Role of Physio in Postnatal Education

Question 1

what is the MAMMI study and what is its objective?

Answer 1

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

Question 2

reasons for referral to physio post natal

Answer 2

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

Question 3

Describe 2nd degree tear of OASIS

Answer 3

: injury to the perineum involving perineal muscle but not involving the anal sphincter

Question 4

Describe 3rd degree tear

Answer 4

– 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

Question 5

describe 4th degree OASIS tear

Answer 5

4th degree tear disruption of the
epithelium

Question 6

list risk factors for OASIS

Answer 6

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

Question 7

List management of OASIS

Answer 7

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

Question 8

describe the clinical practice guidelines for OASIS - HSE and Intitute for Obstetricians and Gyno 2012

Answer 8

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

Question 9

internal symptoms of sphincter damage

Answer 9

 Passive Soiling
 Passive flatus
 Difficulty cleaning

Question 10

external symptoms of sphincter damage

Answer 10

 Urgency
 Faecal incontinence
 Flatus incontinence

Question 11

physio management of OASIS

Answer 11

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

Question 12

definition of urinary retention

Answer 12

 Urinary Retention is the inability to empty the bladder
when voiding

Question 13

overt retention

Answer 13

the inability to spontaneously void at all

Question 14

covert retention

Answer 14

passing small amounts of urine and has an elevated post void residual urine volume greater than 150mls with no symptoms of urinary retention

Question 15

management of urinary retention

Answer 15

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

Question 16

possible problems after Lower uterine segment caesarean section (LSCS)

Answer 16

 Wound infection
 Haematoma
 Nerve entrapment syndrome (Ilioinguinal or
iliohypogastric nerves)
 Shoulder tip pain
 DVT and PE
 Back pain
 Dependent oedema
 Tiredness
 Trauma

Question 17

physio after lower uterine segment caesareans ection (LSCS)

Answer 17

 ACBT, FET, supported cough
 Anti-DVT exercises
 Bed mobility
 Posture
 Progression of mobility
 Trans Ab & pelvic floor exercises, pelvic tilts
 Functional advice

Question 18

Cause of shoulder tip pain

Answer 18

 Phrenic nerve irritation causes referred pain to C4
 It seems that diaphragmatic irritation with amniotic
fluid or blood is the most likely factor

Question 19

advice for the management of shoulder tip pain

Answer 19

 Advise gentle movement, knee rocking, peppermint
water/tea
 Usually self resolves within 48hrs

Question 20

describe the stages of scar massage

Answer 20

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

Question 21

what is a hypertrophic scar

Answer 21

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

Question 22

treatment for keloid scar

Answer 22

silicone therapy plus light
compression.

Question 23

benefits of breastfeeding

Answer 23

s protective for PGP! Prolactin and
oxytocin are anti-inflammatory, except for obese
patients

Question 24

describe epidemiology of postnatal PGP

Answer 24

 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

Question 25

inpatient management of pubic symphysis separation

Answer 25

 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

Question 26

when is it indicated to refer a patient for a medical review or MRI if they present with PGP or other MSK issues

Answer 26

History trauma, unexplained weight loss, cancer history, steroid use, substance abuse, immunosuppression, neurogical symptoms, fever, malaise, no relief with rest, severe disabling pain

Question 27

what is the typical physiotherapy treatment plan for grade a PGP

Answer 27

 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

Question 28

What is diastasis rectus abdominus muscle

Answer 28

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

Question 29

causes of diastasis of rectus abdominus

Answer 29

Caused by hormonal changes, weight gain, abdominal muscle weakness and stretching of the muscles as baby grows

Question 30

Rate of incidence of diastasis of rectus abdominus muscle

Answer 30

Incidence of 66% during third trimester, can persist in 23 to 32% of women at 1 year postnatally (Sperstad et al 2016)

Question 31

predisposing factors of DRAM

Answer 31

older women, obesity, multiple birth pregnancy, lax abdominal wall from previous pregnancies, C-section (Lo et al 1999)

Question 32

describe the Diane Lee-Integrated Systems Model

Answer 32

measured the inter recti distance and distortion index of 26 subjects and 17 controls w/ DRAM tension is more important than width

Question 33

describe the clinical assessment for DRAM

Answer 33

 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)

Question 34

Explain curl up test

Answer 34

 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

Question 35

list the a useful proforma for DRAM

Answer 35

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?

Question 36

exercise management of diastasis of rectus abdominus muscle

Answer 36

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

Question 37

list other conditions that may indicate a post natal physio referral

Answer 37

coccyx pain shoulder/neck pain peripheral neuropathies respiratory carpal tunnel syndrome/de quervains tenosynovitis

Question 38

list the possible aggravating factors of coccyx pain

Answer 38

 Sitting  Rising from chair after prolonged sitting  Changing position  Lifting  Feeding baby  Coughing  Defaecation

Question 39

list possible management tools for coccyx pain

Answer 39

 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