Physical Therapy & Pregnancy Flashcards
Changes to the cardiovascular system due to pregnancy
- blood volume increases progressively from 6-8 weeks gestation & reaches a max at about 32-34 weeks
- increase in plasma volume is relatively greater than that of red cell mass resulting in hemodilution & a decrease in hemoglobin
- cardiac output increases by 30-40% in the first trimester
- the heart is enlarged by both chamber dilation & hypertrophy
- dilation across the tricuspid valve can initiate mild regurgitant flow causing a normal grade I or II systolic murmur
- upward displacement of the diaphragm causes the heart to shift to the left & anteriorly
Changes to the respiratory system due to pregnancy
- capillary engorgement & swelling of the lining in the nose, oropharynx, larynx, & trachea
- nasal congestion, voice change, & upper respiratory tract infection
- can be exacerbated by fluid overload or edema associated with pregnancy induced hypertension or pre-eclampsia
- from middle of the 2nd trimester expiratory reserve volume, residual volume, & functional residual volume are progressively decreased by about 20% at term
Changes in metabolism due to pregnancy
- all metabolic functions are increased during pregnancy to provide for the demands of fetus, placenta, & uterus
Changes in renal physiology due to pregnancy
- renal plasma flow & glomerular filtration rate begin to increase progressively during the 1st trimester
- at term both are 50-60% higher than in the non-pregnant state
Physical changes in the 1st trimester
- first 12 weeks after the first day of the last menstrual period
- breast enlargement
- average weight gain of 5 lbs
- may start to see increase lordosis at 10-12 weeks
Physical changes in the 2nd trimester
- week 13 to week 27
- average weight gain of 1 lb per week
- uterus will expand to 4x its size from week 12 to 27
- shift in center of gravity due to the increased size of the belly & hyperlordosis
- rectus abdominis increasing in length & diastases rectified may be forming
Physical changes in the 3rd trimester
- week 27 to week 40+
- complete core disruption
- increased fatigue
- heart burn
- upper respiratory breathing
- swelling
- hemorrhoids
- varicose veins
- stress incontinence
- shortness of breath
Describe a diastasis recti
- associated with support-related pelvic floor dysfunction, stress incontinence, fecal incontinence, & pelvic organ prolapsed
- 66% of individuals with DR had SPFD
- measure 4cm above & below the umbilicus
Post partum musculoskeletal changes
- persistant RAD (rectus abdominis diastasis)
- scarring of the perineal or abdominal area interfering with fascial support
- persistent pelvic obliquity
- breastfeeding = increased thoracic spine kyphosis & poor posture
- pelvic floor muscle deficits & weakness
What nerve innervates your pelvic floor muscles
- Pudendal nerve
Describe posterior pelvic pain (PGP)
- pain experienced between the PSIS & gluteal fold particularly in the region of the SI joint
- may radiate to the posterior thigh
- can occur in conjunction with pain in the pubic synthesis
- endurance capacity for standing, walking, & sitting is diminished
- diagnosis after exclusion of the lumbar spine
- must be reproduced with specific clinical tests
Common outcome tools for PGP (posterior pelvic pain)
- Disability Rating Index (DRI)
- Oswestry Disability Index (ODI)
- Pelvic Girdle Questionnaire (PGQ)
- Fear-Avoidance Beliefs Questionnaire (FABQ)
- Pain Catastrophizing Scale (PCS)
Examination for PGP (poster pelvic pain)
- high specificity but poor sensitivity
- P4 test (thigh thrust), Patricks Faber, Gaenslens test, & modified trendelenburg test for pain provocation tests
- long dorsal ligament & public synthysis for pain palpation
- active straight leg raise for functional test
Test item cluster for SI dysfunction
- Thigh thrust
- Gaenlens
- Distraction
- Compression
- Sacral thrust
- 3 out of 5 to be positive
Define pelvic girdle syndrome
- daily pain in all 3 joints (pubic symphysis, right, & left SI joint) with pain provocation tests
Define synphysiolysis
- daily pain in synthesis pubis only with positive pain provocation
Define one-sided SI syndrome
- daily pain in one SI joint with positive provocation test
Define double sided SI syndrome
- daily pain in both SI joints with positive pain provocation tests
Define miscellaneous pregnancy related pelvic joint pain classification
- daily pain in one or more pelvic joints with inconsistent objective findings
Treatment for pregnancy related pelvic pain
- manual therapy including soft tissue mobilizations & gentle joint mobilizations for pain inhibition only
- diaphragmatic breathing
- exercise for pelvic & lumbar stability
- postural instruction
- body mechanics
- belting
What treatments should you avoid for pregnancy related pelvic pain
- intravaginal treatment
- intrarectal only with specific OB clearance
- asymmetrical LE movements
- E-stim or ultrasound for pain control
- watch for diastasis recti
What conditions would call for activity limitations to be used
- prevention of preterm birth
- miscarriage
- growth restriction
- hypertension
- bleeding
- multiple gestation
Prevention of preterm birth
- advanced cervical dilation (>2cm)
- frequent uterine contractions
- premature labor
Degrees of activity limitation in order of least to most limited
1) strenuous activity
2) lifting
3) working in a standing position
4) no working outside of home
5) home confined
6) bed rest (meaning bed pan)
Recommendations for activity during pregnancy
- participation in many sports is safe during pregnancy
- avoid activities with high risk of falling or abdominal trauma
- no scuba
- in the absence of complications, 30 minutes of exercise a day is recommended
Absolute contraindications to exercise
- significant heart disease (class 2 & beyond)
- restrictive lung disease
- incompetent cervix
- multiple gestation at risk for preterm labor
- persistent 2-3 trimester bleeding
- placenta prevue after 26 weeks gestation
- premature labor in current pregnancy
- ruptured membranes (water broke)
- pre-eclampsia (HTN)
Precautions to exercise
- severe anemia
- unelevated maternal arrhythmias
- chronic bronchitis
- poorly controlled type 1 diabetes
- morbid obesity
- extremely underweight (BMI<12)
- IUGR (inter-uterine growth rate) in current pregnancy
- poorly controlled HTN
- poorly controlled seizure disorder
- poorly controlled hyperthyroidism
- heavy smoker
Describe the PARmed-X for pregnancy
- previously sedentary women with healthy pregnancies can Strat an exercise program in the 2nd trimester
- women with low risk pregnancies can continue mild-moderate activity throughout pregnancy
- mild-moderate activity in the PARmed-X is considered safe
- muscle conditioning with necessary precautions is safe
Post partum pelvic girdle pain
- similar exam to PGP in pregnancy
- if pelvic floor control appears disrupted then add in a pelvic exam
- remember to rule out the lumbar spine/low back pain
Clock for perineal injuries
- similar to wound care clock
- 12 o’clock = pubis
- 6 o’clock = coccyx
Describe a 1st degree perineal laceration
- vaginal mucosa & perineal skin torn
- no stitches
Describe a 2nd degree perineal laceration
- involves muscles of the perineal body without transgressing the anal spincter
- will have been stitched up on the birthing table
Describe a 3rd degree perineal laceration
- laceration of anal spincter
- would have received stitches in a surgery room not on the birthing table
Describe a 4th degree perineal laceration
- laceration of rectal mucosa
- one opening instead of two
- probably won’t get full continence back
Define an episiotomy
- cutting of the perineal muscles instead of allowing them to tear during birth
Describe the order in which you have to cut through for a C-section
- skin
- superficial fascia
- rectus sheath
- rectus abdominus
-fascia & peritoneum - uterine wall
- amniotic sac
