Role of Physio in Postnatal Education Flashcards
what is the MAMMI study and what is its objective?
longitudinal study Health Research Board
follows 2,600 through pregnancy and 1 year after the birth of 1st baby
collects info on urinary incontinence, mental health, PGP, sexual health , DV, C - sections
reasons for referral to physio post natal
3rd or 4th degree tears - Obstetric and sphincter injury (OASIS)
Urinary incontinence
urinary retention
poor mobility post C section
Diastasis rectus abdominus muscle - DRAM
PGP, LBP
Describe 2nd degree tear of OASIS
: injury to the perineum involving perineal muscle but not involving the anal sphincter
Describe 3rd degree tear
– disruption of the anal sphincter muscles
3a <50% thickness of EAS (external anal sphincter) torn
3b >50% thickness of EAS torn
3c IAS (internal anal sphincter) torn also
describe 4th degree OASIS tear
4th degree tear disruption of the
epithelium
list risk factors for OASIS
Birth weight over 4 kg
Persistent occipitoposterior position (OP) “back to back”
Nulliparity
Induction of labour
Epidural analgesia
Second stage longer than 1 hour
Shoulder dystocia
Midline episiotomy
List management of OASIS
RCOG recommend repair takes place in theatre by
appropriately trained obstetricians
Antibiotics & laxatives
Follow up at 6 weeks- NB direct & specific questioning
about symptoms of faecal incontinence (faecal
urgency, poor flatal control, dyspareunia & perineal
pain
Discuss future pregnancy and mode of delivery
describe the clinical practice guidelines for OASIS - HSE and Intitute for Obstetricians and Gyno 2012
All women should be reviewed by a physiotherapist prior to discharge and should be offered physiotherapy and pelvic floor exercises for 6-12 weeks after obstetric anal sphincter injury and repair.
Encourage referral to physiotherapy during future pregnancies to maximise pelvic floor and anal sphincter muscle function
internal symptoms of sphincter damage
Passive Soiling
Passive flatus
Difficulty cleaning
external symptoms of sphincter damage
Urgency
Faecal incontinence
Flatus incontinence
physio management of OASIS
Advice regarding:
– Positions of optimum comfort
– Use of ice, rest, supportive underwear
– Position for defecation
– Perineal hygiene
– Prevention of constipation
– Pelvic Floor/sphincter exercises
Follow up until symptom free/or adequate strength to refer to specialist follow up
definition of urinary retention
Urinary Retention is the inability to empty the bladder
when voiding
overt retention
the inability to spontaneously void at all
covert retention
passing small amounts of urine and has an elevated post void residual urine volume greater than 150mls with no symptoms of urinary retention
management of urinary retention
Catheterisation to allow bladder to recover
Elevated residual >150 - self intermittent
catheterisation until complete emptying
Fluid management
Advise re: good bladder habits
Tips for emptying bladder
Bladder care nurse tests
Transcutaneous Tibial Nerve Stimulation TTNS
possible problems after Lower uterine segment caesarean section (LSCS)
Wound infection
Haematoma
Nerve entrapment syndrome (Ilioinguinal or
iliohypogastric nerves)
Shoulder tip pain
DVT and PE
Back pain
Dependent oedema
Tiredness
Trauma
physio after lower uterine segment caesareans ection (LSCS)
ACBT, FET, supported cough
Anti-DVT exercises
Bed mobility
Posture
Progression of mobility
Trans Ab & pelvic floor exercises, pelvic tilts
Functional advice
Cause of shoulder tip pain
Phrenic nerve irritation causes referred pain to C4
It seems that diaphragmatic irritation with amniotic
fluid or blood is the most likely factor
advice for the management of shoulder tip pain
Advise gentle movement, knee rocking, peppermint
water/tea
Usually self resolves within 48hrs
describe the stages of scar massage
Stage One involves stretching and desensitizing the skin around the scar
Stage Two involves stretching and desensitizing the skin directly on/ over the scar
Not recommended to use lotion
what is a hypertrophic scar
where the scar grows on top of the borders of
the original scar, and becomes ropelike
caused by excessive production of collagen on top of collagen
treatment for keloid scar
silicone therapy plus light
compression.
benefits of breastfeeding
s protective for PGP! Prolactin and
oxytocin are anti-inflammatory, except for obese
patients
describe epidemiology of postnatal PGP
More postnatal PGP with csections
Although PPGP mostly subsides after the birth, 8-10%
of women continue to have persistent PGP 18-24
months after the birth
inpatient management of pubic symphysis separation
Rest++ in sidelying
Pain relief – Difene, Xydol
Ice
Tubigrip/serola belt
Catheterise if necessary to avoid mobilisation
Use of anti DVT stockings
Help with personal care/baby care
Gradual mobilisation, zimmer frame, crutches
Core rehabiliation
when is it indicated to refer a patient for a medical review or MRI if they present with PGP or other MSK issues
History trauma, unexplained weight loss, cancer history, steroid use, substance abuse,
immunosuppression, neurogical symptoms, fever, malaise, no relief with rest, severe
disabling pain
what is the typical physiotherapy treatment plan for grade a PGP
PTs should advocate for initiating care in early postpartum period to reduce likelihood of chronicity
Inclusion of patient education on PP-PGP, normal changes postpartum
and body mechanics in the intervention
ASLR and P4
Muscle function testing– force production, endurance, resting tone and
muscle length
Strengthening as tolerated for pelvic floor, back flexors, back extensors
and hip extensors
PTs should not apply manual therapies in isolation, but manual
therapy can provide short term improvements
Use of a p
What is diastasis rectus abdominus muscle
DRAM is a thinning and widening of the linea alba
This is the connective tissue in the middle of the abdominal wall
between the rectus abdominus muscles
increased laxity
causes of diastasis of rectus abdominus
Caused by hormonal changes, weight gain,
abdominal muscle weakness and stretching of the muscles as baby grows
Rate of incidence of diastasis of rectus abdominus muscle
Incidence of 66% during third trimester, can
persist in 23 to 32% of women at 1 year postnatally
(Sperstad et al 2016)
predisposing factors of DRAM
older women, obesity,
multiple birth pregnancy, lax abdominal wall from
previous pregnancies, C-section (Lo et al 1999)
describe the Diane Lee-Integrated Systems Model
measured the inter recti distance and distortion index of 26 subjects and 17 controls w/ DRAM
tension is more important than width
describe the clinical assessment for DRAM
Subjective important-back or pelvic pain, pelvic floor dysfunction
Postural analysis
Palpation of linea alba and degree of tension
Curl up test
Functional loading tests: active straight leg raise, stork
Trans ab recruitment, oblique activity, rectus strength
Ultrasound
Sometimes assessed in standing.
IRD is naturally wider in upright
positions (Gillard et al 2018)
Explain curl up test
Patient should be lying supine, one pillow
* Use your fingers to palpate the medial edges of the Rectus
abdominus muscles
* Ask patient to raise head off bed as if coming into a sit up
* Measure inter-recti distance (in finger widths) at the level of
umbilicus and at a set distance above and below
* Document the tension at the linea alba
list the a useful proforma for DRAM
PPP-RR-LD
Person - QOL, body image
Posture - influence motor recruitment
Patterns - overactivity of obliques
Respiration - synergistic relationship of diaphragm, abdominal wall and pelvic floor
Ribcage - symmetry, flaring, infrasternal angle, thoracic expansion
Load - dome or sink at midline (soft or hard)
defect - hernia - refer to GP, surgical intervention?
exercise management of diastasis of rectus abdominus muscle
advocate neutral spine posture and alignment
encourage tension free diaphragmatic breathing pattern
encourage optimal body mechanics and motor activation strategies for everyday tasks
Encourage habitual ADL - that reduce repeated increases in intra-abdominal pressure
list other conditions that may indicate a post natal physio referral
coccyx pain
shoulder/neck pain
peripheral neuropathies
respiratory
carpal tunnel syndrome/de quervains tenosynovitis
list the possible aggravating factors of coccyx pain
Sitting
Rising from chair after prolonged sitting
Changing position
Lifting
Feeding baby
Coughing
Defaecation
list possible management tools for coccyx pain
Coccyx cushion
Lumbar roll
Postural & ergonomic advice
Ice packs, ultrasound
Pelvic floor exercises
Myofascial release/ manual therapy external and/or
internal
Advice on prevention of constipation
