L25: Immediate Postpartum Physiotherapy Management Flashcards
1
Q
What does a LSCS stand for?
A
Lower section caesarean section —> in non-muscular part of uterus
2
Q
What does SVD stand for?
A
spontaneous vaginal
No instrumentation (gave birth with natural contractions) delivery
3
Q
What does NVD stand for?
A
normal vaginal delivery
Instrumentation involved
4
Q
What does VE stand for?
A
vacuum extraction
Bad for baby (bruise) and better for mum –> help with traction during contraction
5
Q
What does Kiwi stand for?
A
vacuum extraction (brand)
6
Q
What does NBF stand for?
A
neville barnes forceps
Bad for mum and better for baby –> need to cut the vagina first (if need to get baby out ASAP –> dire circumstances) high rotational
Forceps to wriggle baby head out when crowning –> this is not bad for mum
7
Q
What does IOL stand for?
A
induction of labour
8
Q
What does BS stand for?
A
birth suite
9
Q
What does BF stand for?
A
breastfeeding
10
Q
What does OA stand for?
A
occiput anterior
Should be delivered this way (chin down)
11
Q
What does OP stand for?
A
occiput posterior
Chin up –> much larger surface area
12
Q
What does SROM stand for?
A
spontaneous rupture of membranes
13
Q
What does AROM stand for?`
A
artificial rupture of membranes
Pierce the bag –> waters break –> contractions begin
14
Q
What does VBAC stand for?
A
vaginal delivery after CS
15
Q
What does DRAM stand for?
A
diastasis rectus abdominal muscle
16
Q
What does BSL stand for?
A
blood sugar levels
17
Q
What does GDM stand for?
A
gestational diabetes mellitus
18
Q
What does IUD stand for?
A
intra uterine death
19
Q
What does D&C stand for?
A
dilation & curettage
20
Q
What does MROP stand for?
A
manual removal of placenta
21
Q
What does FHR stand for?
A
fetal heart rate
22
Q
What does GBS stand for?
A
group beta streptococcus
23
Q
What does NICU stand for?
A
neo natal intensive care unit
24
Q
What does SCN stand for?
A
special care nursery
25
What does PIH stand for?
pregnancy induced hypertension
26
What does Gravida stand for?
pregnancies
27
What does Parity stand for?
-# of times woman has delivered a fetus (eg, G1P0)
28
What does G6, P4, T2 mean?
6 pregnancies
4 births
2 terminations
29
What are 5 modes of delivery?
Caesarean (spinal anaesthetic or GA)
1. Emergency (Em LSCS)
2. Elective (El LSCS)
Vaginal delivery
1. SVD
2. IOL
3. Instrumental vaginal birth
30
What are 3 situations when a Emergency (Em LSCS) is done?
1. Mother or child at risk
2. Obstructed labour
3. Twins / Triplets + (attempted vaginal delivery)
31
What are 9 situations when a Elective (El LSCS) is done?
1. Mum elected to have a C-section or there was a reason
2. Mother or child at risk
3. Previous 3rd/ 4thdegree perineal trauma (differing opinions)
4. \> 2 previous LSCS
5. Breech presentation
6. Twins / Triplets +
7. Maternal request (social reasons)
8. Severe non weight bearing SPD
9. Placenta previa(grade 4) + accreta+/-hysterectomy
* Placenta going over the top of cervix --\> can have vaginal birth --\> placenta rips and bleeds (becomes an artery which can be dangerous for high bleeding)
32
What is a situation when a Vaginal delivery SVD (Spontaneous vaginal delivery) is done?
A vaginal birth (regardless of the onset of labour) that is not assisted by forceps or vacuum and is not a vaginal breech delivery
33
What are 4 situation when a IOL (Induction of labour) is done?
1. Onset of labour requiring medical intervention
2. Prostin
3. Syntocinon
4. AROM
34
What is an Instrumental vaginal birth?
Forceps or Vacuum
35
What is a 1st degree perineal tear?
Injury to skin or vaginal epithelium only = Graze
36
When does repair of 1st degree perineal tear happen?
Can be repaired or not repaired dependent on severity
37
What is a 2nd degree perineal tear?
Injury to the perineum involving perineal muscles but not involving the EAS.
38
When does repair of 2nd degree perineal tear happen?
Always repaired in birth suite (BS)
39
What is a 3rd degree perineal tear?
1. 3a (\<50% EAS)
* Tear through skin, perineal body and \<50% of EAS
2. 3b (\>50%) EAS
* Tear through skin, perineal body and \>50% of EAS
3. 3c (entire thickness of EAS)
* Tear through skin, perineal body and all of EAS
40
When does repair of 3rd degree perineal tear happen?
Always requiring repair (BS vs OT)
41
What is a 4th degree perineal tear?
Injury to perineum involving EAS and IAS and anal epithelium (into mucuosa).
42
When does repair of 4th degree perineal tear happen?
Always repaired in OT
43
What happens when a perineal tear does not get repaired?
can never be functional --\> can't just improve
44
What is an episiotomy?
Surgical incision made between vagina and anus (perineum) –commonly mediolateral
45
When was an episiotomy done?
Used when high likelihood of severe perineal trauma, soft tissue dystocia, accelerate birth
46
When does repair (episiotomy) perineal tear happen?
Repaired in BS
47
What is the risk with episiotomy?
Must cut at 60 degrees (risk of extended episiotomy if cut at wrong angle)
48
How should an episiotomy be done?
Medio-lateral --\> good
49
Do not want midline episiotomy. Why?
Encouraging tear to the anal sphincter
50
What are the 3 roles of ICE?
1. Pain relief
2. Stop swelling --\> cause pain and doesn’t allow for tissue healing
3. Vasoconstrictor
51
What are 17 characteristics of acute care for vaginal delivery and physiotherapy?
1. Perineal Ice (10-15 minutes every 2-3 hours with adequate insulation in lying)
* Decrease swelling and pain
2. Limit prolonged sitting or ‘bed head up’sitting (increases peri swelling)
* Standing and sitting encourages pooling of blood --\> swelling
3. Rest (lying flat every 1-2 hours in hospital) first 48 hours
4. Gentle pelvic floor contractions (swelling control program to stimulate circulation) see pelvic floor prescription slide) eg.10 x 2 sec holds.
5. Compression with shape-wear pants / medical compression.
6. Passive support of perineum (cough / sneeze / when emptying bowels)
* Eg. hand underneath or sitting with pressure --\> without = can cause stitches to rip
7. Minimise intra abdominal pressure (straining for bowels, lifting)
8. Appropriate underwear (reduce friction)
9. Perineal support underwear / garments may be helpful Shape wear with pad --\> stops swelling from accumulating
10. Good hygiene (midwife / OBGYN also encourages)
* If they have stitches, after birth --\> no faecal matter near wound
11. Pain relief (eg. Panadol, Brufen)
12. No haemorrhoid rings or rolled towels (encourages perineal swelling)
13. Side-lying or sitting on soft surfaces encouraged
14. Treatment for acute MSK pain ?
15. DRAM assessment and management
16. Epidural headache vs MSK pain ?
17. Bladder and bowel advice
52
Why are rolled towels and haemorrhoid rings not adviced?
Swelling likes compression --\> better without it (won't have swelling pooling)
53
What is an epidural headache?
* When the epidural goes in and goes out (little hole should seal)
* Doesn't seal --\> CSF leaks out
* Traction of on the bottom of brain
* Gives a head ache
54
What position is an epidural headache worst?
Very aggravating when standing up --\> more gravity pulling down on brain
55
What is the treatment of an epidural headache?
* Get blood from body
* Inject blood into epidural site
* Blood clotting
* No longer any traction on brain
* Headache is cured
56
What are 13 characteristics for acute care for LSCS and physiotherapy?
1. Chest physiotherapy if required (rare)
2. DVT check
3. Lower limb circulation exercises encouraged
4. LSCS wound support with cough / sneeze / vomit
5. Bed mobility (roll and sit) patients are mostly independent
6. Pain relief well controlled? (Panadol / Brufen / Targin / Endone) no PCA’s
7. Fluid intake Change in homeostasis --\> eg. drink 5L/day (which is overhydration) --\> when they drink 4L they feel thirsty even though they are overhydrating
8. Bladder function (decreased urge to void, dysfunctional flow, bladder retention, dysuria)
9. Bowels –constipation management if required (movicol, lactulose, coloxyl & senna) generally BO day 2 or 3 is OK.
10. Bowels –bloating and wind (gentle abdominal massage, peppermint tea, mobilise, heat)
11. Minimise intra abdominal pressure (straining for bowels, lifting)
12. Support garments may be helpful if DRAM (limit stress on LSCS wound)
13. MSK pain post LSCS?Epidural headache vs MSK pain?
57
Why is this important to maintain bed mobility post LSCS?
need to check on baby (eg. crying, feeding)
58
Why must void be under 100mL?
Can't have bladder continually expanding due to fluid but not excreting this fluid --\> affects the health of the bladder ( might have to have a catheter for a few days)
59
What are 4 characteristics of trial of void (TOV)?
1. After IDC removed –Ax bladder function
2. 6 hours to void ( 400mls) with x 2 voids
3. IDC removed between 6 am and 7am.
4. If failed TOV: physiotherapy intervention
* Running water
* Shower
* Supra pubic pressure
* Education on TOV
* Defecation position
* Don’t panic or strain
* Hydration levels.
60
What are 7 long term goals for vaginal/LSCS for inpatient physiotherapy?
1. Pelvic floor program (6 months min) based on this delivery and previous deliveries
2. Bladder health/habits
3. Bowel health
4. Reduce risk of MSK conditions developing Teaching proper baby handling (eg. carry their baby, or feed in bed long lie --\> slump position --\> can have neurological symptoms)
5. Posture
6. Manage any evidence of DRAM (abdominal support and advice + follow up)
7. Appropriate activity guidelines well explained dependant on intrapartum factors)
* Risk of fatigue, wound infection for activities
* 0-6 weeks –pain / swelling tolerated walking
* 6-12 weeks –all low impact exercise generally OK
* 12 weeks and beyond –high impact trial
8. Assess need for outpatient physiotherapy follow up
61
What are the 3 groups depending on weeks in terms of Appropriate activity guidelines well explained dependant on intrapartum factors) in vaginal/LSCS for inpatient physiotherapy?
1. 0-6 weeks –pain / swelling tolerated walking
2. 6-12 weeks –all low impact exercise generally OK (eg. Yoga, pilates)
3. 12 weeks and beyond –high impact trial
62
What is Appropriate activity guidelines well explained dependant on intrapartum factors) in vaginal delivery?
1. Within 1-2 weeks as long as you don’t feel heavy (have gone too far) = can start to do some light activity (eg. walking)
2. Wait 3 days and then try again
63
What are 8 risks that the patient should be screened for?
1. SUI (stress urinary incontinence)
2. Levator ani muscle injury (LAM)
3. FI (fecal incontinence) / fecal urgency
4. POP (pelvic organ prolapse)
5. OAB- Overactive bladder
6. Chronic constipation
7. Chronic pelvic pain
8. Residual PGP (pelvic girdle pain)
64
What does transient mean?
* Can come and go
* Might not be a predictor of long term outcome
65
What is Levator Ani Muscle Injury (LAM)?
Avulsion of puborectalis from inferior pubic ramus / os pubis in vaginally parous (Delivered vaginally) women.
Can be unilateral or Bilateral.
66
\_\_\_\_\_\_\_\_ occurs in 15-30 % of vaginally parous women within most research
Levator Ani Muscle Injury (LAM)
67
What are 6 Intrapartum risk factors?
1. Forceps (esp. high rotational)
2. Maternal age \> 40 years at first delivery
3. Prolonged second stage labour- Longer than 2 hrs of 2nd stage (eg. pushing stage)
4. Birth weight \> 4000g
5. 3rdand 4thdegree perineal tears
6. Episiotomy ?
68
What does a Transperineal USS (3D/4D) Unilateral LAM Injury look like?
69
The progression of symptoms is fast and your job on the ward is to identify _____ risk factors and refer to appropriate experienced physiotherapists
intrapartum
70
If no experience performing vaginal exams -a _____ injury can be hard to accurately diagnose!
LAM
Can only determine LAM --\> can only be diagnosed via vaginal exam
71
With a LAM, start early ________ contractions on the ward or in your clinic
pelvic floor
72
What are 6 characteristics of acute care in 3rd and 4th degree perineal tears?
1. Soft tissue management / pain management
2. Positioning
3. Perineal support
4. Bowels
5. Gentle pelvic floor pulses for circulation
* eg. (10 x 2 sec holds)
6. Activity guidelines (0-6 weeks)
* Contraction of pelvic floor = Traction of EAS
73
What are 8 characteristics of follow up care in 3rd and 4th degree perineal tears?
1. Wound Healing
2. Pelvic floor progression at 6 weeks
3. Treating any SUI / OAB / POP
4. Think about assessing for LAM injury
5. Follow up at 6 weeks and 12 weeks (physio)
6. ? Colorectal (endoanal USS) and 12 weeks
7. Activity guidelines (6-12 weeks and 12 weeks +) Can't do anything with sutures in
8. Only can be done after 12 weeks once sutures have dissolved
74
What are 5 Long term risk factors of 3rd and 4th degree Tears?
1. LAM injury (associated)
2. Fecalincontinence
3. Fecalurgency
4. Flatus Not holding wind in (fart)
5. Deficient perineum
75
What is Diastasis Rectus Abdominus Muscle (DRAM)?
A condition where the RA muscle separates in the midline at the linea alba.
Thinner and stretch out during pregnancy
76
What is linea alba?
a complex connective tissue –connecting left and right abdominal muscles
77
What is a +ve test in Diastasis Rectus Abdominus Muscle (DRAM)?
Head tilt and ASLR = linea alba bulges = +ve result (there is a diastasis)
78
What is a -ve test in Diastasis Rectus Abdominus Muscle (DRAM)?
If its thick and not bulging = =ve result (no problems)
79
What are 8 managements of Diastasis Rectus Abdominus Muscle (DRAM)?
1. Assessment on ward (2 finger spaces above umbilicus) after day 2.
2. Does it affect LSCS wound?
3. PFM activation / TrA activation if PFM achieved
4. External abdominal support
5. Teach patient to monitor throughout activities
6. Outpatient follow up at 6 weeks.
7. Surgical repair? Time, right exercises will fix problem
8. Support garments are more for comfort and restricts movement more (rather than fixing problem)
80
What are the 3 cues for pelvic floor contraction rehabilitation?
1. “squeeze and lift”
2. “Stop the flow of urine”
3. “Pulling up front and middle passage”
81
What are the 4 techniques pelvic floor contraction rehabilitation?
1. Lying with knees bent /sidelying
2. Looking for accessory muscle movement
3. Can view perineum for lift
4. May have access to a RTUS on ward.
82
What is the aim for Pelvic floor Rehabilitation?
Aim for gentle pelvic floor exercises pain tolerated
83
What does Pelvic floor Rehabilitation encourage?
Encourages healing / circulation/ and reduction in swelling (with ice)
84
What are 5 characteristics of pelvic floor (progressions) rehabilitation?
1. Stronger contractions
2. 8 x 8 sec holds –10 x 10 second holds
3. Any position
4. X 3 per day
5. 5 months (esp. post vaginal delivery)
85
What are 12 Post natal MSK conditions /treatments for coccyx pain?
1. Physical trauma during birth, pre-existing dysfunction during pregnancy, or previous coccyx injury (coccydynia vs # coccyx)
2. Common with OP presentations/forceps/ previous anterior displacement coccyx
3. Minimise any weight bearing on coccyx (b’feeding / seating surfaces).
4. Foot stool / coccyx wedge/ folded towel
5. Side lying most comfortable (pillow between legs)
6. Ice (as tolerated)
7. Manage constipation
8. Oral pain relief in hospital
9. Gentle pelvic floor (no pain) remember pubococcygeus attachments!
10. Physiotherapy follow up at 6 weeks
11. NSAID’s vs guided corticosteriod injection (if pain not reducing)
12. Relocation (manual) PR of dislocated coccyx
86
What are 3 causes of Severe pelvic joint (SIJ or symphysis pubis pain)?
1. Pre-existing (PR-PGP)
2. Labour (vaginal)
3. Testing: trendelenberg / ASLR / palpation over joint / good subjective Ax
87
What are 4 management for acute acure for post natal MSK conditions?
1. Rest (48-72 hours)
2. Ice (esp. symphysis pubis)
3. Oral pain relief (enable breastfeeding and bed mobility)
4. Positioning advice
* Back roll onto side, strong brace, legs must travel with body
* Pillow between legs with side lying
* Avoid 1 –leg stance (eg. Stepping into pants)
* Limit lumbar rotation
* Aim for bilateral weight bearing
88
What are 9 characteristics of positioning advice for acute management for Post natal MSK conditions?
1. Back roll onto side, strong brace, legs must travel with body
2. Pillow between legs with side lying
3. Avoid 1 –leg stance (eg. Stepping into pants)
4. Limit lumbar rotation
5. Aim for bilateral weight bearing
6. Pelvic floor / TrA (when able)- No need immediate TrA - encourage abdominal contraction --\> increase IAP
7. Treat any associated Lx spine pain
8. Support Garments
* SIJ belt if SIJ only
* Flexible compression for any symphysis pubis involvement.
9. Mobility Aids (severe, non weight bearing)
* Wheelchair
* Flexible compression for any symphysis pubis inv
89
What are 7 characteristics of thoracic pain (causes) in Post Natal MSK Conditions?
1. Delivery position?
2. Pre-existing?
3. Poor breastfeeding positions
4. Exhaustion
5. DDx: Epidural headache? (severe headache with lying to sit/sensitive to light, no relief with pain relief)
6. DDx: thoracic crush fractures (low osetrogen / low BMI/ low Vit D / low Calcium) often severe pain at night and pain in supine ++ // no relief
7. DDx: Mastitis/systemic referral
90
What are 8 characteristics of thoracic pain (management) in PostNatal MSK Conditions?
1. Mobilisation (sidelying/sitting)
2. STM
3. Heat
4. Taping for biofeedback settle UT.
5. Posture advice (chin poke)
6. Thoracic stretches (rolled towel, bow and arrow)
7. Shoulder girdle stretches (shoulder retraction ex’s)
8. Exhaustion
91
What are 5 low back pain causes in Post Natal MSK Conditions?
1. Flexed posture
2. Epidural site (bruising)
3. DOMS (labour)
4. Exaggerated lx lordosis
5. Pre-existing LBP.
92
What are 7 low back pain management for Post Natal MSK Conditions?
1. Ergonomic advice (re; solve activity that caused condition)
2. Postural stretches
3. Bed mobility
4. PFM and TrA
5. STM / heat
6. Support garment
7. Gentle passive mobilisation
93
What are 2 characteristics of Post Natal Exercises from Day 0- Week 2?
1. Pelvic Floor, TrA, postural stretches, posture
2. Gentle walks (pain and heaviness tolerated)
94
What are 4 characteristics of Post Natal Exercises from Week 2- Week 6?
1. Progress walking
2. Continue PFM / TrA
3. Light weights from 4-5 weeks
4. Monitor for symptoms of UI / heaviness
95
What are 5 characteristics of Post Natal Exercises from Week 6- Week 12?
1. Progress walking
2. Low impact exercise from 6 weeks (bike, yoga, gym classes)
3. Continue PFM / TrA
4. Monitor for symptoms of UI / heaviness
5. Trial high impact (running, cross fit)
96
What are 5 characteristics of Post Natal Exercises from Week 12+
1. Continue Low impact exercise from 6 weeks (bike, yoga, gym classes)
2. Trial high impact exercise (if PFM / TrAfunctional) to withstand increased intra abdominal pressures
3. Continue PFM / TrA
4. Increase strength and endurance / stability
5. Monitor for symptoms of UI / heaviness
97
What are 12 factors to consider when choosing exercise program in post natal exercise?
1. Low oestrogen and breastfeeding
2. Exercise intensity breast milk production
3. DRAM
4. UI / FI / OAB / POP / LAM injury / 3rd/ or 4thdegree tear
5. Delivery
6. PGP (residual) or MSK pain
7. Vitamin D levels
8. Calcium (levels / dietary intake)
9. Iron Levels (PPH?)
10. Diagnosed with decreased bone density (bone density test)
11. Taking corticosteroids
12. Low BMI (underweight)
98
Why is depression a risk factor?
Should not stop exercising --\> still do it
Risk factor if depression before pregnancy = post natural depression (eg. have booked their bed to a depression facility) Hormonal
