Week 6- Women’s Health Physiotherapy Flashcards
1
Q
What does gravida mean
A
Number times a person has been pregnant
2
Q
What does parity mean
A
Number of births
3
Q
What does nulligravida mean
A
Never been pregnant
4
Q
What does primigravida mean
A
Pregnant for first time/one time
5
Q
What does multigravida mean
A
Pregnant more than once
6
Q
What is full term and the associated trimester
A
40 weeks, divided into three trimesters
1st trimester= week 1 to 12 (month 1-3)
2nd trimester= week 13 to 28 (month 4-6)
3rd trimester= week 29 to 40 (month 7-9)
7
Q
Explain what’s expected in in the first trimester
A
- Baby Growth 0.1mm–7cm
- Placenta develops Wk 5
- Extreme fatigue
- Urinary frequency
- Constipation
- ↑ Blood Volume
- Weight gain or loss
- Heartburn & Headache
- Nausea & vomiting, cravings/distaste
- Emotional & hormonal changes
- Breast tenderness, ↑ size, nipple changes
8
Q
What is expected in the second trimester
A
- Baby Growth 7cm to 35cm
- Foetal movements 5th month
- Continued breast changes, heartburn, constipation
- Shortness of breath, ↑ RR, tidal volume
- Bleeding gums, nosebleeds, nasal stuffiness
- Dizziness & fainting
- Skin changes
- Body aches, round ligament pain, sciatica
- Increase in joint laxity (relaxin)
- Swelling of ankles/hands/face, leg cramps
- Varicose veins
9
Q
What is expected in the third trimester
A
- Baby Growth 36-50cm
- 28wk=1kg, term=2.5-3.8kg
- Colostrum production, ongoing breast changes
- Cervix thinning
- Braxton-Hicks contractions
- Painful joints, dragging feeling in pelvis
- ↑ shortness of breath, then lightening
- Urinary frequency/incontinence, constipation
- Swelling, fatigue, trouble sleeping, varicose veins
- Heartburn, haemorrhoids, stretch marks, skin changes
10
Q
What is the typical weight gain in a typical pregnancy
A
10-16kg
Increased blood volume= 1.2-1.8kg Breasts= 0.5-0.9kg Uterus= 0.9kg Amniotic fluid= 0.6-0.9kg Placenta= 0.6kg Baby= 2.5-4kg Fat= 1.8-4.0kg Water retention= 1.5-2.5kg Increased blood and fluid= 1.0-1.8kg
11
Q
What is the weight gain for twins or triplets
A
Twins= 16-21kg Triplets= 21+kg
12
Q
What is low weight gain associated with
A
Premature birth
13
Q
What is overweight/ high weight gain
A
- High BP
- Gestational diabetes
- Large baby
- C-section
- Difficulty losing weight post natal
14
Q
What are advised total weight gain
A
15
Q
What are the specific MSK changes in pregnancy
A
- Force across some joints ↑ x2
- Change in COG & joint mobility
- Spine: ↑ Lx lordosis, Cx protraction, downward mvmt of shoulders, stretch of spinal ligs, ↑ breast size
- Abdominals: stretching, weakness, separation
- Pelvis: Widening of SIJ and PS, ↑ pelvic anterior tilt=↑ use hip extensors/abductors and ankle PF
- Widened stance to maintain trunk movement
16
Q
Prevalence of pregnancy-related pelvic girdle pain
A
up to 72% prevalence of lumbopelvic pain in pregnancy
17
Q
Where May pregnancy related pelvic girdle pain present
A
Pain of musculoskeletal origin that is experienced in the lumbar and/or sacroiliac area during pregnancy and/or immediate post partum period. Pain may occur in conjunction with or separately in the symphysis pubis.
18
Q
Lumbar pain in pregnant people
A
• 2/3 pregnant women (Pennick, 2013)
• 2nd half of pregnancy
• Consider BPS model: biomechanics (e.g. posture, muscle weakness, Z-jt irritation), hormonal (e.g. fluid retention, joint
flexibility, neural sensitivity), psychosocial
• Activity-aggravated, local pain or radiation down thigh, often
worse at night
19
Q
What are risk factors for lumbar pain in pregnancy
A
- pre existing LBP, Hx LBP
- previous pelvic trauma
- ? Occupation, multiparity, hypermobility, obesity (less evidence)
20
Q
What is the management of LBP/PGP
A
- Multimodal approach (PT, joint mob, brace, exs) better than usual care
- Multimodal approach more beneficial
- Aerobic + PFM + stabilisation exs = sig. effect on LPP prevention
- Positioning, exercise, support belts, acupuncture
- Hydrotherapy some benefit
- Heat, ice, massage
- Exercise that is enjoyed and individually-tailored/supervised
Moderate evidence:
• Acupuncture or exercise decreases LPP/PGP more than usual care
• Women who exercise cope better with LPP
Low quality evidence:
• Exercise significantly decreases pain/disability LBP
• Hydrotherapy sig. reduced LBP-related sick leave
Note: even if low evidence, if they enjoy that activity it will be beneficial for them
21
Q
Pelvic girdle/ SIJ pain in pregnancy aggs and prevalence
A
- Pain worse on WB, prolonged sitting, SLS, shear
- SIJ provocation tests +ve
- 20-45% of pregnant women
- 80-90% recover 6/12 post delivery
22
Q
Pelvic girdle/ SIJ pain in pregnancy risk factors
A
multigravida, Hx LBP, stress, obesity, young age, occupational/strenuous work, SE status, C-Section
23
Q
Pelvic girdle/ SIJ pain in pregnancy management
A
- support brace
- acupuncture (+exercise)
- stabilisation exercises (hip add/abd, glutes, TAB)
24
Q
Symphysis pubis pain in pregnancy
A
- increase mobility; insidious or traumatic
- normal wiring in pregnancy 9-10mm
- joint May click or crunch (with or without pain)
- local anterior pain, pain on weight bearing, leg separation, SLS
- usually resolves 4-12/52 PP
25
How to manage symphysis pubis pain
Rest, advice/education, walking aids (crutches/walking frame), pelvic support braces, stabilising exercises
26
What is advice you can give around PSG/PGP/LPP
```
Try:
• Pillows between legs when sleeping
• Sit to put on shoes/socks/underwear
• Legs together to get in/out of bed/car
• Less stress/more sleep
```
```
Limit:
• Uneven weight distribution
• Bending/lifting/carrying weights
• Wide leg separation
• Crossing legs
```
27
What are benefits of exercise in pregnancy
* Increased bone strength / lean muscle mass
* Improved maternal physical fitness / PFM function
* Fewer delivery complications / reduced rate C/S
* Decreased risk of elevated BP / pre-eclampsia
* Reduced risk gestational diabetes
* Improved physical / mental wellbeing
* Decrease back / pelvic pain
* Maternal weight control
* Childcare prep
28
What are potential risk factors of exercising in pregnancy
* Hyperthermia -> avoid hot weather/dehydration
* Falls risk -> due to COG/weight changes
* Risk abdominal injury -> ?low risk
* ↑ joint laxity -> ?injury risk
* ↑ extracellular fluid load -> wrist pain/CTS
* Effect on birth weight (ACOG, 2003) -> Birth weight not affected by exercise in women with sufficient caloric intake
29
What are high risk exercise activities
* High altitude training
* Pressure changes (e.g. diving)
* Abdominal trauma/pressure (e.g. weightlifting)
* Contact/collision sport (e.g. MMA, soccer)
* Risk of falling (e.g. horse riding, judo, skiing)
* Hard equipment used (e.g. cricket ball, hockey stick)
* Extreme balance/coordination/agility (e.g. waterskiing)
* ?Exercise in supine after 28/40 (due to pressure on major vessels)
30
What are exercise guidelines during pregnancy
Aerobic Exercise (SMA guidelines):
• Healthy women can begin/maintain moderate intensity aerobic exercise
• No study has found negative effect on foetus/pregnancy
• Swimming, running, aerobics, cycling = safe
• Safe upper limit uncertain
• Avoid excess stretching / ballistic movements
• No effect on course or outcome of labour
• Associated with fewer birth interventions
Resistance Exercise (SMA guidelines):
• Recommended 2 sessions/wk, submax intensity
• Light-moderate training with free weights, machines, bands, body weight or combo
• Recommendation: light to moderate weights, avoid heavy max isometric contractions
• Avoid Valsalva, supervise safe technique
• Minimise supine position 2nd and 3rd trimester
• No obvious effects on weight gain, complications, course of labour, birth weight
31
How often should pregnant women be exercising
* Exercise program of average 43min, 3x/wk, max HR 144bpm leads to no adverse effects
* Sedentary women can commence a light to moderate exercise program during pregnancy (SMA guidelines)
* Healthy women can continue preconception regular aerobic exercise program (SMA guidelines)
* Elite athletes – continue/adapt and monitor exercise
32
When to stop exercising
* Abdominal pain
* Amniotic fluid leakage
* Uterine contractions/labour, PV bleeding
* Calf pain or swelling (DVT)
* Chest pain/tightness/palpitations
* Decreased foetal movements
* Dizziness or presyncope
* Dyspnoea pre-exertion, excessive SOB
* Excessive fatigue, muscle weakness/poor balance
* Headache (unfamiliar, sudden onset)
33
What are contraindications and precautions to exercise
34
What are post partum changes
• Separation of linea alba (rectus diastasis) = NORMAL during pregnancy/early PP
-Birth injuries common:
• Large birth weight >4kg —> PFM injury
• Forceps>ventouse —> diastasis pubis, PFM injury
• Prolonged labour (active pushing )—> diastasis pubis, PFM injury
• Pressure on coccyx —> LBP/coccydynia
• Bleeding into SIJ —> sacroiliitis
-Pelvic floor dysfunction common:
• Prolapse
• Incontinence
• Pelvic pain
35
What are the 4 grades of perineal tears
Note grade 3/4: High risk of future faecal +/- flatus incontinence
36
What education do you give inpatient c-section
- Post-op advice, scar and wound cares
- Mobilise & progress walking as pain allows
- Remember: MAJOR SURGERY
• No lifting heavier than baby - 6 weeks
• No heavy housework - 6 weeks
• No driving - 6 weeks
• No sit-ups/crunches – log roll
• Pelvic floor exercises post-op
• Static TAB contractions/pelvic rocking
• Ease into gentle aerobic exercise as pain allows (aim 30min walk by 6weeks)
37
What is the post partum return to activity guidelines
* Aim for 30min/day walking/low impact exercise by 6/52
* Can begin gentle walking/PFMX/TAB after birth
* Practice “good”3/12 post birth
38
What is pelvic floor muscle function
Sphincteric Function
- conscious control over bladder & bowel
- Contract = pelvic organs lift, sphincters tighten
- Relax = allow you to wee and poo (and fart!)
Supportive Function
- Support pelvic organs
- Workswithin“corecylinder”tosupport/stabilize
- PFM+Diaphragm+TAB+MF
Sexual Function
- proprioceptive sensation
- erectile function and ejaculation/orgasm
39
What are they 3 layers of the pelvic floor called
1- urogenital triangle/ superficial perineal
2- deep urogenital diaphragm
3- pelvic diaphragm
40
What are the muscles in the 1st layer of the pelvic floor, urogenital triangle/ superficial perineal
* Bulbospongiosis
* Ischiocavernosis
* Superficial transverse perineal
* External anal sphincter
41
What are the muscles in the second layer, deep urogenital diaphragm
* External urethral sphincter
| * Deep transverse perineal
42
What are the muscles in the 3rd layer, pelvic diaphragm
* Levator Ani: pubococcygeus, puborectalis, iliococcygeus
* Coccygeus (aka ischiococcygeus)
* Piriformis
* Obturator internus
43
What is urinary incontinence
“Accidental or involuntary loss of urine from the bladder”
• Leakage with ↑ abdo pressure
• Constant or urgent need to urinate
• “Stress Incontinence” = SUI = activity-related leak
• “Urge Incontinence” = UUI = sudden + strong urge leak
• “Mixed Incontinence” = SUI + UUI
• Frequency/urgency
• “overactive bladder” = OAB (wet/dry) +/- nocturia
• ?detrusor instability / ?behavioural
• ?hypertonic PFM / ?UTI
44
How many Australians experience incontinence
-4.8 million Australians (>50% are >50yr old)
• 4.2 million with Urinary
• 1.3 million with Faecal
-By 2030: 5.6 million urinary, 1.8 million faecal
- 77% Nursing Home Residents are incontinent
- 40-60% of residents will wet the bed tonight
- In 2010, total financial cost $66.7 billion (~$14,014 pp)
- projected rise of > $450 million by 2020
45
Prevalence of urinary incontinence
* 80% are Women
* 65% women and 30% men sitting in GP room report incontinence, only 31% seek help
* 70% with urinary leakage do not seek advice or treatment
46
Faecal incontinence prevalence
* 20% men, 12.9% women
| * 1 of 3 major causes of admittance to Rest Home in Elderly
47
What are risk factors for PFM dysfunction
* Pregnancy & childbirth
* Constipation / straining
* Chronic coughing
* Heavy lifting / high impact exercise
* Age
* Obesity
* ↓oestrogen levels (menopause)
* Co-morbidities: MS, Parkinsons
* Hx of poor bladder habits
* Prostate issues
48
What is management of incontinence
* Pelvic Floor Muscle Exercises (PFMX)
* 84% of women with stress incontinence are cured with PFM training after 5 physiotherapy sessions
* General lower limb muscle strengthening
* Reduce strain on PFM, support pelvis/sacrum
* Lifestyle modifications
* Medications
* Surgical Interventions
