Maternal Health

Ekta modi
2nd MPT in Rehab

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 Topics Covered
Anatomy,
Physiological changes in pregnancy and
peuperium.
Musculoskeletal changes and other discomforts of
pregnancy.
Antenatal period.
Physiology of labour and Coping with labour.
Postnatal period.
Pelvic floor dysfunction in Perinatal period and its
physiotherapy management.

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 Anatomy
The Pelvis:
• A protective shield for important pelvic
contents.
• Consist of two innominate bones, sacrum to
which coccyx attach.
• Inlet: level of sacral promontory and superior
aspects of pelvic bones.
• Outlet: pubic arch, ischial spines,
sacrotuberous ligaments and the coccyx

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• Space enclosed within inlet and outlet is
called true pelvis.
• Pelvic inlet: four types,

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1. Gynaecoid: most common shape, almost
round.55% of women
2. Android or male: heart shaped.20%
women
3. Anthropoid: oval, longer
anteroposteriorly.20% women
4. Platypelloid: longer transversely.5%
women
Narrow suprapubic arch is
associated with consequential prolonged
labour and postpartum anal incontinence.
(Frudinger et al 2002)
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Pelvic diameters:

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•Diameters of Gynaecoid true pelvis.
A/P (cm) Oblique(cm) Trans(cm)
Inlet 28 30.5 33
Midcavity 30.5 30.5 30.5
Outlet 33 30.5 28

• Foetal head enters inlet transversely

placed, rotates in mid-cavity and leaves by
its longest dimension lying
anteroposteriorly.
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Pelvic floor and muscles of pelvis:

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 Zacharin(1980) used the term pelvic
trampoline characterizing pelvic floor.
Layers of pelvic floor from deep to
superficial:
1. Endopelvic fascia: fibromuscular tissue
composed of collagen, elastin, smooth
muscle fibres.
• Connects pelvic organs to pelvic side
walls.
• Major ligaments: cardinal (transverse
cervical) and uterosacral

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• Their downwards extensions are known as pubocervical and rectovaginal fascia
respectively,that attach middle third of vagina to pelvic side-walls.
2. Levator ani muscles: also called pelvic diaphragm.
• Three muscles are classified under it,
a) puborectalis
b) pubococcygeus
c) iliococygeus

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• Ischiococcygeus muscle can be
considered as part of levator ani.
contributes to sacroiliac joint stability.
• Levator ani: made up of large
diameter type1 (slow twitch) and
type2 (fast twitch) striated muscle
fibres.( Gilpin et al 1989)
• Supplied by perineal branch of
pudendal nerve. (S2-S4)

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3. Perineal membrane: also called
urogenital diaphragm.
inferior to levator ani,at the level of
hymenal ring.
provides lateral attachments for
perineal body and supports urethra.
4. External genital muscles:
a) ischiocavernosus
b) bulbocavernosus
c) transverse perineal muscles
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• First two act upon clitoris and are
probably involved in female sexual
response. ( DeLancey 1994)
5) External genitalia and skin.
Chief function of pelvic
floor: support abdominal and pelvic
viscera, maintain continence of urine
and faeces; allow voiding,
defaecation, sexual activity and
childbirth.

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The abdominal muscles

• Deepest group : transversus

abdominis,lies internally to internal
and external oblique muscles.
all three insert into broad
aponeurosis,which is reinforced by
two rectus abdominis muscles.
• PFMs are part of abdominal capsule
along with deeper muscles of
abdomen, spine, diaphragm.
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These muscles are affected by
respiration and posture.
Hence should be considered in
muscle training as a complete unit
when treating any one part.( Sapsford
2001)

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The Breast

• 15 – 25 secreting
lobes composed of
many lobules.
• Each lobe has its
duct.
• Just proximal to
opening of duct is
lactiferous sinus,
temporary reservoir
of milk.

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• Surrounding loose pigmented skin is
called areola. Has modified sweat
glands present called Montgomery’s
tubercles which enlarge during
pregnancy.
• Lymphatic drainage: 95% into anterior
axillary nodes (Bundred et al 2000)
• Nerve supply: anterior nad lateral
cutaneous branches of 4th -6th thoracic
nerves.

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Reproductive tract

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1. Ovaries
• Two pinkish grey structures with the
size and shape of almonds,
consisting of thousands of primary
follicles.
• Produce ova and secretes
oestrogens and progesterone.
• At ovulation,ovum is directed to
fallopian tube by fimbriae.

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• After ovulation follicle collapses and
become corpus luteum which
secretes oestrogens and
progesterone.

• If fertilization occurs,it enlarges and

remain active for 4months. If the
ovum does not fertilize,it shrivels in
10 days.

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2. Fallopian tubes
• Outer end of tube is funnel shaped
and fimbriated.
• Proximal end gain access to uterine
cavity.
• Coat of smooth muscle, consists of
outer longitudinal and inner circular
layer which is responsible for
peristaltic waves.

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• Conception occurs at the junction of
distal third and proximal two-thirds of
the tube.
• Capacitation: tubal secretions contain
essential ingrediants to condition
sperm and ovum for fertilization.
• Ectopic pregnancy: implantation in
tube.

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3. Uterus :
• Consists of fundus, body, isthmus
(develops into lower segment during
pregnancy) and cervix.
• Shape: inverted pear.
• In nulliparous measures 9cm long,
6cm wide and 4cm thick. Weighs 50g.
• It is hollow organ with thick
myometrium, Highly vascular
endometrium apprx 1.5mm thick
called decidua during pregnancy.
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• Myometrium has three muscle layers:
a) inner circular layer: pulls open lower
segment and cervix in labour.
b) middle oblique layer: involved in
expulsive contractions of labour and
clamping off bleeding vessels after
placental delivery.
c) outer longitudinal layer: pushes
foetus down into the more passive
lower segment in labour.
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• Cervix :
Forms a fusiform or spindle shaped
canal at the junction of main body of
uterus and vagina.
Distal two-third protrudes into and
form vault of vagina-lowest portion is
called external os.
Mucoid secretions from cervix along
with constrictive nature of cervix acts
as deterent to rising infection.

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4. Vagina :
• About 7.5cm long, passes upwards
backwards and meet longest axis of
uterus at about 90degrees.
• Consist of layer of smooth muscle
whose fibres are placed longitudinally
and circularly.
• It is positioned posteriorly to urethra and
base of bladder and anteriorly to
rectum.

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• Urethra embedded in anterior vaginal
wall is vulnerable to trauma during
childbirth, pelvic surgery and
occasionally during intercourse.

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Suspensory ligaments:

• Female
reproductive tract
is suspended
across midline of
true pelvis enfolded
within double layer
slack broad
ligament, attached
to lateral inner
surface of pelvis

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• Ovaries are attached to the posterior
layer of broad ligament.
• Uterine round ligaments attach
anteriorly to either side of the fundus
of the uterus,pass forward via deep
inguinal ring to insert into
subcutaneous tissue of labia majora.
• Round ligaments keep the uterus
anteverted and anteflexed.

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• Lower fringe of broad ligament
condense to form transverse cervical
ligaments also called cardinal and
Mackenrodt’s ligaments,connecting
cervix to lateral walls of pelvis.

• Two bands- pubocervical fascia- pass

anteriorly either side of neck of
bladder to posterior surface of pubis.

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• Two other bands of fascia-
uterosacral ligaments- connect cervix
and upper part of vagina to lower
portion of sacrum.

• Thus cervix is suspended by ‘guy

ropes’. This support is supplemented
by lifting support of PFMs- base of the
pelvic cavity.

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Pregnancy And Foetal development

Following fertilization,
• Ovum divides
• Nourished by secretions from
fallopian tube
• Outer layer (trophoblast) of increasing
group of cells (morula) produces
HCG.
• Morula gets implanted to survive and
additional hormone production.
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• Chorion: outer and inner layers of
cells are together called chorion.
it divides to form villi which burrow
into uterine endometrium/decidua.
• Blastocyst: spherical ball of cells.
Hollow, inner mass of cells on one
side develops into embryo.
• Placenta: innermost site where
blastocyst contacts decidua develops
into placenta.
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• Its disc shaped, 20cm diameter, 3cm
thick, weight 500-700gms.
Maintains foetal circulation.
Vital functions like respiration,
nutrition, excretion.
Acts as both lungs and gut.
Major hormone producing structure:
oestrogen, progesterone and HCG.

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• Naegel’s rule: method to calculate
expected date of delivery (EDD)
• For first 8wks, developing baby is
called ‘embryo’, then till delivery its
called ‘foetus’
• Foetus grows in amnion, bathed in
amniotic fluid.
Fluid contains proteins, sugars,
oestrogens, progesterone,
prostaglandins and cells from foetal
skin.
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Physiological changes in pregnancy

Pregnancy brings changes in following

systems of body,
1. Endocrine system
2. Reproductive system
3. Cardiovascular system
4. Respiratory system
5. Immune system
6. Breasts
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7. Skin
8. Gastrointestinal system
9. Nervous system
10. Urinary system
11. Musculoskeletal system

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Endocrine system
• Hormones of major importance to us are:
progesterone, oestrogen, relaxin.
• Progesterone: first produced by corpus
luteum for 10wks then by placenta in
entire pregnancy. Starting from
30mg/24hrs at 10wks to 250-
300mg/24hrs at the end of 40wks.
• Oestrogens: produced same as
progesterone.

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• Output of about 5mg/24hr at 20 wks
to 50mg/24hrs at 40 wks.
• Relaxin: produced in theca and
luteinised granulosa cells in corpus
luteum and later decidua.
Produced as early as 2wks of
gestation, highest in 1st trimester and
then drops by 20% to remain steady
(Weiss 1984)

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 Effect of progesterone,
1. Reduction in tone of smooth muscle,
• Reduced Peristaltic activity in stomach
• Constipation
• Reduced uterine muscle tone
• Detruser muscle tone reduced
• Urine stasis due to dilatation of
ureters: urinary infection

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• Urethral tone reduced : stress
incontinence
• In blood vessels: lowered diastolic
pressure.

2. Increase in temperature (0.5 to 1C)

3. Reduction in alveolar and arterial

Pco2 tension, hyperventilation.

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4. Development of breasts milk
producing glands.

5. Increased storage of fat.

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 Effects of oestrogens:
1. Increase in growth of uterus and
breasts ducts.
2. Increase in level of prolactin for
lactation.
3. assist maternal calcium metabolism
4. Increase water retention.

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 Effects of relaxin:
1. Gradual replacement of collagen in
target tissues, increase in its water
content.
2. Inhibition of myometrial activity till
28wks.
3. Towards end of pregnancy, soften the
cervix. (Verralls 1993)
4. Relaxation of pelvic floor muscles.
(Verralls 1993)

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Reproductive system
• Amenorrhoea: first sign of pregnancy
• Change in the colour of cervix within
few days of conception.
• Gradually in final weeks, softening,
greater distensibility, effacement and
eventually dilatation of cervix.
• Growing uterus rises to become an
abdominal organ at about 12wks
gestation.
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Average fundal heights,

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• At term, weight of the uterine tissue :
1000gm and can hold 5000ml which in
non-pregnant women is 6ml.
• Braxton Hicks contractions:
• False labour or prelabour: sequences of
contractions of variable lengths (20secs
to 4min)
• Recent research in effect of exercise on
pregnant women and foetus: Sharp
2003

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Cardiovascular system

Undergoes great changes during

pregnancy,
Cardiac output
• Changes in cardiac output (SV * HR)
includes,
40% increase persisting throughout
pregnancy.
30% increase in CO.
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 Heart rate increase by 15 beats/min
• Increased output directed to uterus,
kidneys and G.I.T.
Blood flow increase approx
500ml/min
(de Swiet 1992)

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 Blood pressure
• Little change in systolic pressure,
decrease in diastolic pressure.
• PIH: when systolic increases more
than 30mmHg or diastolic more than
15 mmHg.( Blackburn et al 1992

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 Supine hypotension
• reason
• Moving the women into sidelying gives relief
(Kinsella et al 1994)

Venous blood pressure

• Rise in lower limbs:
• May result in varicosities,oedema.

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 Peripheral vasodilatation
• Occurs because of effect of
progesterone.
• Women with raynaud’s disease
experience relief.
• Epistaxis, haemangioma, palmar
erythma, vascular spiders may occur

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 Blood volume
• plasma volume increase by 50%
• Red cell mass by 20-30%
• Thus total blood volume increase by
40%,from 4L to 5.5L.
• Haemodilution leads to physiological
anaemia.

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 Heart and myocardial contractility
• Apex shifts more lateral and higher
than normal:
• ECG changes may mimic IHD.
• Increased tendency to
supraventricular tachycardia, rhythm
disturbances.(Beischer et al 1989)
• Myocardial contractility increase due
lengthening of muscle fibres.

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Respiratory system
• Increased progesterone sensitizes
respiratory centre in medulla to CO2.
• R.R goes high slightly, from 15 to 18.
• Tidal vol increase by 40%
• Vital capacity seems as it was.
• Towards term diaphragm is displaced
up by 4cm.

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• Subcostal angle increase from
68degrees to 103degrees

• Relaxin softens costochondral

junction: women sometimes complain
of costal margin ache or rib ache.

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Immune system

• Capable of producing antibodies from

Rh-positive foetus in Rh-negative
mother.
• Prone to diseases like pnuemococcal
pnuemonia, influenza, poliomyelitis.
Predisposes to reactivation of latent
virus like CMV or herpes. (Stirrat
1991)
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• Baby is protected against
transplacental and postnatal
infections by passive antibodies i.e.
IgG by placental transfer,gaining
passive immunity.

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Breasts

• Tenderness and tingling may be

experienced around 2-4wks.
• Rise in oestrogens develop duct
system and progesterone alveoli.
(Sweet 1997)
• Weighs 400-800gms.
• At about 8weeks,Montgomerry
tubercles appear.
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• By 12 weeks, primary and secondary
areola become more pigmented.
Remains till 12 months after
parturition.
• As early as 12th week, little serous
fluid expressed from nipple.
• By 16th week, colostrum is expressed.
• Human milk ‘comes in’ about 3rd or 4th
postpartum day.

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Skin
Pigmentation
• Linea nigra
• Increase in colouring of vulva
• Chloasma

Striae gravidarum
• On abdomen, breasts, buttocks, thighs in
varying degrees.
• Cause:

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• Marks are permanent. Change from
blue/red to small silvery lines.
• Some women genetically susceptible.
• Sayer et al 1990 found women with
stress incontinence and prolapsed
bladder neck had significantly greater
incidence of abdominal striae.
• Also association with hypermobile
joints.

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Gastrointestinal system
• Morning sickness: thought to be the
response to HCG.
• Triggered by food odours
• Hyperemesis gravidarum:
• Gut muscules become hypotonic,
motility decreases.
• Prolonged gastric emptying time.
• Delay in the large bowel movt,
constipation.
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• Gastric reflux or heart burn
• Softening and hyperemia of gums.
• Pregnancy involves energy
expenditure of about 1000kJ/day.
• Average weight gain: 10 to 12 kg
(Hytten et al 1980)

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Nervous system

• Mood lability, anxiety, insomnia,

nightmares, food fads and aversion,
slight reduction in cognitive ability,
amnesia.
• Decrease in brain size in pregnancy
(Oatridge et al 2002)
• unusual pressure on nerves: carpal
tunnel syndrome.
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• Paraesthesia in hand due to traction
on nerves.

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Urinary system

• Presence of HCG in urine: basis of

pregnency tests.
• Increase in blood supply to urinary
tract.
• Increase in the size and weight of
kidneys and dilatation of renal pelvis.
• Urinary tract infections: hypotonic
musculature of ureters.
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• Increased urinary output.
• Changes in tubular resorption can
lead to gestational diabetes.
• Bladder changes its position.
• Complain of frequency of urination in
early as well as late pregnancy.
• Towards term, possibility of urge and
stress incontinence.

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Musculoskeletal system

• Generalized joint laxity: hormonally

mediated.
• Returns to pre-pregnant state in
6months postpartum
• Process behind laxity: studies on
animals.
• Postural changes.

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• Current Recommendation from
Centre for disease control and
prevention and ACSM for non-
pregnant women regarding exercise.
• Study by Artal et al (2003) for
pregnant women.
• Kramer (2003) undertook systemic
review: effects of aerobic exercise
during pregnancy.

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Physiological changes during
Puerperium
Puerperium: period of 6 to 8 wks
following delivery.
Process by which this occurs is called
‘involution’
Decline of placental hormones
production level.
Endocrine system:
it takes time for changes in this
system to occur.
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Effect of relaxin maintained for 12 weeks.
Cardiovascular system:
Returns to normal in two weeks.
Skin changes:
Chloasma and linea nigra takes time to
fade.
Respiratory system:
Returns to normal soon after delivery.

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Oxygen saturation come up to 98% day
after delivery; during labour which had
reduced to 87% (de Swiet 1991)

Uterus:
• Uterus reduces in size by 3 process:
1. Uterine contractions continue after
delivery.
suckling by baby

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 ‘After pains’: throbbing or cramping
kind of pain of moderate to severe
intensity.

2.Actual reduction in uterine tissue:

3.For 2 to 3 weeks, woman experience

discharge of lochia: consist of blood
and necrotic tissue of decidua.

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• Sign of involuting uterus: can be
palpated.
On 1st postpartum day: above
umbilicus
By 6 days: midway
By 10 days: dissapeared down
behind symphysis

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Lactation
• Prolactin, produced by anterior pituitary
steadily rises throughout pregnancy.
Effect inhibited by placental hormones.
• On 3rd to 4th postpartum day,it is free to
act.
• Milk is produced by glandular cells and
stored in alveoli.

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• Suckling and conditioned reflex
stimulates posterior pituitary to
release oxytocin: causes
myoepithelial cells around alveoli to
contract.
• ‘let-down’ or milk ejection reflex:
• Recommendation by RCM(2002):
regarding breast feeding.

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Back and pelvic girdle pain
• First episode of pain:between 4th and 7th
months in majority.(Bullock et al 1987)
• Radiated to buttocks and thigh,
occasionally down the legs as sciatica
(Fast 1999)
• Made worse by standing, sitting, forward
bending, lifting – when combined with
twisting (Berg et al 1988)

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• Pain can also be felt in posterior
pelvis,deep in gluteal region.
• Ostgaard et al (1995) report stabbing
pain in buttocks distal and lateral to
L5 S1 area,with or without radiation to
posterior thigh,not in foot.
• Pain can be provoked by Posterior
pelvic pain provocation test.
• Mechanical cause is not clear
although it may be related to
sacroiliac joint.
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 Prevention of back pain:
• Ostgaard et al (1994) found pain was
reduced by early individual education.

Principles of back care:

• Lying: additional support in form of pillows.
Long periods supine lying should be
discouraged.after first trimester.

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• Rolling:
maintain adduction at hips and flexion at
knees.
a) turn head in direction of travel:
fascilitate upper trunk.
b) folding arms across the chest with top
arm leading: fascilitate middle trunk.
c) slightly flexing outside knee and
laying it on inside leg: fascilitate lower
trunk.

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• Sitting:
on chair, follow the criteria:

• Standing and walking:

Avoid for prolonged period.
Transfer weight from one foot to
other.
Avoid trunk on hip flexion, twisting.
Move up and down spine.
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 Getting something from floor, women
should be properly advised:
• Lifting:
held close to the centre of mass.
divide in two hands eg: shopping
bags.

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Assessment of the patient:
• Subjective examination:
Onset:
History:
Berg et al(1988): back pain in
previous pregnancy increased
likelihood of S.I. dysfunction in
present on.
General health, occupation and
lifestyle:

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• Objective examination:
a) Positioning:
standing
prone
supine
b) Routine observation:
c) Functional assessment:

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• Treatment:
Gentle heat and massage.
TENS if pain continues.
Exercise programme, to maintain
results.
Corsets for lumbar spine.

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Sacroiliac joint dysfunction
• Vleeming et al (1990): stability of SI
joint based on principles of two
sources of force generation.
a) form closure
b) force closure
• Vleeming et al identifies four muscles
that affect force closure:
erector spinae, gluteus maximus,
latissimus dorsi and biceps femoris.
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• Osteitis condensans ilii, seen on X-
ray after childbirth.
Disappears in few months.

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Treatment:
‘gapping’ of the joint,enabling it to return
to more normal approximation is
effective.
• Technique 1:affected knee flexed and
flexed knee across the body
• Technique 2: affected hip and knee
flexed, pull left knee towards a point
lateral to left shd.

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• Technique 3:sit or stand with hip knee
flexed, foot up on cahir and rock
forward
• Technique 4: by Cyriax
• Technique 5: lying, longitudinal leg
pull.
• Technique 6: lying, hips at 90
degrees,lower legs supported on
table. Thigh press against the firm
surface.
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Symphysis pubis dysfunction

• Width increase: from abt 4.8 to 7-

9mm.(Abraham et al 1934)
• Pain type: burning or bruised
may radiate suprapubically or medial
aspect of thigh.
• Difficulty activities:
Getting in and out of car, changing
position in bed, dressing, walking.
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 Treatment
• Rest. Avoid single leg standing.
• Pelvic support
• Gentle isometric contraction of hip
adductors, in sitting.

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Thoracic spine pain

• As a result of rib cage expansion.

• Mechanical effect on costochondral
joint.
• May be linked with costal margin pain
and intercostal neuralgia.

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 Treatment :
• mobilisation.
• Posture correction
• Rib lifting techniques:
• Hot water bottle or ice pack

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Diastasis of rectus abdominis
Seperation of rectus abdominis in
midline.
Any seperation of larger than 2cms is
considered significant.
May occur as aresult of hormonal
influence on connective tissue.
Factors having strong causal
relationship with degree of diastasis:
(polden and mantle1990)
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Examination for diastasis rectii:
patient position and procedure:

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Pregnancy associated osteoporosis

• May be underdiagnosed.
• Brayshow (2002) found, symptoms
experienced by women were,
a) backache sometimes radiating
around chest wall.
b) hip/groin pain
c) vertebral fractures.

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Nerve compression syndromes

Carpal tunnel syndrome:

there is higher incidence of about 50%
( Gould ET AL 1978, Voitk et al 1983)
• Treatment:
Ice packs.
Resting with elevation
Wrist and hand exs.

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Ultrasound
Splinting limiting wrist flexion.
Modify position of wrist in prone
kneeling exercises.

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Brachial plexus pain:
treatment: exercises, stretching,
elevation

Meralgia paraesthetica:
TENS is helpful ( Fisher et al 1987)

Posterior tibial nerve compression:

Treatment: elevation, foot ankle exs,
ice packs, ultarsound
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Circulatory disorders:
Varicose veins in legs:
Treatment:
a) avoid standing for prolonged
periods
b) vigorous foot exs
c) brisk walking
d) elevation
e) support tights or elastic stockings
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 Vulval varicose veins:
rare.painful and stretching
• Treatment:
Rest with foot of bed raised
Keeping sanitory pad in situ
PFM contractions
Avoid prolonged standing.
Avoid constipation

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 Haemorroids:
straining can cause ballooning of
veins in and around anus
• Treatment:
PFM exs
Ice pack for pain relief
Teaching defaecation techniques.
Dietary advice.

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 Muscle cramp:
could be due to: calcium deficiency,
ischemia, nerve root pressure, fluid
retention with reduced activity towards
term.
Treatment:
• Calf stretches
• Knee extension with dorsiflexion
• Massage
• Vigorous foot exercises
• Prebedtime brisk walk and warm bath
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Other problems

Chondromalacia patellae:
avoid full squat

Restless leg syndrome:

unpleasant creeping like sensation
associated with fatigue, anxiety or
stress.

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 Uterine ligament pain:
sudden sharp stabs of lower
abdominal pain or constant dull ache.
often unilateral.

Treatment:
• Warmth or cold
• Massaging or stroking

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 Heartburn:
Treatment:
• Eat little and often
• Avoid food that increase symptoms
• Raise head end of bed
• Consult doctor to have suitable
antacids

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 Morning sickness:
Treatment:
• Acupressure (De aloysio eta l 1992):
between flexor carpi radialis and
palmaris longus
• TENS (kahn 1988): 120hz 150 m/s to
web space between thumb and
forefinger on right arm
• Eating ginger, biscuits esp before
rising

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Antenatal education
The setting:
Physiotherapists can provide antenatal
education in:
1. Large obstetric hospitals
2. A community setting where a team
education structure has been
established
3. A community setting where therapist
is sole practitioner
Maternal health 109
4.Rural setting where physiotherapist
may work in isolation

Maternal health 110

Awareness of couples need and
attitude
• Purpose to learn about person /
couple ,establish a relationship and
gain information.

• Father’s response to pregnancy

should also be considered.
Couvade syndrome:

Maternal health 111

Antenatal class aims

Educate couple about physical,

emotional changes of pregnancy,
labour and peuperium
Explain importance of antenatal care
Prepare mother to cope with process
of labour

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Value of exercise in pregnancy is
controversial as both benefits and
risks have been hypothesized.
( Hatch et al 1993)

Maternal health 113

Risks: what the literature says?
Pregnancy and neonatal outcome:
1. Clapp 1990: regular aerobics and running
has beneficial effect on course and
outcome of labour.foetal stress was also
less.
2. Maternal exs reduced duration of second
stage of labour (Botkin 1991)
3. Exercisers tend to weigh less,deliver
smaller babies than nonexercisers (sady
1989)

Maternal health 114

 Maternal risks:
1. Greater risk of musculoskeletal trauma
due to hormone relaxin.
Associated Postural changes.
but with good exs and advice these can
be reduced.(carpenter 1994)
2. Increase demands on cardiovascular
system already altered by pregnancy.

Maternal health 115

3. Hypoglycemia may arise which could
lead to foetal hypoglycemia.
4. thermoregulation: hyperthermia can
cause teratogenic effects to foetus.
39.2 C is threshold for neural defects.
5. Respiratory changes: increase in
minute ventilation by almost 50%.
Increase in oxygen uptake with
increase in oxygen consumption of
10%-20%
Maternal health 116
 Foetal risks:
1. Vigorous exercise have shown
incrtease in foetal heart rate by 5-15
beats.
Exercise intensity upto 70% of
maternal aerobic power does not
affect foetal heart rate.
2. Alderman et al 1998 found,moderate
exercise for 2hrs per week was
associated with reduced risk of
large birth weight babies.

Maternal health 117

Regular activity in first two trimesters
may be associated with reduced risk
of caeserean in primiparous
( Bungum 2000)

Maternal health 118

Guidelines for exercises:
Summary of guidelines by RACOG (1996):
1. Consult with medical caregiver
2. Gradually increase exs if previously
sedentary
3. Exercise regularly 3/week
4. Maximum H. R. should not exceed 140-
150 b/min

Maternal health 119

5. Moderate exs not more than 20 mins
6. Avoid overheating and exercising in hot
climate
7.Maintain adequate fluid intake.
8. Donot exercise with febrile illness
9. Avoid exercising in supine after 4 months.
10. Avoid contact sports after 16 weeks.

Maternal health 120

Contraindication

Cardiovascular, respiratory and renal

diseases
Diabetes
Thyroid disease
h/o miscarriage, premature labour,
cervical in competence
Vaginal bleeding
hypertension
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Multiple pregnancies
Abnormal placntal position
Sudden pain
Decreased foetal movements
Anaemia
Breech presentationin 3rd trimester

Maternal health 122

Benefits of exercises:

General benefits of regular aerobic

exercise(Koniak 1994)
Weight control, reduction in coronary
artery disease, decreased physical
discomforts and positive mental
benefits.

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Preclass assessment:

Should consist of,

1. History: obstetric (gestation,
miscarriages)
2. Any other medical problems
3. Current and previous level of activity
4. Musculoskeletal problems
5. Abdominal strength, presence of
diastasis
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6. Posture
7. doctor’s permission to exercise.

Maternal health 125

Structure of pregnancy class

Some classes can be of low impact

aerobic class with component of
cardiovascular work
Some can be of stretches,slow
controlled movements with relaxation
training and breath awareness.
Incorporate ergonomic principles for
back care and changing positions.
Maternal health 126
 Example of a class format:
• Introduction – emphasize safety and
correct posture.
• Monitor resting pulse
• Warm up 10 mins
• Modified cardiovascular component
20mins
• Monitor pulse and water break

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• Gentle cool down
• Specific strengthening, stability,
toning and balance work
• Stretches
• Relaxation
• Encourage fluid intake
• Question / discussion time

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Introduction to the class

Physiotherapist should introduce

herself and outline the structure of
the class.
Warning signs and symptoms:
1. Tachycardia
2. Palpitations
3. Shortness of breath
4. dizziness
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5. Faintness
6. Vaginal fluid loss
7. Pain

responsible for her own body and

report any discomfort.
Reinforce the importance of drawing in
when changing the posture during
class.

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 Warm-up:
• Purpose of the warm up period:
increase the circulation and enhance
neural and connective tissue function
(Bruker and Kahn,1994)
• Reduce the likelihood of injury.
• Implication in antenatal class:
Stroke vol. declines in third trimester.
Causes pooling of blood in lower
limbs and pelvis.(Morton,1985)
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 Katz in 1991 showed that there was
decrease in 15% cardiac output in
standing during 3rd trimester.
Modified cardiovascular section:
• Maintain the previous fitness level.
• Increase the heart rate and respiratory
rate for workout acc. to the norms.
• Avoid sudden changes of
direction,jumping motions or high level
balance work.( Artal et al,1995)

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• At the conclusion, women should take
pulse while keeping lower limbs
moving.
explained by simple physiology:
(Morton,1985)

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Break:
Drink water to maintain adequate
hydration.
Cool down:
sustain activity of lower limbs.
Pulse rate measured.

Maternal health 134

Strenthening, stability and toning
exercises:

should be gentle and encourage

mental and physical relaxation.

Emphasize the muscles that become

weak and stretch due to adaptations.

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Lengthening of tight soft tissue
structures:
Dangerous exercise is partnered
streches.as this decrease the control
of the woman to stretch safely.
Lengthen slowly and not upto the
extremes.

Maternal health 136

Relaxation:
Most enjoyable section of exs.
Different approaches to teach
relaxation.
Can be taught in fully supported
sidelying or supported sitting.
Class conclusion:
Time allocated in addressing
individual concern.
Maternal health 137
Exercises in antenatal classes:
Posture exercises:
muscles that require stretching and
strenthening are:
• Stretching (with caution)
1. upper neck extensors and scalenes
2. Scapular protractors, shd int rotators,
levator scapulae
3. Low back extensors

Maternal health 138

4. Hip flexors, adductors and
hamstrings
5. Plantarflexors.
strenthening (low intensity):
1. Upper neck flexors, lower neck and
upper thoracic extensors
2. Scapular retractors and depressors
3. Shd external rotators, biceps triceps
4. abdominals
Maternal health 139
5. Hip extensors
6. Knee extensors
7. Ankle dorsiflexors.

Small hand weights (0.5 to 1kg) can be

used for upper limb strenthening.

Maternal health 140

 Exercises for diastasis:
Exs should be used only after
seperation is corrected tp 2cm or
less.
1. Head lift: hook lying,

2. Head lift with pelvic tilt: hook lying,

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 Abdominal muscle exercises:
1. Pelvic tilt exercise:
Patient position and procedure:
quadruped,
Practice the same in sidelying and
standing.
2. Leg sliding:
Position and procedure: Hook lying
with pelvis posteriorly tilted,

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3. Trunk curls:
a) Curl up and curl down:

b) Diagonal curls:

Research in non pregnant subjects

indicates that Tr. Abdominis and
internal obliques have prime role in
trunk stability. (Richardson et
al,1995)
Maternal health 143
Therefore rationale of concentric
trunk flexion is questionable.

Stabilizing role should be of prime

consideration while designing a
programme (Wohlfahrt et al, 1993)

Clinical experience suggests

importance of Tr. Abdominis exs on
all-fours.
Maternal health 144
 Stabilization exs:
Can be done the same way as in
non-pregnant women.
limb loading can be added gradually.
• Precautions:
a) There is tendency to hold breath
when contracting the trunk muscles
isometrically.
Hence maintain relaxed breathing
pattern and exhale during exertion
phase.
Maternal health 145
b) If diastasis present protect linea alba
as described before.

Maternal health 146

 Pelvic motion training:
helpful in postural back pain, improving
proprioceptive awareness as well as
lumbar,pelvic and hip mobility.

• ‘The pelvic clock’:

Position of patient and procedure:
Hook lying.
Visualize face of clock on lower abdomen with
umbilicus at 12o’clock and pubic symphysis at
6.
Procedure:

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 Modified upper and lower extremity
strengthening:
1. Standing push ups:

2. Supine bridging: Hook lying, posterior pelvic tilt,

3. Quadruped leg raising:

Position and procedure:

Discontinue if there is stress on sacroiliac joints.

if woman cannot stabilize the pelvis,have her just
slide one leg posteriorly and return.

Maternal health 148

Modified squatting:
Strengthen hip and knee extensors
and also help to stretch perineal area.

Position and procedure:

standing with back supported, feet
shoulder width apart,

women with knee problem: partial

squat.
Maternal health 149
For optimal success with squatting during
stage 2 of labor, increase duration of
squat gradually to 60 to 90 secs.

5. Scapular retraction:
In sitting or standing.

Maternal health 150

 Perineum and adductor flexibilty:
Self stretching:
a) Supine or sidelying.
Instruct the patient to abduct the hips and
pull the knees toward the sides of her
chest. Hold the position.
b) Sitting on a short stool.
Hips abducted as far as possible, feet flat
on floor.

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Have her flex forward slightly at hips
with back straight.
Or have her gently press the knees
outward for additional stretch.

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 Pelvic floor awareness, training
and strengthening:
• Begin with empty bladder.
• Gravity assisted positioning: hips
higher than heart such as supported
bridge, if there is extreme weakness
and proprioceptive deficits.
• Positional change introduced as
strength and awareness improve.
(supine, side lying, quadruped, sitting
and standing.)
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Contract-relax:
Tighten the pelvic floor as if stopping
urine flow.
Hold for 3 to 5 secs and relax.
Repeat 10 times.
watch for any substitution with gluteals,
abdominals or hip adductors.
Watch for Valsalva, ask woman to count
loud.

Maternal health 154

Quick contractions: perform quick
repeated contractions of pelvic floor
with normal breathing rate.
15 to 20 repetitions per set.
this is a type2 fibre response,
important to develop to withstand
pressure from above eg:
coughing,sneezing.

Maternal health 155

‘Elevator exercise’
instruct imagining an elevator.
as the elevator goes from one floor to
other,she contracts pelvic floor a little
more.
increase the difficulty by asking the
woman to relax the muscles
gradually, as if descending elevator.
it requires eccentric contraction.

Maternal health 156

Pelvic floor relaxation:
after contracting, instruct her to relax
completely,total voluntary release.
Elevator imagery can be used.
Its relaxation is closely linked with
breathing and facial muscle
relaxation.
important in stage 2 and vaginal
delivery.

Maternal health 157

 Relaxation and breathing:
requires awareness of stress and
muscle tension.
1. Mitchell method:
It utilizes knowledge of typical
stressful posture and reciprocal
relaxation of muscle.
One group relaxes as opposing
group contracts.

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For eg: for hunched shoulders- Pull
your shoulders towards your feet.
Stop.
Proprioceptive receptors in joints and
muscle tendons record resulting
position of ease and this is relayed to
and registerd in cerebellum.

Maternal health 159

2. Contrast method:
given by Edmund Jacobson.
Involves alternately contracting and
relaxing muscle group progressively.
To develop recognition of difference
between tension and relaxation.

3. Visual imagery:
Payne 1998, encourage the person to
think in pictures as opposed to words.

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Ask the patient to imagine pleasant
image such as beach, mountain.
Suggest her to focus on the same
image throughout pregnancy so that
can be called up on during labor for
relaxation.

4. Touch and massage:

Soothing stroking, effleurage or
kneading to appropriate areas may
have good effect.
Maternal health 161
5. Breathing:
Outward breath is the relaxation phase
of respiratory cycle.
This fact can be used to enhance
relaxation.

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Unsafe postures and exercises
during pregnancy
Knee chest position with buttocks
elevated above heart level.
Air embolism may occur.
Pressure change may cause air to
enter vagina and uterus,where ir can
enter circulatory system through open
placental site.
Not to assume this position for 6wks
postpartum
Maternal health 163
Bilateral SLR:

‘Fire hydrant’ exercise:

patient on hand and knees. One hip
abducted and externally rotated at the
same time.
stress S.I joint and lumbar spine

Maternal health 164

All fours hip extension:
should be performed only with care.

Unilateral weight bearing activities:

Can cause S.I.Joint irritation
Can cause balance problems.

Maternal health 165

Physiolgy of labour
Labour : defined as the process in
which foetus, placenta and
secundies are canal after minimum
period of 20 weeks. (Beishner and
Mackay,1986)
Physiological changes in mother
and foetus during labour:
a) Maternal respiratory:
increase in ventilation.
Maternal health 166
 decrease PCO2.
b) Maternal cardiovascular:
increase 10mHg systolic BP.
increase 5-10mmHg diastolic BP.
c) Maternal gastrointestinal:
decrease motility and absorption.
nausea/ vomiting- dehydration
d) Foetal cardiovascular
sometimes there is slight fall in H.R.
Maternal health 167
due .to cord compression, cord stretch
or foetal head pressure. H.R.
recovers at end of contraction

Maternal health 168

 Causes of spontaneous onset of labour:
1. Hypertrophy of myometrial cells.
2. Gradual formation of thick upper and thin
lower uterine segments in 3rd trimester.
3. Rising estrogen level,stimulating
myometrial sensitivity to oxytocin
4. Release of prostaglandin from
myometrium, decidua and membranes.

Maternal health 169

Signs that indicate that labour is
imminent
Mucoid discharge and ‘show’
mucus plug which occludes
endocervical canal is released.
show of blood is due to detachment
of membrane from cervical wall.
Spontaneous rupture of membranes:
Rupture of the amniotic sac with loss
of fluid occur at the end of 1st stage of
labour.
Maternal health 170
Rhythmic regular contractions:
which progress in amplitude,
frequency and discomfort.

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Induction of labour
It means onset of labour by artificial
means.
Methods of induction:
1. Artificial rupture of the membranes
(surgical induction):
Stretching the cervix and stripping the
membranes from lower uterine
segment. Stimulates release of
prostaglandins from decidua.
Maternal health 172
 Oxytocin:
Administered intravenously.
Much more effective in association with
ARM.
It produces severe pain associated with
uterine contractions.
Prostaglandins:
divided into 4 groups:A,B,E,F
Further subdivided into 1 or 2

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E1,E2 nd F2 have intrinsic stimulating
effect on myometrium as well as
causing oxytocin release from
posterior pituitary gland.
Common side effects: nausea,
vomiting, diarrhoea and hot flushes.

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 Indications for induction:
Conditions favourable include:
a) Foetal head well applied to cervix
b) Cervix effaced
c) Gestation of 40-41weeks.

Done for following reasons:

a) pre-eclampsia
b) Prolonged pregnancy
c) Intra uterine growth retardation
d) Hypertention
e) Diabetes mellitus

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 Contraindications:
a) Cephalopelvic disproportion
b) Abnormal presentation
c) Unstable lie
Complications:
a) Prolapse of umbilical cord
b) Foetal distress
c) Ruptured uterus
d) Amniotic fluid embolism
e) Infection.
Maternal health 176
 Stages of labour:
1. Stage 1:
From onset of labour till full dilatation of
cervix.
It accounts for about half of the durtion
of labour.
12-16 hours in primigravidae
6-8 hours in multipara.
Dilatation of cervix occur at rate of
1cm/hour.
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Measure of activity of uterus is in
Montevideo units.
i.e. intensity of contraction (mmHg)
multiplied by number of contraction in
10 mins.
Pain in stage 1:
Parturition pain pathway: nerves from
uterus and cervix enter primarily to
T11 and 12, secondary to T10 and
L1.
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Distribution of pain: over large
area,lower abdomen and small of
back. Later more intense including
thigh and perineal area.

Pain is due to:

a) Diatation of cervix
b) Contarction and distention of uterine
muscles
c) Pressure on surrounding sensitive
structures.
Maternal health 179
 Stage 2:
Duration: shorter in multipara, upto 2 hours in
primiparae.
2 phases of second stage:
a) Phase of descent:
It is extension of 1st stage where head is high
and there is no distension of perinium.
Vigorous pushing at this time may introduce
metabolic disturbances hence should be
discouraged till the baby is well placed for
delivery (pearson et al 1990)

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2. Perineal phase:
Phase of stretching and bulging of
perinium through which head will
pass.
Presenting part is now low in birth canal
and can be visualised at vulva.
Hence expulsion efforts can now be
encouraged.
Pain pathways in stage 2: nerves from
cervix and pelvic floor pass to sacral
segments S2,S3,S4.
Maternal health 181
 Stage 3:
From birth of baby untill delivery of placenta.
Contractions are less painful and less
frequent.
Sometimes expulsion is assisted by
controlled traction on remnant of umbilical
cord.
Oxyticic drugs: syntometrium, ergometrium
are usually administered to stimulate
uterine contraction and reduce the chance
of postpartum haemorrhage.

Maternal health 182

Coping with labour
Educational content should include,
1. Introduction to labour suite
2. Introduction to pain relief available
3. Physiology of labour
4. Coping skills
5. Relaxation
6. Breathing awareness
7. Positions in labour
8. massage

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Relaxation
Techniques of relaxation:
Randall (1958) in her book suggested two
reasons for relaxation in labour,
1. To prevent mother from getting unduly
tired,thereby causing nervous fatigue.
2. To help mother control her thoughts and
feelings or emotions.

Maternal health 184

 Jacobson relaxation:
Concerns regarding use of this method
because can cause,
1. initiation of cramps
2. Risks of hyperventilation
3. Induce anxiety/ anger
4. Exacerbation of pain esp. low back.

Maternal health 185

 Mitchell method:

Touch relaxation:
Kitzinger (1987) discusses this concept,
where women relaxes to the touch of
her partner.

Imagery :

Maternal health 186

Along with the positive effects to cope
with labour, relaxation tech. has a
positive effect on preterm labour
outcome. (Janke 1999)

Maternal health 187

Breathing

Effects of alteration of breathing

pattern:
Breathing primarily controlled by CO2
levels via brain stem.
Rise in CO2 is not tolerated and is
followed by Hyperventilation.
This results in hypocapnia.

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Low levels of CO2 will cause respiratory
alkalosis leading to decrease in calcium
ionisation, which affect nerve
conductivity.
Maternal hyperventilation could affect foetus
in 2 ways:
1. Reduce uterine blood flow by lowered
B.P and uterine vasoconstriction
2. Haemoglobin ‘hangs on’ to oxygen,
reducing amount of oxygen available to
foetus.

Maternal health 189

Maternal apnoea, follows periods of
hyperventilation.
How?
Hence the women should be
encouraged to return to normal level
of breathing to redress the balance.

Maternal health 190

Breathing for labour

Teaching techniques:

Our bodies receive more oxygen

when the breathing is slow and deep.
Once the technique is learned, it can
be incorporated to relaxation practice.
Maternal health 191
Breathing and contractions

3 phases of contraction,
Preparatory phase
Action phase
Recovery phase.
labour compared to sea and explain
the mother.

Maternal health 192

First stage:

Deep, slow easy breathing- pausing

between expiration and inspiration-
may be all that some women use in
first stage.
Imagine a feather or candle in front
and breath in such a way that it
barely move.

Maternal health 193

Transition phase:
Pain may be well intense.
Woman feel desperation, anxiety.
Reassure with positive response that the
2nd stage is not far away.
It is at this point that hyperventilation with
its side effects might be noticeable.

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To cope with it, women should be
encouraged to sigh out softly (SOS)
Many women worry about making
noise during labour. They should be
encouraged to use their voices to
express difficulty.
Balaskas (1983) suggests that
making sounds stimulates production
of endorphins and alters level of
consciousness.

Maternal health 195

Stage two:
Pain of the 1st stage recedes and all
becomes purposeful effort with stage
two.
Desire to bear down usually come in
waves, perhaps 3 or 4 emptying
urges per contraction.
Hence each mother should be
encouraged to work with her own
internal expulsive urge.
Maternal health 196
 Length of time that a women
actively push should be monitored.
Prolonged pushing will have
following effects:
1. Large rise in BP.
2. Venous compression in chest and
abdomen reducing blood flow back
to heart.
3. Fall in CO followed by BP.
Maternal health 197
4. Dizziness results.
5. Placental blood flow reduces,
reflected in foetal heart
decelerations.

Maternal health 198

Breathing and pushing
Woman should be trained to breathe
in and slowly out on exertion.
once trained, it will become instinctive
and she would be able to maintain
push and at the same time breathes
in.
Each push last for about 5 to 10 secs.
Each contraction demands 3 to 4
pushes.
Maternal health 199
Positions in labour

Because of the anteversion of uterus

during first stage contractions, many
women find the need to lean forward
on some sort of support.
Different postures should be
demonstrated and practised in
antenatal classes.

Maternal health 200

Sometimes cervix dilates unevenly,
anterior lip remains between
presenting part and pubis while rest
of the cervix is well drawn up.
discourage women from pushing.
adopting prone kneel fall position can
be helpful.
Russell (1982): demonstrated
increase in pelvic outlet size in
squatting posture.
Maternal health 201
Gardosi et al (1989): upright positions
had higher rates of intact periniums
and reduction in forceps deliveries as
compared to lateral or
semirecumbent.

Maternal health 202

Massage in labour

Wells 1988: probably, stroking,

effleurage and kneading activates
gate closing mechanism at spinal
level.
Tissue manipulation possibly
stimulate release of endogenous
opiates.

Maternal health 203

 Massage to the back:
1. Sattionary kneading, either single
handed or reinforced, applied slowly
deeply to painful area.
2. Double handed kneading, with
loosely clenched fists, directly over
S.I joint. Hand held tennis balls can
be used.
3. Effleurage from sacrococcygeal
area, up and above the iliac crests
Maternal health 204
4. Slow rhythmical longitudinal stroking,
from occiput to coccyx, single or
double handed.
Massage to abdomen:
Pain usually experienced on lower half
of abdomen.
a) Light finger stroking or brushing
from one ASIS to other.
b) Double handed stroking ascending
either side of midline and across
iliac crest.
Maternal health 205
 Massage to the legs:
Labour pain may percieve in thighs and
cramps in calf or foot.
Effluerage or kneading may help

Perineal massage:
It encourage stretching of skin and
muscle and thus prevent tearing or
episiotomy.
Maternal health 206
 Technique:
A natural oil can be used.
Index and middle fingers of one hand
are put about 5cms into vagina.
Rhythmic ‘U’ or sling type movement
upwards along the side of vagina with
downward pressure, stretches the
perinium from side to side.
As elasticity improves, three or four
fingers can be used.

Maternal health 207

Avery et al (1987): effect of perineal
massage on 55 women.
Experimental grp: 52% had intact
perinium, 48% had episiotomy or
2nd,3rd,4th degree tear
Control group: 24% had intact
perinium, 76% had episiotomy and
tears.

Maternal health 208

Pain relief in labour

Three P’S play a part in length of

labour and pain:
Power
Pelvis
Passenger

Maternal health 209

TENS

Johnson 1997 surveyed use of TENS

in 17896 women.
7122 (71%) claimed good pain relief
but 6125 needed additional
analgesics.
Caroll et al 1997: said there will be
decreased need for additional
analgesia with the use of TENS.
Maternal health 210
 Mode of stimulation:
a) Burst train TENS:
Characterized by low frequency
bursts(less than 4Hz) of higher
frequency stimulation.
Has properties of both conventional
and acupuncture like TENS.
Stimulates Abeta and Adelta fibres to
inhibit C mediated pain sensations
presynaptically at spinal segmantal
level.
Maternal health 211
Conventional TENS takes 5-10 mins
before pain relief.
Acupuncture like TENS produce
analgesia that is long lasting but
takes 30mins before effects noted.

b) Brief intense TENS:

Characterised by high freq (greater
than 100Hz), long pulse
duration( greater than 150 microsec)
and highest intensity tolerated.
Maternal health 212
 Best used fro short periods of time
(10-15 min) because of fatigue in
nerves from intense stimulation.
Two modes are used for specific
instance of labour.
Burst train TENS is used all time during
labour to relieve dull aching type of
labour pain.
Brief intense TENS for pain increased
during contractions.
Maternal health 213
Press button mechanism is available
in obstetric TENS machine, to switch
between these two modes.

Maternal health 214

 Placement of electrodes:
One pair of electrodes covering either
side of spinous process of T10-L1
Other pair covering either side of S2-S4

Maternal health 215

 Safety limits:
Only 3 papers exist that examined effects on
foetus with the use of TENS.
Bundsen et al 1982 suggested foetus was at
most risk if,
a) Electrodes were palced abdominally
b) Thin woman,with only 1inch abdominal
fat
c) Foetus occipitoposterior

Maternal health 216

Same author in the next research sated
‘no adverse effect on neonate by
TENS’

Maternal health 217

Acupuncture

Ancient method of relieving pain

Ramnero et al 2002: acupuncture
could be good alternative or
complement other forms of analgesia
but whether its effect is analgesic or
relaxing is not known.

Maternal health 218

Hypnosis

Anaesthetics, obstetrician and GP

use hypnosis for pain relief. But it is
time consuming.
Freeman et al 1986: hypnosis was
more satisfying for women although
anlgesic requirements were present.

Maternal health 219

Homeopathy / aromatherapy

Kleijnen 1991: 77% yielded positive

results and therefore worthy for
further research.
Therapist has to be fully trained for
aromatherapy

Maternal health 220

Water

Was first introduced in UK in 1980s

Balaskas et al 1990: labour is shorter,
easier and more comfortable in water.

Maternal health 221

Entonox

Mixture of 50% nitrous oxide and

50% oxygen.
About 75% women use entonox
(Hobbs 2001)
Method to use:
Deep breath with 20 secs of deep
inhalation.
Use entonox before a contraction.
Maternal health 222
8 to 12 breathes may be needed.
Maximum anlgesia reached within 45-
60 sec and effects wear off rapidly.
Side effects: nausea, dehydration since
breathing is through mouth.

Maternal health 223

Pethidine
Synthetic opiod analgesic derived
from morphine.
Generally administered
intramuscularly,100mg
Can be self-administered
intravenously via a pump.
When administerd parenterally,there
is unrestricted placental transfer from
mother to baby.
Maternal health 224
 Maternal side effects:
Nausea and sometimes vomiting.an
antiemetic is often given
simultaneously.
Drowsiness, distressing
hallucinations,dysphoria.
Pethidine reduces tone of lower
oesophageal sphincter and delay
gastric emptying.
Could give rise to hypotension and
respiratory depression.
Maternal health 225
 Foetal and neonatal side effects:
If the mother recieves pethidine
between 1 and 4 hours before birth,
prolonged side-effects will be
apparent in neonate.
Side-effects observed would be foetal
acidosis, depressed foetal heart
rate,slow response to
sound,respiratory depression.

Maternal health 226

Respiratory depression can be
reversed with drug naloxone.
Other subtle effects include, baby less
alert, more easily startled, slow
response to face and sound.
Hence administration 4 hours prior to
delivery is reasonably safer for baby.

Maternal health 227

Epidural anaesthesia
Benefits:
1. Administered as a single dose, as continuous
infusion or as client induced pump.
2. Mother will be fully conscious, her mind
unclouded by analgesia.
3. Effects of bupivacane on baby are minimal.

Maternal health 228

It is helpful in cases of pre-eclamptic
toxaemia and incoordinate uterine
activity.

Maternal health 229

 Technique:
Mother on her side, curled up as much
as possible or sit wth her legs over
the edge of table supported by her
companion.
Loacal anaesthesia induced into skin
around L2-L3 or L3-L4 prior to
insertion of tuohy needle.
Before a dose of local anaesthetic is
injected, careful aspiration for blood
or CSF is made.

Maternal health 230

A fine plastic catheter is threaded
through the needle.
First dose is given by anaesthetist and
subsequent top-up dose is given by
midwife.

Maternal health 231

 Side- effects and complications:
1. Increased rate of forceps dilevery
with maternal and fortal
trauma.three main factors
responsible:
b) ferguson’s reflex is abolished and
uterine activity is less because of
the drop in oxytocin output.
c) Because of the sensory blockade,
woman will not experience bearing
down reflex.
Maternal health 232
c) It will lead to guttering of pelvic floor
muscles which interfere with rotation
of baby’s head.

2. Sympathetic nerves affection would

lead to vasodilatation of blood
vessels in lower abdomen and legs.
hence there will drop in B.P. and
reduced placental blood flow.

Maternal health 233

3. Legs feel heavy, difficulty to move
easily.
4. Urinary retension may occur. So
Mother should try to micturate every
2 hourly. Catheter will be passed if
retention is obvious.
5. Accidental puncture of dura and
relaese of CSF can give rise to
postpartum headache.
6. Pain and tenderness postpartum at
epidural site due to tiny haematoma.
Maternal health 234
7. Total spinal anaesthesia may occur
if accidentally injected into
subarachnoid space.
Fatal condition. Needs artificial
respiration, injection of vasopressor
drugs and rapid infusion.
8. Neurological complications may
persist; muscle weakness in leg,
loss of sensation.

Maternal health 235

Third stage of labour

Most dangerous because of risk of

maternal haemorrhage (Sleep 1989)
Injection of syntocinon and
ergometrine is injected as anterior
shoulder is delivered.

Maternal health 236

Postnatal physiotherapy
Assessment:
PT working in postnatal set up should assess
each new mother as soon as possible
post delivery.
Awareness of needs, propotional to mode of
delivery is essential.
Thompson et al study shows that,
a) Primiparas
Were more likely to report perineal pain and
sexual problems.
Maternal health 237
b) Caesarean births:
More likely to suffer exhaustion and
bowel problems
Less perineal pain and urinary
incontinence.
More likely to be readmitted.
c) Forceps and ventouse deliveries
More perineal pain.

Maternal health 238

 Symptoms to look out for include:
Diastasis rectii
Inability to voluntary contract pelvic
floor
Perineal pain / discomfort
Symphysis pubis pain
Back pain

Maternal health 239

 Exercise:
• Encourage to be mobile, which would
reduce circulatory and respiratory
dysfunction.
• Pelvic floor muscle exercises for
strengthening and pain relief.
Will also speed healing by reducing
edema and encouraging good
circulation.

Maternal health 240

 Two essential early advices are:
a) Contract the PFM every time the intra-
abdominal pressure is increased.
b) Support sutures by appling pressure to
the perineum when defeacation is
attempted.

Principles of muscle reeducation should

be follwed when exercising abdominal
muscles.

Maternal health 241

i.e progressing from static to dynamic.
with different starting positions.
Sattic abdominal contractions
followed by pelvic tiliting can aid relief
in ‘after-pains’ or backache.

Maternal health 242

 Early postnatal class:
Participants may be sitting, satnding ao lying.
1. sitting:
Well supported back.
Exercises in sitting for posture, abdominals,
PFM.
2. Standing :
Stable base of support.

Maternal health 243

Appropriate footwear.
Exercises in standing for posture and
abdominals. This can reduce
abdominal girth upto 12cms.

3. Lying :
Pillows and wedges for support.
Teach checking and correction of
diastasis rectii.
Raise awareness regarding at risk
movements.
Maternal health 244
Exercises: abdominals, pelvic floor,
postural.

Realxation:
It reduces tension and maternal fatigue.
(sapsford 1999)
Skill for relaxation fascilitate ‘let down’
reflex for breast feeding.

Maternal health 245

 Teaching ergonomic principles:
1. sitting:
• Thighs should be fully supported
• Feet flat on floor
• Weights evenly distributed on both
buttocks.
• Trunk fully supported maintaining
natural curves.

Maternal health 246

2. standing:
• Feet slightly apart and angled
slightly.
• Weight evenly distributed.
• ‘soft’ knees.
• Shoulder relaxed.
• Arms held loosely
• Maintain natural curves
• Head in midline.
Maternal health 247
Kneel sitting:
bilateral: may be cushion at back of
the knees.

Half kneel sitting:

unilateral- sitting on one heel, other
hip forward flexed with feet on the
floor.

Maternal health 248

3. Lying :
Fully supported with pillows.
Legs not crossed.

4. Kneeling :
Knees hip width apart.
Knees directly under hips, may be on
cushion
Maintain natural spinal curves.
Maternal health 249
5. feeding:
New mother may feed baby 8 or more
times in a day.
Hence ergonomic principles should be
followed to avoid musculoskeletal
discomfort.
a) Sitting on chair
b) Long sitting
c) Sidelying
Maternal health 250
6. Nappy changing:
Suggested positioning could be:
a) Sitting and changing in lap.
b) Standing and changing on a surface
of appropriate height.
c) Kneeling or half kneel sitting

Maternal health 251

Postnatal problems

Perineal dysfunction / pain:

Problems include bruising, oedema,
labial tears, haematoma, tight
stitches, infection, break down of
suturing and haemorrhoids.
May cause varying degrees of pain.

Maternal health 252

Treatment:
1. Pelvic floor muscle exercises:
Self help technique for pain relief.
Pumping action:
It activates pain gate mechanism and
may also stimulate production of
endogenous opiates.
pain is maximum in first contraction,then
decreases with repitition as oedema
disperses.

Maternal health 253

2. Functional activity:
Pain relief can occur rapidly with
appropriate positioning for activities
like feeding, relaxation and sleep.

3. Ice:
Its pain relieving effect is well
documented. ( knight 1989,
palastanga 1988)

Maternal health 254

The technique is cheapest.
Following are suitable techniques:
1. Crushed ice, wrapped in damp
disposable gauze or put into plastic
bag, applied for 5-10 mins.
women in comfortable half lying
position.
2. Ice cube massage: by the women
herself.

Maternal health 255

Dangers of using ice therapy should be
warned, since sensation may be
diminished after birth.

4. Warm baths:
Relaxed feeling of well being with use of
warm bath.
Warm water can be poured on perinium.
Eases burning sensation when urinating.

Maternal health 256

5. ultrasound:
Treatment should commence as soon as
possible after delivery.
Best position: crook lying or side lying,
Technique:
Clean the area with cotton wool and warm
water.
Pulsed ultrasound is used for its
analgesic effects.

Maternal health 257

For initial treatment, dosage: 3MHz, 0.5
W/cm, 2mins per head sized area of
trauma ( Mcintosh 1988)
If pain too intense: condom can be
used as a water bag between
treatment head and area.
couplant is applied to patient’s skin ,
bag and treatment head.

Maternal health 258

6. PEME:
Bewly 1986 and frank 1984 have
described its pain relieving and
therapeutic effects for bruising,
hemorrhoids, suturing etc.
its ‘no touch’ mode of operation.
Dosage: pulse width- 40- 65 pulses with
repitition of 10-220 pulses per sec (low
1988)
Treatment time: twice daily, from 5 to 20
mins

Maternal health 259

 Genitourinary dysfunction / pain:
1. Incontinence:
Close relationship between pelvic
organs.
Thompson et al 2002: bowel and
bladder problems resolved between
8 and 24 weeks postpartum.
Fratton et al 1999: strong relationship
between first childbirth and obstetric
trauma.
Maternal health 260
Faecal incontinence:
Signorello et al 2000: women with
midline episiotomy had higher risk of
foecal incontinence at 3 nad 6
months.
Incontinence can result from damage to
innervation of pelvic floor during 2nd
stage of labour.
Neurapraxia resolves by 2months.

Maternal health 261

Stress incontinence:
Caused by distension and weekening
of PFM and connective tissue, and
damage to their innervation.
Kegel suggested 200 contractions per
day.
Counter bracing during coughing,
sneezing.

Maternal health 262

2. Constipation:
Extremely common after child birth.
Causes:
Large diastasis rectii, relaxation of smooth
intestinal muscles, diet, iron medications,
fear of perineal pain.
Remedies:
Abdominal muscle strenthening.
Perinium support with pad during
defaecation.
Change in diet.

Maternal health 263

Repeated strain can lead to USI and
faecal incontinence.( henry 1982)

3. Urinary retention
Causes:

Frequent gentle PFM contraction.

Having warm shower may be of help.

Maternal health 264

4. Urgency:
Trauma to nerve supply to detruser and
urethral sphincter are possible causes.

Frequent PFM contractions can help.

Contraction of levator ani muscle directly
inhibits sacral micturation centre
( Mcguire 1979) and voiding surge can be
controlled.

Maternal health 265

 Musculaskeletal dysfunction:
1. Diastasis rectii abdominis:
Assessment and re-education.

2. Back pain:
Ostgaard and anderson 1992 found out
of 817 women, 67% had back pain
diractly after delivery and 37% still
had it 18 months later.

Maternal health 266

Double layered tubigrip support initially
can help.
Ergonomic principles followed.

3. Thoracic pain:
Relieved with active exs and hot or ice
packs.

Maternal health 267

4. Coccydynia:
Due to damaged ligaments or aggravation
of previous injury.
Ultrasound, ice or hot packs, TENS can
help.
Martin 1998 suggests excellent pain relief
with IFT.
In sitting, cushion can assist comfort.
Prone lying is comfortable.

Maternal health 268

5. Symphysis pubis pain:
It may have occurred antenatally or
follow a traumatic delivery.
Fry et al 1997: depending on pain
severity, advice bed rest fro 24-48
hours with analgesia.
full assistance with baby. Gradual
mobilisation with walking aids if
required.

Maternal health 269

Advice and treatment:
Avoid non essential weight bearing,
abduction of legs, one leg standing,
twisting lifting.
Teach proper functional activities like
knnes flexed and tightly adducted
when moving in bed.
Ultrasound and ice may speed healing
and absorption of edema.

Maternal health 270

6. After pains:
Practising relaxation and breathing can
help.
TENS applied over nerve roots
innervating uterus and perinium may
be helpful.

Maternal health 271

 Circulatory dysfunction:
1. Varicose veins:

2. Oedema:

3. Superficial and deep vein thrombosis:

4. Pulmonary embolism:

5. Haemorrhoids:

Maternal health 272

 Breast problems:
1. Breast engorgement:
Ultrasound to the periphery of breast
and then moving towards nipple
(Semmler 1982)
Warm compresses or crushed ice
packs help in pain relief.
PEME as a non contact treatment may
be less painful.

Maternal health 273

2. Sore and cracked nipples:

It is suggested that symptoms are

directly related to the position of
baby on breasts.
Position of baby: by RCM 2003

Maternal health 274

 Fatigue:
Though normal symptom,is
overwhelming in early days.
Mother usually ‘running’ on adrenaline
high for first 2 or 3 days.
Had a long or difficult labour.
Assure her that it is normal occurrence
and can be dealt with rest.

Maternal health 275

Advice:
Rest and sleep when baby sleeps.
Ask the partner or friend to take baby
for long walk, mother can catch up on
sleep.
Go to bed after early evening feed and
wake up with baby
Prioritise household duties.

Maternal health 276

 Psychological symptoms:
Three common manifestations:
1. Maternity blues:
Occur in first 2 to 3 weeks.
Mother is weepy, anxious and agitated.
Sore perinium, uncomfortable breasts,
fatigue aggravate the condition.
Mother’s response to baby changes.

Maternal health 277

Research suggests, 25% of mothers with
severe postnatal blues may develop
PND.(Cox 1986)

2. Puerperal psychosis:
More severe condition.
Mother lose contact with reality, have
delusions, mood swings, anxiety,
agitation.

Maternal health 278

Suicidal and infanticidal thoughts may
occur.
High likelihood of recurrence in
following pregnancy.

3. Postnatal depression:
Begin early in postpartum period.
Mother sad, depressed, worry for
herself and baby.
In severe PND, mother feel suicidal.

Maternal health 279

Hormonal, neuroendocrine and even
social factors may play part in above
problems.

Maternal health 280

Caesarean section

Between 1997/8 and 2000/01

caesarean rate has increased from
18.2% to 21.5%.
Surgical approach: transversely
through lower uterine segment- LSCS
Can be elective or emergency.
Performed using spinal or epidural
anaesthesia.
Maternal health 281
Danish research 1998 shows 86%
women opt for epidural anaesthesia.
Indications for caesarean section:
Elective CS:
CPD
Placenta praevia
Malpresentation (breech, unstable lie)
Previous CS
Active genital herpes

Maternal health 282

Pre-eclampsia and eclampsia
Multiple births
Low birth weight

Emergency CS
Obstructed labour
Foetal & maternal distress
Ante partum haemorrhage
Placental abruption

Maternal health 283

Prolapsed cord
Failed trial of forceps
Failed trial of previous CS scar.

Maternal health 284

 Physiotherapy management:
Pre-operative:
Discussions to minimize negative
feelings about surgery. Videos or
pictures can help.
Mobilization tech.: helpful post
operatively should be taught.
Use of Abdominal supports to control
floppy abdomen post-surgically can
be taught.

Maternal health 285

 Post operative management:
Supervised programme should be started
within first 24hrs.
• Active assisted and active movt of limbs.
• Encourage movt around bed, using crook
lying, bottom lift techniques.
• Encourage deep breathing exs.
• Gentle exs, like crook lying: pelvic rock,
knee rolls from side to side, gluteal
contractions, PFM exs

Maternal health 286

Ambulation can be started when
permitted with abdominal support.
Demonstrate in and out of bed and
chair techniques.
Feeding: proper guarding techniques
should be taught.
eg: tucking the baby’s feet under the
arm, positioning pillows to protect
wound.

Maternal health 287

Wound healing:
Expose wound to air, keep area dry.
PEME can be used, to relieve pain,
improve circulation and healing.

Maternal health 288

Post operative problems:
1. Respiratory problems:
Deep breathing, huffing , coughing
would help.
Support the abdomen with towel binder.
Abdominal and pelvic floor sustained
contractions are encouraged during
expulsive effort.

Maternal health 289

2. Excessive abdominal pain:
Following conditions will increase pain
around CS site.
• Wound infection
• Haematoma: therapeutic ultrasound
accelerate resolution.
• Excessive localised oedema
• Nerve entrapment syndrome:
illioinguinal or iliohypogastric nerve
entrapment syndrome:
Maternal health 290
3. Wind pain:
Severe intermittent colic type of pain.
• Deep breathing
• Drawing in of abdomen
• Early ambulatuion
• Massage in clockwise direction
along line of colon
• Heating pads.

Maternal health 291

4. DVT & PE:
Pelvic surgeries are associated with highest
incidence of DVT( Gray et al 1992)

Prevention:
Application of stockings
Early mobilization
Avoid sitting with knees acutely flexed
Lower limb movements, deep breathing exs

Maternal health 292

Treatment:
Anticoagulant therapy.
Antiembolic stocking

5. Back pain:

6. Dependent edema:

Maternal health 293

Urinary dysfunction

Lower urinary tract dysfunction:

ICS divides LUTS into 3 main groups:
Storage,voiding and post micturation
symptoms.
a) Storage: eg: abnormal bladder
sensations, frequency, urgency and
leakage of urine

Maternal health 294

b) Voiding: deviation from speedy and
continous flow of urine. Eg: slow or
intermittent stream, hesitancy,
terminal dribble.
c) postmicturation: eg:feeling of
incomplete emptying.

Maternal health 295

Common types of urinary
incontinence
Main groups of patients referred to
physiotherapist are those with storage
symptoms.

1. Extraurethral incontinence:
loss of urine through channels other than
urethra.
May be due to congenital
abnormality.eg:aberrant ureter draining into
vaginal vault

Maternal health 296

Fistula between bladder or urethra and
vagina due to trauma at pelvic
surgery like hysterectomy.
Management: usually require surgery.

2. Detrusor overactivity incontinence:

Symptom: urge incontinence,which is
involuntary leakage of urine
accompanied by or preceded by
urgency

Maternal health 297

Sign: overactivity observed at
urodynamic assessment as provoked
detrusor contractions during filling
phase.
Condition: may be neurogenic or
idiopathic,due to infections.

Management:
Removal of cause if possible.
Pharmacotherapy.

Maternal health 298

Exercises to strengthen PFM.
Bladder training to regain confidence
Alternative therapy to
pharmacotherapy,is continous E.S
with pulse duration 500microsec at 5-
10 Hz for 20-30mins.

Maternal health 299

3. Urodynamic stress incontinence:
Symptom: incontinence when
intraabdominal pressure is raised by
exertion
Sign: involuntary spurt, dribble or
droplet of urine observed to leave
urethra on increase in intraabdominal
pressue. Test should be conducted in
standing also.

Maternal health 300

Condition: could be due to incompetent
closure mechanism of urethra.
associated with bladder neck
hypermobility.
detrusor overactivity frequently
coexist.

USI often associated with urgency and

frequency.

Maternal health 301

Prolapse of bladder and urethra possibly
due to loss of pinchcock effect may
cause USI.
Weakness can result from any of the
following:
a)Trauma to muscle or adjacent tissues
b) Damage to the nerve supply to
sphincter or levator ani.
c) Weakness from underuse.
d) Stretching from overuse

Maternal health 302

Management:
Can be treated conservatively or
surgically.
For conservative treatment, voluntary
contractions of PFM. i.e. intense
rehabilitation
Those with weak PFM,biofeedback with
or without E.S can be used.

Maternal health 303

 Nocturnal enuresis
Urinary incontinence during sleep.
It affects 15-20% of 5yr old children and upto
2% adults.
Management:
Reward charts, scheduled awkening can be
tried.
Various alarm systems can be used.
Antidiuretic drugs may be prescribed eg:
desmopressin.
PFM contractions,it may have inhibitory effect
on detruser.
Maternal health 304
 Giggle incontinence:
Generally seen in girls around puberty.
Positive family history.
Caused by detrusor overactivity
induced by laughter (Chandra et al
2002)
Management:
PFM exs regularly.
Develop the habit of contracting these
muscles while giggling.
Maternal health 305
 Functional incontinence:
Involuntary loss of urine due to deficit in
ability to perform toileting functions
secondary to physical or mental conditions.
Physiotherapist in collaboration with
occupational therapists can help such
patients.
eg: arranging for easily accessible toilets,
solutions for obstacles like heavy doors,
insufficient turning space, etc.
Time voiding technique may help.

Maternal health 306

 Voiding difficulties:
Causes:
Due to faecal impaction
Large cystocele kinking the urethra.
Urethral dyssynergia, as in multiple
sclerosis.
Neurological damage affecting pelvic
innervation eg: diabetic neuropathy
Detruser atonia as in cauda equina
lesions

Maternal health 307

Assessment:
By uroflowmetry.

Management:
Removal of cause.
Faecal impaction can be treated by diet and
bowel training.
Weak detrusor activity can be enhanced by
drugs like bethanechol chloride.
In neurological cases,intermittent self
catheterization may be taught or suprapubic
catheter implanted.

Maternal health 308

Physiotherapy assessment
methods
Assessment in quite private room.

History of the patient’s condition:

Present and past history.
Two things worth remembering:

Maternal health 309

 Urinalysis:
Reagent strips.
Within one hour,strip dipped into
specimen of urine.
Change in colour acc to abnormal urine
content.
PTs need official training in reading
strips.

Maternal health 310

 Frequency / volume chart:
Patient asked to Note the time of the
day and measure vol of urine voided
each time.
From chart it is possible to determine,
• Actual freq of micturation
• Precise degree of nocturia
• Altered diurnal variation
• Total vol voided per 24hrs
• Incidence of urinary accidents.
Maternal health 311
 Pad test:
Test approved by ICS, takes 1 hour
1. Test started without patient voiding
2. Preweighed perineal pad is put on
and timing begins
3. Patient drinks 500ml of sodium free
liquod within 15 mins
4. Following half hour patient walks,
climbs stairs, perform exs like
standing from sitting, coughing,
running, bending down,etc
Maternal health 312
At the end of hour, pad is weighed, any
difference is recorded.
Increase of upto 1gm is considered
normal.

Maternal health 313

 Paper towel test:
Researched by Miller et al 1998.
Patient holds coloured paper towel
against perinium and coughs 3 times.
Assessment of amount of leakage
measured by weighing or measuring
area of dampness.

Maternal health 314

 Perineal and vaginal assessment:
RCOG(2002) and ACA(2003) has
published guidelines for intimate
examinations.
PT are strongly advised to study all
these guidelines and undertake
specialist practical training from an
expert.

Maternal health 315

Explanation of the examination
procedure and purpose is given to the
woman.
Written consent taken.
Universal precautions should be
taken.
Position of woman: crook lying with
hips abducted and feet apart.

Maternal health 316

 Internal examination:
1. Observe the perineum:
2. Apply lubricant to gloved index
finger.
3. Gently slide palmar surface of finger
along posterior vaginal wall. Check
for rectocele
4. Ask the patient to ‘draw in strongly
and lift up towards head’
5. Feel the anterior shift.that is
puborectalis. Assess the strength.
Maternal health 317
6. Palpate laterally, in region of 3-4 or
8-9 o’clock. Ask the patient to draw
in. medial shift felt is pubococcygeus.
Assess the strength and endurance.
7. Feel the anterior vaginal wall. Check
for cystocoele.
8. Check for superficial perineal
muscles.
Avoid examination during menstruation
and untill postpastum loss has
ceased.
Maternal health 318
 Manual grading of strength of PFM
contraction:
Six point scale modelled on oxford
scale:
1. Flicker
2. Weak
3. Moderate
4. Good
5. Strong.
Maternal health 319
Laycock & Jerwood(2001) validated the
‘PERFECT’ scheme where by:
P: power,
E: endurance’
R: repititions
F: fast
ECT: i.e. ‘every comtraction timed’ to
complete acronym.

Maternal health 320

 Thirteen ways of confirming PFM
contraction:
1. Vaginal Ex by PT
2. Self- Ex by pt
3. Hand on perinium by PT
4. Hand on perinium by pt
5. Observation by PT
6. Observation by pt
7. perineometer
Maternal health 321
8. Stop and start midstream
9. Using Neem healthcare ‘Educator’
10. Using vaginal cones
11. Asking partner at intercourse
12. Manometric and EMG biofeedback
13. Transperineal or labial ultrasound.

Maternal health 322

 Biofeedback:
For PFM, proprioceptive tech of touch,
stretch, pressure and verbal
encouragement can be used during
digital assessment.
Following may also be available in
assessment:

a) perineometer:
Record changes in activity in region of
vagina.
Maternal health 323
Maternal health 324
Two types:
1) Recording pressure changes
2) Monitoring EMG activity.
Most commonly used is Peritron.

Maternal health 325

 The Educator
Simple device inserted in vagina.
Voluntary contraction cause indicator to
move downwards.
Upward movt indicates ‘Valsalva
manoevre’

Maternal health 326

 Computerised manometric and
electromyographic equipment
For manometry: vaginal probe is used
For EMG: two electrodes are mounted
on vaginal probe
Signals are produced and relayed on
VDU.
Can be used in assessment, treatment
and monitor patient progress.

Maternal health 327

 Quality of life questionares:
King’s health questionare,validated and
specific for urinary incontinence.
Takes 30mins.
ICIQ: international consultation on
incontinence questionnaire in its short
form has just 6 ques and is validated.

Maternal health 328

 VAS:
10cm line.
One end suggests ‘no leakage’ and
other end ‘always wet’.

Imaging ultrasound scanning of

bladder:
Small portable ultrasound scanner to
scan bladder and calculate volume of
urine.
Maternal health 329
Post void residual of less than 100ml is
normal.
It has been used transvaginally with
probe and transperineally or
translabially.

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 Electrophysiological tests:
1. Electromyography:
Single needle EMG has been used to
examine peborectalis and external
anal sphincter.
Fine needle inserted and MUAP are
recorded.
Single fiber density: normal FD in
puborectalis and anal sphincter is 1.5

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20 recordings during mild contraction in
various parts of muscle are taken and
mean counted.

2. Motor conduction tests:

a) Pudendal nerve terminal motor
latency:
Intrarectal stimulating and recording
device introduced into anus and
record the response of EAS muscle.

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Latency measured and recorded.

b) Perineal nerve terminal motor latency:

Similar test using catheter mounted recording
electrode in urethra

c) Central motor conduction times:

By stimulating motor cortex,record stimulus
from pelvic floor. Eg:in multiple sclerosis.

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Physiotherapy treatment
For the pts with stress urinary
incontinence:
If no VPFMC is possible then
biofeedback and ES should be
considered.
If VPFMC is possible then pts should
be taught ‘the knack’
For ES: pulse duration-250 microsec,
frequency- 30-40 Hz, for 10-20 mins.
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Vaginal electrodes is used and pt is told to
join in.
For pts with urge incontinence:
Series of repeated strong PFM,perineal
pressure and encouraged to desist from
going ‘to loo just in case’ to increase
period between voids.
For ES: freq- 5-10 Hz, pulse duration- 500
microsec, for 20-30 mins.

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 Teaching PFM contractions:
Teaching points:
1. Visualisation:
2. Language:
3. Starting position:
4. Example of instruction to patient:
instructions for all the three
passages.

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5. Duration and repetition:
Long, strong contractions one after
other with rest of about 4 secs, each
held as long as possible. Record
length of hold and no. of repetitions
Short, sharp quick contractions until
fatigued, no. is recorded.
6. Change of starting posititions:
7. General advice: ‘the knack’

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 Biofeedback:
Two types of equipment:
For clinic use and home use.
1. Manometry:
With vaginal pressure probe and feedback
by means of manometer or visual
display.
a) Computerised manometric equipment:

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Display is shown on VDU screen.
b) Perineometer:
c) Hand held devices: manometric hand held
devices for home.

2. electromyography:
Computerised EMG equipment:
Vaginal electrode is used.
Periform is popular because of its ellipsoid
shape.

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3. other:
a) Vaginal cones:
Progressively weighted cylinders,
ranging from 10 to 100g
Each cone has the nylon string
attached.
Selecting appropriate cone:
Lightest cone inserted in semiquatting
or half lying position.
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Patient stands and walks around, if
retained for 1min, pt progress to next
cone.
Heaviest cone retained for 1min is used
for exs.
Treatment sessions:
Twice a day.
Pt inserts the cone and walks around
for up to 15mins.
Over time, coughing and other activities
introduced.
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 Electrical stimulation:
Used for two purpose:
a) To produce muscle contraction
b) To utilise sensory stimulation to
inhibit detrusor overactivity.
IFT, medium freq currents was used
extensively for urinary incontinence.
Incrasing use of biofeedback has made
it less popular.
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 Bladder retraining:
Described by Jeffcoate & Francis.
Main aims are:
• Correct faulty habits
• Control urgency
• Prolong periods between voids
• Reduce incontinence episodes
• Reduce daily no. of voids and
increase void vol.
• Build pt’s confidence
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 Timed and prompted voiding:
A routine of toileting times is set.

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Bowel and anorectal dysfunction

Two main categories:

a) Difficulty in evacuating faecal
material. Eg:constipation
b) Inability to store faecal material. Eg:
diarrhoea, soiling

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 Factors contributing to difficulties in
defaecation:
1. Abnormal defaecation techniques:
Uncoordinated defaecation pattern:
failure of anal relaxation with
lowered levator ani.
Intensive abdominal training may lead
to rigid abdominal wall.
Position of anus at rest:
descending perinium syndrome:
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2. abuse:
Can lead to anismus, paradoxical
puborectalis contraction and pelvic
floor dyssynergia on attempted
defaecation.
3. Eating disorders:
In patients with anorexia nervosa, binge
eaters.
4. Food And drink:

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5. Ignoring call to stool.

6. Irritable bowel syndrome:

Divided into,
Spastic constipation having abdominal
pain
Painless diarrhoea complaining of stool
frequency.

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7. Megacolon and megarectum:
Megacolo: dilated segment with normal
phasic contractility but decreased
tone
Megarectum: incresaed compliance
with maximal tolerable volume.

8. menstruation:

9. Neurological conditions:
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10. Pain with anal fissure:

11. Pregnancy and postpartum:

12. Prolapse:

13. Psychiatric disorders:

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 Factors contributing to anal
incontinence:
a)age:
b)Anal sphincter dysfunction:
Childbirth: physical damage to ext or int
anal sphincter, due to perineal tear
extending upto anus.
Surgery:
Accidents:
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Trauma: to the anal sphincters, tears,
episiotomy, traction on pudendal
nerve during childbirth.
Habitual chronic straining at stool:
can cause descending perineal
syndrome.

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 Physiotherapy assessment of faecal
incontinence:
1)History
Bowel habit diary should be adviced
prior to starting treatment.
Food diary should also be adviced.
Any past history of obs, gynaec, urinary
symptoms, drugs, psychological.

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 Physical Ex:
Inspection of lower back: may reveal
spina bifida oculta
Abdominal examination:
Neurological assessment:
dermatomes: i.e. S2,S3,S4
Myotomes of lower limbs.
Anorectal Ex: in side lying, with pt’s
prior consent.

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Anorectal Ex:
a)Visual assessment
b)Perineal Ex:
c)Internal Ex:
Introduction:
Puborectalis:
Anal sphincter:

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 Investigations:
1. Anorectal manometry:
It includes,
a) Resting anal canal pressure
b) Anal canal squeeze pressure
c) Pressure during cough and
defeacation
d) Sensory threshold in response to
balloon distention

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2. Colonic transit studies:
Ingestion of radio opaque different
shape and sized markers, followed
by abdominal X-rays on several days
afterwrads. Cannot be done in
pregnancy.

3. Concentric needle EMG:

For EAS and puborectalis

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4. Defaecating proctogram:
Barium paste is introduced and
evacuation observed during
radiography.

5. Endoanal ultrasonagraphy:
360 degrees rotating transducer
introduced in anal canal, gain image
of both IAS and EAS.

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6. Pudendal nerve terminal motor
latency:
Special device placed inra-rectally.
Two electrodes: one at tip, one at the
level of anal sphincter.
Activity on anal sphincter is recorded.
Normal: less than 2.2ms
Nerve damage: longer than that.

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7. Strength duration curve:
Of EAS. Significantly correlates with
other diagnostic measures.

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Treatment

Diet

Bowel retraining:
Toiletting 20-30 mins after meal, to
utilize gastrocolic response.
Four stage holding programme for
bowel urgency and frequency.

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 Medications:
Physiotherapy for bowel dysfunction:
1)Effective defeacation techniques:
Proper posture
Breathing patterns: diaphragmatic
Abdominal activity during defaecation:
brace and bulge
Pelvic floor activity during bearing
down: anal relaxation with rectal
support
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2. Anal sphincter exercise:
Technique: pt sitting on chair
It include strong hold oof maximal length,
longer contractions of half the maximum
hold for endurance and finally fast
contractions.

3. biofeedback:
Via anal pressure probe or EMG
electrodes.

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a) constipation:
Place small electrodes around anal
sphincter at 2 o’clock & 10 o’clock
position.
Ask to observe both contraction and
relaxation of sphincter.
b) Faecal incontinence:
Norton et al 2002 investigated on 4 groups.
Biofeedback and exs help patients with
faecal incontinence.

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4. Massage for constipation:
Contraindications: cancer of bowel, any
abdominal herniation, recent
abdominal surgery or scarring.
Technique:
5 part tech,
a)Stroking from stomach to groin for
relaxation
b)Effluerage along colon
c)Circular kneeding in same direction
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d) More effleurage
e) Side to side stroking across
abdominal wall.

5.Neuromuscular stimulation:
Anal electrode should be used.
Freq: 35-40 Hz
Pulse duration: 250 microsec.

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6. Rectal sensitivity training:
Simple device: rectal balloon attached
to a plastic tube with three way tap
to enable air to be introduced is
introduced.
Importance of slow and fast distension.

7. Anal plugs:
Disposable anal plugs are inserted in
upper part of canal. Useful on
occassional basis.
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