Increase carpal tunnel --\> increased fluid --\> increase compression 6. Foot pain 7. Chest wall pain 8. Abdominal wall pain 9. Arthritis 10. SUI –denovo, pre-pregnancy 11. Perineal preparation for birth
28
In the mechanics of normal labour and delivery, what are 2 functions of uterine contractions in active labour?
1. Dilate cervix 2. Propel the fetus through the birth canal
29
What are the 3Ps in successful negotiation of birth canal by fetus?
1. Powers 2. Passenger 3. Passage
30
What is powers (mechanism of normal labour and delivery)?
Force generated by uterine contractions
31
How is powers (mechanism of normal labour and delivery) assessed?
* Assessed qualitatively by observation of the mother, palpation of uterine fundus trans-abdominally, or use of external tocodynamometry- Eg. mother in fb, twitter = not on active labour * Assessed quantitatively by use of internal manometry- Only in a research setting--\> not used clinically
32
What does the passage (mechanism of normal labour and delivery) consists of ?
Consists of bony pelvis and soft tissues of the birth canal
33
How is the bony plevis in passage assessed?
* Bony pelvis assessed by pelvimetry * Clinical assessment * Imaging –X-ray, CT, MRI –very rare
34
What is the main resistance in stage 2 of normal labour and delivery?
Musculature of pelvic floor
35
What does the musculature of pelvic floor (main resistance in 2ndstage) facilitate?
Facilitate flexion and rotation of fetal head
36
What are the different pelvis shapes and how can that impact the difficulty of birth?
37
What pelvic shape is the easiest for delivery?
Gynecoid
38
What 3 pelvic shape is the most difficult for delivery?
1. Anthropoid 2. Android 3. Platypelloid
39
What are the 3 stages of labour?
1. First stage 2. Second stage 3. Third stage
40
What is the first stage of labour?
Interval between onset of labour and full cervical dilatation
41
What are the 2 phases based on rates of cervical dilatation?
1. **Latent phase** –between onset of labour and when change in rate of dilatation noticed 2. **Active phase** –faster rate of dilatation and usually begins at 3-4cm
42
What is the latent phase in the first stage of labour?
between onset of labour and when change in rate of dilatation noticed
43
What is the acute phase in the first stage of labour?
faster rate of dilatation and usually begins at 3-4cm
44
What is the second stage of labour?
From full cervical dilatation to delivery of infant
45
What is second stage of labour characteristised by?
Characterised by descent of the fetus through the birth canal and culminates with its expulsion
46
What are 4 indications of commencement of 2nd stage of labour?
1. Bloody show increases 2. Maternal desire to bear down 3. Feeling of pressure in rectum +/-desire to defecate 4. Onset of nausea and vomiting
47
What is different in the mother's role in second stage of labour?
* Mother assumes a more active role * Desirable durations in presence of normal CTG * Nulliparous with no EDB–2 hours * Nulliparous with EDB–3 hours * Multiparous with no EDB–1 hour * Multiparous with EDB–2 hours * Longer times may be given if continued progress and no evidence of maternal or fetal compromise
48
What is EDB?
Epidural block
49
What is the third stage of labour?
From delivery of infant to expulsion of the placenta
50
What are the 3 classic signs of signs of placental separation in the third stage of labour?
1. Lengthening of umbilical cord 2. Gush of blood from vagina 3. Uterine fundus changes from discoid to globular and fundal height elevates
51
What are 3 forces in extension during normal labour and delivery?
1. Uterine contractions 2. Maternal expulsive efforts 3. Resistance of pelvic floor
52
What are the 3 cardinal movements in labour?
1. Changes in position of fetal head during descent through the birth canal 2. Necessary due to asymmetry between shape of fetal head and maternal bony pelvis 3. Seven in all
53
What are the 5 steps of mechanism of normal labour and delivery?
1. Engagement 2. Descent and flexion 3. Internal rotation 4. Extension and restitution 5. Expulsion
54
What are the 3 characteristics of engagement in normal labour and delivery?
1. Passage of widest diameter of fetal head to a level below the plane of the pelvic inlet * Cephalic, flexed –widest diameter is BPD of 9.5cm * Breech –widest is bitrochanteric 2. Assessed clinically by abdominal or vaginal examination * Abdominally –2/5- Truly engaged --\> can only feel 2/5 of head * Vaginally –station at or below spines- Imaginary line draw between ischial spine 3. Demonstrates bony pelvis is adequate to accommodate passage of fetal head
55
What are 3 characteristics of descent in normal labour and delivery??
1. Downward passage of presenting part through pelvis 2. Not a steady continuous process 3. Greatest rate during end of first stage and in second stage
56
What are 2 characteristics of flexion in normal labour and delivery?
1. Passive process due to the shape of the fetal head and resistance of soft tissues of maternal pelvis 2. Complete flexion * presentation of the smallest diameter –suboccipitobregmatic * optimal passage through birth canal
57
What are the diameters of the fetal head at term?
Flexed --\> suboccipitobregmastic Deflected --\> occipitofrontal Very deflected --\> occipitomental (very difficult delivery)
58
What are the presentation,breech and cranial diameters?
59
What are the 3 characteristics of internal rotation in normal labour and delivery?
1. Passive rotation of presenting part from its original position to the AP position as it passes through the pelvis 2. Typically results in the fetal occiput rotating toward the pubic symphysis * Widest axis of fetal head lining up with widest axis of maternal pelvis 3. Curvature of sacrum --\> asynclitismat first, usually corrects
60
What are 4 characteristics of extension in normal labour and delivery?
1. Occurs when presenting part is at level of introitus 2. Base of occiput in contact with inferior surface of pubic symphysis 3. Fetal head is delivered by extension and rotates around symphysis pubis 4. Forces involved * Uterine contractions * Maternal expulsive efforts * Resistance of pelvic floor
61
What is the aim of a vaginal birth?
aim to protect perineum
62
What are 3 characteristics of restitution (external rotation) in normal labour and delivery?
1. Rotation back to correct position in relation to fetal torso 2. Passive movement due to release of forces exerted on fetal head by maternal bony pelvis and musculature 3. Mediated by basal muscle tone of fetus
63
What are 4 characteristics of expulsion in normal labour and delivery?
1. Delivery of body of fetus 2. Further descent brings anterior fetal shoulder to level of maternal pubic symphysis- Gentle traction to baby's shoulders 3. Anterior shoulder rotates under pubic symphysis 4. Rest of body delivers, usually without difficulty
64
What are 6 characteristics of assisted vaginal birth?
Mother and baby 1. Trained obstetric personnel 2. Appropriate backup or supervision 3. Appropriate clinical situation 4. Appropriate instruments 5. Recourse to caesarean section 6. Appropriate neonatal personnel- If baby is compromised
65
What does the vacuum structure used in labour care?
66
What are 3 characteristics of third stage of labour?
1. Time between delivery of the infant and the placenta 2. Mean duration 6 minutes 3. 97thcentile 30 minutes 4. Direct relationship between length of 3rdstage and maternal morbidity
67
Why is the 3rd stage of labour important?
Placenta needs to be removed --\> can cause infection if not
68
What are the 3 influencing factors of timing and mode of delivery in labour care?
1. Maternal –health, preference 2. Fetal wellbeing 3. Previous birth history
69
What is the aim for delivery?
delivery of a live and healthy baby and to keep mother safe and well * Work as hard as possible to take maternal wishes in to account in terms of birthing preferences etc.
70
What are 3 modes of delivery in labour care?
1. SVD unassisted 2. Assisted Vaginal Birth * Vacuum * Forceps 3. Caesarean Section –emergency or elective Decision regarding mode of delivery can be straightforward or more complex interaction of different factors
71
In perineal repairs, what are the statistics?
1. 85% of women who have a vaginal birth will have some degree of perineal trauma 2. 60 –70% of these will require suturing If there is any bleeding or once healing occurs, it will be in correct area and position
72
What are 2 indications for a vacuum or forceps assisted delivery (for assisted vaginal birth and perineal trauma)
1. Maternal * Medical (cardiac, neurological)- Try to shorten 2nd stage = minimize maternal effort * Labour (prolonged second stage)- Maternal exhaustion 2. Fetal * Evidence of compromise * prematurity- Protection of baby's head (high pressure in uterus to suddenly going out)
73
What are 6 characteristics of assisted vaginal birth?
1. Trained obstetric personnel 2. Appropriate backup or supervision 3. Appropriate clinical situation 4. Appropriate instruments 5. Recourse to caesarean section 6. Appropriate neonatal personnel
74
What do forceps look like in labour care?
75
When are forceps used (necessary/optimal course of action) ?List 3.
1. Prematurity (\<34 weeks) 2. Poor maternal effort 3. Attempt of the vacuum which was unsuccessful
76
What are female pelvic muscles at the level of the pelvic floor?
77
What are muscles of the female perineum?
78
What does the anatomy of the anus look like?
79
What are 10 predisposing factors of labour?
1. First birth 2. Precipitous / unattended births 3. Instrumental delivery 4. Forceps 5. Vacuum extraction 6. Episiotomy 7. Macrosomia 8. Malpresentation/ malposition- Distance between structures 9. Ethnic background 10. Age / Nutritional status / co-morbidity
80
What are 7 perineal injury consequences?
1. Pain 2. Urinary incontinence 3. Fecal incontinence * Up to 10% at 3 months 4. Sexual dysfunction * 23% superficial dyspareunia at 3 months 5. Vulvar deformity 6. Disruption of social, family life and breastfeeding 7. Longtermmorbidity can lead to major physical, social and psychological complications
81
What is the classification for first degree of perineal trauma?
Epithelial / subepithelialtissues of the vulva, perineum and vagina
82
What are 3 characteristics of caesarean section?
1. Low transverse abdominal incision 2. Rectus sheath divided and reconstituted- At the end of operation 3. Rectus muscles separated along linea alba, not divided transversely
83
What is the classification for third degree of perineal trauma?
1. a: \<50% EAS 2. b: \>50% EAS 3. c: IAS torn with complete rupture of EAS
84
What is the classification for fourth degree of perineal trauma?
All of the above plus tears into the anorectal cavity
85
What is the OASIS?
Identification and timely repair by trained personnel- Done right the first time rather than repaired later * Delay for transport to another facility may be appropriate
86
What are 4 post repair care?
1. Antibiotics 2. Avoid Constipation 3. Physiotherapy 4. Counselling Cost (economic) issue
87
What are 3 consequences of OASIS labour care?
1. Pain/dyspareunia 2. Flatalor faecal incontinence * 1:6 chance of permanent symptom s if subsequent vaginal delivery 3. Psychological and social
88
What are 2 implications for future delivery mode?
1. Elective caesarean section? 2. 5.3% risk of recurrent OASIS
89
What are 3 characteristics of caesarean section?
1. Low transverse abdominal incision 2. Rectus sheath divided and reconstituted- At the end of operation 3. Rectus muscles separated along linea alba, not divided transversely
90
What are 4 characteristics of SVDUnassisted or Assisted Vaginal Birth?
1. Perineal trauma/pain 2. UI- Urinary incontience 3. FI- Faecal..etc injury 4. Pudendalnerve praxis/neuralgia
91
What are 2 characteristics of Caesarean Section in post natal care for physio?
1. Abdominal incision and movement 2. Pelvic floor 3. Affected by pregnancy, not just labour
92
What are 3 general characteristics of post natal care for physio?
1. Encourage mobilisation 2. Avoid constipation 3. Surveillance for bladder dysfunction 4. Avoid undiagnosed retention
93
What are 5 ongoing assessment and treatment in later post natal care?
1. Pelvic floor dysfunction 2. UI 3. FI 4. Prolapse 5. Abdominal wall –rectus diastasis * Important input into decisions regarding future delivery mode if complex or complicated delivery with long term consequences
94
What are 2 of the usual red flags?
1. Neurological signs/symptoms 2. Weakness, altered sensation 3. Systemic symptoms 4. Fever, night sweats
95
What are 4 pregnancy related red flags?
1. Fluid or blood loss 2. Concerns about fetal movements 3. Contractions 4. Mental health concerns

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