Pregnancy and Postpartum: A Physiological Overview of System Changes and Obstetric Terminology Flashcards
Pregnancy Basics:
How many trimesters?
How long are they?
- 3 Trimesters, 12 wks in length
- 1st→ 0-12
- 2nd→ 13-27
- 3rd→ 28-40
Gestational Age (GA) ===>
Duration of pregnancy in weeks
Full term ==>
40 weeks +/- 2wks
Pre-term ==>
LESS THAN 37wks gestation
Obstetrics Terminology:
Gestational Age (GA)
Duration of pregnancy in Weeks
Obstetrics Terminology:
Estimated Date of Delivery (EDD)
Due Date
Usually bw 38 and 42wks
Gravida
Woman who IS pregnant
Nulligravida
NEVER conceived child
Primagravida
1st time pregnant
Mutligravida
Completed 2 or more pregnancies
Nullipara
Never completed pregnancy beyond abortion
Primapara
Delivered 1 fetus beyond 20wks
Multipara
Delivered more than 1 fetus beyond 20wks
Para
Completed pregnancies beyond 20wks gestation
Gravida
of pregnancies woman has had
Ex. prima/gravida
30yo primagravida GA 28wks c/o severe RLE sciatica, LBP. Onset 4wks ago
Overview of Physiological Changes in Pregnancy
BOLD=Important!!!
-
IMPORTANT ONES:
- 25-35lbs wt gain
- INC in CV function
- INC edema
- Hormonal changes drive many of these physio. changes
- Other
- Laxity of soft tissue structures (ligs, fascia), changes are NOT pathological, but physiologically normal
Endocrine changes during Pregnancy
- Secretion of estrogen/progesterone
- *Estrogen rises 30x pre-pregnancy lvl→ INC uterine/breast size
- Placenta develops and becomes primary source of reqd hormones @ WEEK 11
- Relaxin, prolactin, adrenal hormones (aldosterone, cortisol) play important roles to support pregnancy
Rapid rise of hormones when???
1st Trimester!!!!
- Estradiol→ Less cranky, bigger boobs
- Progesterone→ Cranky hormone
CV System Changes
BOLD=IMPORTANT!!!
-
IMPORTANT ONES:
- INCd CO by ~30%
- reaches MAX in 2nd trimester*
- INCd HR by ~12bpm by term
- INCd SV by ~25%
- INCd blood volume (swelling calves/ankles)
- 50% inc in plasma vol.
- INCd O2 consumption
-
Remodeling of heart
- 50% inc in L vent mass, reduces afterload on heart
- DECd systemic vascular resistance w/ an initial DEC in BP
- returns normal late pregnancy
- INCd CO by ~30%
CV System Changes
Other
Relaxin
Relaxin may be primary agent responsible for many of the CV changes during pregnancy!!!
may be primary agent responsible for many of the CV changes during pregnancy!!!
Relaxin
Respiratory System Changes
- INCd tidal volume, hypERventilation, DECd functional residual capacity, DECd residual volume, Dyspnea
- How might this affect PT?→* LOWER tolerance! Warm-up is Important*** and monitoring response to exercise!!!
Respiratory changes
More on Dyspnea…
May occur as early as 20 weeks
MILD exercise, stairclimbing
Skeletal Changes during Pregnancy
BOLD=IMPORTANT!
- Ribcage moves laterally INCing sub-costal angle
-
IMPORTANT:
- INCs as pregnancy progresses
- Hormonally stim’d
- Occurs prior to uterine enlarge.
- Intercostal mm’s and cartilage may sustain overstretch injury
More Skeletal Changes during Pregnancy
- Changes in Bone Mineral Density (BMD) due to incd need for Ca+ by fetus:
- *INCd intestinal Ca+ absorption
- Ca+ conservation by kidney
- Mobilization of Ca+ from maternal skeleton
- Transient OP in pregnancy
- LOWER BMD than controls persists postpartum, incomp. recovery of bone loss @ 5mos after weaning
Postural Changes in Pregnancy
- FHP w/ inc thoracic kyphosis, INCd lumbar lordosis, INCd APT
- Change in BOS:
- Wider, Hip ER, Genu recurvatum, Foot PROnation
Gait Changes during Pregnancy
“Waddling Gait”
- INCd APT
- INCd demands→ hip ABDs, hip EXTs, ankle PF’s
- INCd load on lateral foot and hindfoot
Mood Disorders:
Postpartum psychosis
MEDICAL EMERGENCY!!!!
Precautions and Contraindications to Exercise during Pregnancy and Postpartum
SAFETY ISSUES
HTN
Vaginal Bleeding
Precautions and Contraindications to Exercise during Pregnancy and Postpartum
ACOG Precautions
- *HTN (Safety issue)
- Gestational DM
Precautions and Contraindications to Exercise during Pregnancy and Postpartum
ACOG Contraindications
- Premature rupture of membranes (PROM)
- Risk factors for preterm labor
- *Vaginal Bleeding (Safety issue)
Precautions and Contraindications to Exercise during Pregnancy and Postpartum
More
- Fatigue
- Borg, “Talk Test”
- LE edema
- limit standing
-
Avoid:
- PRONE > 2nd trimester
- <6wks postpartum:
- Knee to chest, Double leg lowering, High impact activity
AVOID prone when?
>2nd trimester
AVOID:
Knee to chest, double leg lowering, high impact activity
WHEN??
<6wks postpartum
Avoid SUPINE pos. after mid-2nd trimester
WHY???
Inferior Vena Cava Occlusion*
- NO MORE THAN 2mins Supine
- Recovery position→ LEFT S/L
- Dizzy, faint, INC HR, sweaty
INFERIOR VENA CAVA OCCLUSION IS A THING….
Bc of this…..
AVOID Supine pos. after mid-2nd trimester
*NO MORE THAN 2mins!!!
Lumbopelvic Pain
Gen Facts
- More than ½ exp LBP or lumbopelvic pain during pregnancy
- ⅓ who dev. pain during pregnancy will CONTINUE to have sx’s post-partum
Lumbopelvic Pain
Risk Factors
- Parity, maternal age, hx of pain in prev. pregnancy, hx of LBP, intensity of pain during pregnancy, work factors, BMI, delivery pos., multiple births
- ***A set of physical and psychosocial factors appears to be MOST predictive of lumbopelvic pain
Lumbopelvic Pain during Pregnancy
Predictors
A set of physical and psychosocial factors appears to be most predictive of Lumbopelvic pain
Special Tests for LumboPelvic pain
2 she mentions (specific to lumbopelvic)
- P4 Test (Posterior Pelvic Pain Provocation)
- ASLR (Active Straight Leg Raise)
P4 Test
Posterior Pelvic Pain Provocation
See details in pic and ACTUALLY TRY IT!!! (AGAIN!)
ASLR for LumboPelvic Pain
Active Straight Leg Raise
See pic for details and ACTUALLY DO IT!!! (AGAIN!)
Interventions: Functional Mobility
This can include 3 things:
- Positions of comfort
- Transfers
- Use of quadruped
Pos’s of Comfort
Supported Sitting
see pics
Pos’s of Comfort:
Supported S/L
see pics
*NOTE: BIG body pillow bw legs and under stomach
Quadruped Exercises for Lumbopelvic pain
2:
- Side sit to heels (BIG Lat stretch too!)
- Look to Opp heel
*see pics
Interventions:
LE Stretching
2 big ones?
Hip flexor
Piriformis
Interventions:
LE Stretching
Hip Flexor Stretching for LumboPelvic Pain
- ½ kneeling
- Side sit in chair
- Modified “Runner’s Stretch” @ counter w/ front knee flexed (bc pregnant***)
Interventions:
LE Stretching
Piriformis, Glute stretches
2:
-
Supine “Figure 4” Stretch
- Symptomatic leg crossed on top of opp leg, making shape of “L” or “4 points”
- Low lvl: gently pull thigh towards ipsilat shoulder
- Higher lvl: gently pull contralateral thigh upwards toward chest
- Sitting Mods for work tasks, pregnancy
-
Supine Piriformis Stretch
- Symptomatic leg pulled to opp shoulder
- Floor: symptomatic leg in front, lean over leg (“Paper Readers”)
Diastasis Rectii Abdominus (DRA)
Gen Facts
- Separation of rectus abdominus mm bellies
- Due to expansion of abdomen during pregnancy and “softening effects” of maternal hormones
- *MORE THAN 2 finger breadths==> Positive
- NOTE: Ineffective abdominal control may lead to LBP, PGP, or postural dysfunction**
Diastasis Rectii Abdominus (DRA)
What is considered POSITIVE?
MORE THAN 2 finger breadths
DRA Assessment
TRY IT/DO IT!!!
-
Palpate in hooklying:
- @ Navel
- 2” Above
- 2” Below
- Instruct isometric TrA contraction→ “Bellybutton to spine”
- Pt performs head lift w/ exhalation
- *Document # finger breadths present
- Ex. 1/3/2 (bc 3 pos’s)
Risk Factors for DRA
- Older women (>33yo)
- Multiparous women (women having had @ least one prev. birth)
- Multiple gestation
- Carrying larger baby (>3636g)
- Wt gain during pregnancy (>35lbs)
- C-Section delivery
TrA and DRA Connection
- Muscle synergy exists bw TrA and Pelvic Floor
- BOTH play important role in stabilizing pelvis, spine
- Exercise has protective effect for DRA
DRA Mgmt:
4:
- SUB-max, isometric, pain-free contraction of TrA
- Abdominal bracing or taping (towel, manual approximation→ exactly what it sounds like!)
- Training in Pelvic Floor Muscle Contraction (PFMC)
- Exercise progression into abdominal and hip strengthening program
Abdominal Re-Education: Progression #1
Take the ideas and be able to design/write it on your own!!
See pics
Abdominal Re-Education: Progression #2
See Pics
Abdominal Re-Education: Progression #3
See pics
Use and be able to write/implement/design!!!
*Understand the progressions!!!
Symphysis Pubis Dysfunction (SPD)
- Occurs during pregnancy OR as result of trauma during delivery
- *Lithotomy pos.
- Radiographic testing→ Reveals separation post-partum
- ***Occurs in conjuction w/ lumbopelvic, PGP
- *Often severe case presentation
Symphysis Pubis Dysfunction (SPD)
Examination and Mgmt
BOLD=IMPORTANT!!!
-
BOLD/IMPORTANT STUFF:
-
AVOID asymmetrical pos’s!
- → Promote EQUAL WB thru pelvis
- Provide AD for gait (SW, RW)
- Modalities to DEC inflammation: pulsed US (postpartum), ice
- Supportive belt around greater trochs
-
AVOID asymmetrical pos’s!
SPD Exam/Mgmt
Other stuff
Palpate pubic tubercle if tolerated (consent!), Pt edu. for transfers, ADLs, Core/Pelvic stabilization program
Pelvic Stability Belts & Binders
- Assists→ Form closure of pelvic joints, force closure of abdominals*
- LOW cost, user friendly, min. risk of harm
Summary Slide:
Mods for Prenatal & Postpartum Clients
- Asymmetrical pos’s and lumbopelvic pain
- Wt bearing helps to DEC pain and promote form-force closure thru pelvis
- Quadruped for INCd WB, comfort
- S/L***
THINK BACK ON THE LECTURE!!! YOU KNOW THESE!!!
