Physical disability

Prepared by:
Aashma Bidari
M.Sc. In Midwifery
KUSMS
 Disability
• Disabilities may be physical, sensory,
developmental, intellectual, or psychiatric in
nature or a combination of these.
• While there are many definitions of
disability, there is general agreement that
disability is a limitation in a major activity,
caused by a chronic health condition.
• In the past the women with physical disabilities
did not meet potential marriage partners and so
did not become pregnant.
• Today woman with varying degrees of disabilities
attend public schools, work in offices, establish
sexual relationship, marry and plan pregnancies.
• Because such woman face special problem
related to physical disabilities, nursing care
during pregnancy must be designed with the
special concerns in mind so that it addresses the
woman and her family’s problems and needs.
 Pregnant woman
with visual
impairment
• Visual impairment in women of child-
bearing age may be the result of variety of
causes –for example, accidental injury in
childhood, diabetes mellitus or congenital
anomalies such as cornea or lens
destruction from rubella invasion in utero.
 Modifications for pregnancy
• Visually impaired women need to come early and
consistently for prenatal care because they may
not be able to self-assess some of the danger
signs of pregnancy such as diplopia, blurring of
vision, edema or vaginal spotting.
• It is important to determine the reason for the
woman’s visual impairment when taking a health
history and to address her worries about the
impairment being passed on to her baby.
• If her lack of eyesight is for congenital reasons,
she might benefit from genetic counseling.
• This is important if the loss of vision is due to
retinoblastoma, an inherited malignancy.
• If the cause was rubella, the woman might be
advised to be certain her serum titre against
rubella is adequate before undertaking a
pregnancy to prevent this from occurring in
her child.
 Planning child care
• Ask during pregnancy about the woman’s
plans for child care.
• Encourage her to breast-feed.
• If she chooses to use formula, suggest she use
the ready-prepared kind that needs no dilution
and can be poured into a clean bottle just
before feeding, so that she can avoid having to
measure amounts.
• Caution her against propping the baby bottle
which could cause aspiration.
 Child birth
• Encourage the woman to attend a childbirth
preparation class.
• Labor can be confusing time for the visually
impaired woman.
• Be certain that everyone who comes into the
birthing room introduces so she is not frightened by
stranger’s voices speaking to her.
• Be sure to give the baby to the visually impaired
woman as soon as possible so she can reassure
herself that the child is perfect.
• Describe the baby to her.
 Postpartum period
• Be certain that a woman has her child with her for
long stretches of time so she can become used to
such phenomena as the irregular pattern of breathing
of a newborn and she is comfortable with changing
diapers and feeding.
• Teach her to look at the child when talking to him
because making eye contact is important to the child
in feeling secure and developing vision.
• Be certain that she has an appointment for follow-up
• Ask if she desires contraceptive information.
Pregnant woman with
spinal cord injury
Since fertility in women is based on hormonal
balances rather than on needing certain
neurological inputs, fertility is completely normal
after SCI. However, there are a few issues that a
woman who endures a SCI should know about
pregnancy:
Fertility
1)First of all, many women experience a delay in
return of their menstrual cycle after a SCI, for up
to 6 – 12 months. This is normal, and it should
return to a regular cycle within a year or a bit
later.
During Pregnancy
1) DVT - Women with SCI are at higher risk of
getting clots in the veins of their legs, called
"DVT" or deep vein thrombosis.
• Therefore it's important to keep the legs
moving, whether that means the woman doing
that herself, or someone doing it for her.
• Also, pressure stockings should help reduce the
risk. Leg swelling or "edema," is also more
common, both in SCI and in pregnancy, so
putting the legs up when possible and wearing
the stockings can help.
2) Bladder infections and incontinence-
Women with SCI often have a neurogenic
bladder, and as the baby increases in size, it
can push on the bladder, causing incontinence.
• As the end of pregnancy draws nearer, many
women find they need to catheterize more
often to prevent incontinence, or even rarely
use a Foley catheter for a few weeks.
• Also, urine infections may be more common,
and it's important to get these treated, as
infected urine is more likely go backwards to
infect the kidneys, when there is pressure on
the bladder from the baby.
3) Autonomic Dysreflexia (AD) -This can
occur in people with SCI with lesions at T6
or higher. This can result in severely high
blood pressure, headaches, or even coma
stroke, or death.
• A woman with a SCI at or above T6 needs
to make her obstetrician aware of what AD
is, and even how to treat it.
 During Labor and Delivery
1) Lack of awareness of the onset of labor -
• Signs of labor are not always recognized in females
with SCI. Contractions may not be felt, or they may
just be felt as a dull ache.
• When the water breaks, it may be mistaken for
urinary incontinence or vice-versa.
• A headache from autonomic dysreflexia or increased
spasticity may be the only signs of the onset of labor.
• The woman and/or her care givers should be taught
how to feel the abdomen to feel for contractions of
labor.
2) Autonomic Dysreflexia (AD)-
Once again, it is important to
stress that AD is extremely
common and can be very
dangerous in labor and
delivery.
• Those women at risk (injuries
at T6 or above) should consider
an epidural to help avoid this.
• Induction of labor is possible,
but should only be done if
those with lesionsT6 or above
get an epidural first.
3) Vaginal delivery -There is no good reason
why a woman with SCI should need a
Caesarean section any more than someone
else.
• The only reasons not to have a vaginal birth,
include the normal obstetrical indications,
and if AD is uncontrolled despite
medications.
• With vaginal birth, those that cannot push
may need help getting the baby out with
forceps or a vacuum device.
 Post Delivery
1)Breast feeding - Women with SCI can breastfeed,
even tetraplegics, with or without different aids.
• Occupational Therapy department can be helpful
to design pillows or other devices to help with
this.
• Soreness of the nipples from breast-feeding can
also trigger AD. Preventing chaffing can be
helped by using Lanolin on the nipples.
• Occasionally women with SCI do not experience
the "letdown" response with breast-feeding and
nasal spray with oxytocin may be needed.
2) Perineal pain/breakdown - After an
episiotomy or tear, the increased pressure
on the area from sitting in a wheelchair
can lead to increased risk of breakdown.
• The area should be inspected frequently
and if it starts to break down, the woman
needs to get off of it as much as possible.
This perineal breakdown may also be a
trigger for AD.
3) Baby handling- This may be difficult,
especially for women with tetraplegia.
• Occupational Therapy and Rehab
Engineering can be very helpful by
supplying equipment, modifying cribs,
change tables and suggesting positions
and other ways to handle the baby
 Woman with cerebral palsy
• Cerebral palsy is condition, sometimes thought of
as a group of disorders that can involve brain and
nervous system functions such as movement,
learning, hearing, seeing, and thinking.
OR
• Cerebral palsy (CP) is the term used for a group of
non progressive disorders of movement and
posture caused by abnormal development of, or
damage to, motor control centers of the brain. CP
is caused by events before, during, or after birth.
• Secondary conditions can include seizures,
epilepsy, apraxia, dysarthria or other
communication disorders, eating problems,
sensory impairments, mental retardation,
learning disabilities, and/or behavioral
disorders.
• Cerebral palsy (CP) is divided into four major
classifications to describe different movement
impairments. These classifications also reflect
the areas of the brain that are damaged. The
three major classifications are:
1. Spastic
• This is the most common type in woman
People with this type of CP are hypertonic
and have what is essentially a neuromuscular
mobility impairment.
• Spastic hemiplegia is one side being affected.
• Spastic diplegia is the lower extremities
affected, with little to no upper-body
spasticity.
• Spastic monoplegia is
one single limb being
affected.
• Spastic triplegia is
three limbs being
affected.
• Spastic quadriplegia is
all four limbs more or
less equally affected
2. Ataxic
• Ataxia type symptoms can be
caused by damage to the
cerebellum. 10% of all cases.
• Some of these individuals have
hypotonia and tremors.
• Motor skills such as writing,
typing, or using scissors might be
affected, as well as balance,
especially while walking.
• It is common for individuals to
have difficulty with visual and/or
auditory processing.
3 Athetoid/dyskinetic
• Athetoid or dyskinetic cerebral palsy is
mixed muscle tone — both hypertonia
and hypotonia. People with athetoid
CP have trouble holding themselves in
an upright, steady position for sitting
or walking, and often show involuntary
motions.
 Effect in woman
✔Spasticity of all body muscles leading to
hypertonic movement (lack of fine
coordination).
✔Speech may be unclear if her facial and throat
muscle are affected.
✔In severe form woman will be limited to wheel
chair for ambulation and difficult performing
even the daily living such as self-feeding.
✔Pain is common and affect the chronic sleep
disorder.
 Modifications for pregnancy
• As pregnancy progress, referral to physical
therapist to evaluate carefully her ability to
maintain self ambulation.
• The weight of abdomen may necessitate the use
of crutches.
• Appreciate her to achieve the degree of
ambulation.
• Help her to see the reducing degree of
independence during pregnancy is not a step
backward for her but a step forward as it allow
her to have self pregnancy without repeated falls.
• To maintain the strength of muscle especially
the knees and hips, and to prevent contracture
she may need to perform active range of motion
exercise.
• If the speech cannot be readily understood,
evaluate whether she can use telephone for
help in emergency. When calling to the health
care agency, ask her to state her name first.
• Pregnancy counseling for woman with cerebral
palsy is to increase her self-esteem and ability
to see herself as capable of maintaining a
pregnancy and caring for child
 Planning child care
• Help the woman to think how she will carry the
crying, struggling infant if she is unsteady on her
foot or uses crutches to ambulate.
• Encourage to use an infant backpack or a wheelchair
with an baby sling.
• Encourage her to breastfeed because this will
eliminate her having to walk an extra distance to
warm or prepare formula milk.
• If her spasticity is severe, she may not be successful
at breastfeeding as the let down reflex, which
depend on muscle relaxation may not occur.
 Childbirth
• Encourage the woman to attend the childbirth
preparation class even though she may not be
able to do breathing exercise effectively during
labour, because the spasticity of her muscle may
not allow for breathing pattern.

• Labour may be acutely painful because her

abdominal muscle remain tight and uterus grow
tender, raising and pressing against a tense
abdomen with each contraction.
• She has poor use of abdominal muscles so
she may not be able to push effectively
during the pelvic division of labour hence
fetal descent may not occur and cesarean
birth or forceps delivery may be
necessary.
• If she is unable to assume lithotomy
position because of hip contractions, she
will be vaginally delivered from a sim’s or
dorsal recumbent position.
 Postpartum period
• Help the woman to begin self care at the level with
which she is capable.
• Use the infant disposable diapers so does not
employ safety pins because with a quick,
uncontrolled hand motion she could injure the infant.
• Allow her adequate time to feed and hold the infant
to increase her competence.
• Be certain that she has a return appointment for
healthcare supervision for herself and the infant.
Provide knowledge on family planning methods.
The woman with a hearing impairment
• Hearing impairment
ranges from having
difficulty hearing
whispered
conversation to being
totally deaf.
• A hearing loss of 30
dB-mild hearing loss.
• A loss of 50 dB or
more-severe hearing
loss.
• The most probable cause of hearing loss
are because of infection such as rubella
during intra uterine life, meningitis in
early infancy or a genetically inherited
hearing disorder.

• If it occurred because of an infection

ensure that her rubella titre is adequate
so that her own child will not be infected
 Modifications for pregnancy
• A woman with a hearing impairment needs to
establish a regular pattern of prenatal care.
• Make a habit of showing the woman the
printed words. if she uses sign language, she
may bring an interpreter with her to translate.
• If you have difficulty understanding her
questions, ask her to write it down for you.
• Use visual aids liberally to explain the
physiologic changes of pregnancy or what care
is planned at a health visit.
 Childbirth
• Encourage the woman to attend a childbirth
preparation class.
• During labour the hearing impaired woman
cannot hear information on how she is
progressing, communicate with her support
person.
• Remember that she cannot hear the infant cry at
birth, so be sure she knows the baby is crying
and breathing well.
• They have a strong need to see their infants and
concerned that the infant is hearing impaired.
• You can assess for this disability by
showing her how the infant startles at a
loud noise, such as clapping your hands.

Planning child care

• She will not be able to hear the baby
crying especially at night.
• help her to plan to bring the infant’s cribs
close to her bed so she can feel the
vibrations of the baby’s stirring or walking.
 The postpartum period
• Unfortunately the child may develop her
speech pattern and need speech therapy
during preschool years.
• If her partner is not hearing impaired, he
should be encouraged to talk and sing to the
baby to provide a normal pattern of speech.
• Tapes of songs, stories and nursery rhymes
can also be played.
• Schedule a follow-up care appointment for
both her and her child.
 Psychosocial / Mental Health
Issues
• Women with disabilities are at risk for depression
and mental health disorders because of the
isolation, dependence, low self-esteem and lack of
intimate relationships with others that often occur
with disability.
• Women with disabilities should be assessed for
depression during each health care visit.
• Changes in women’s medications, home situation,
support systems, and stress level should be
assessed.
• Their usual coping strategies should be
identified and unhealthy methods of coping
(e.g., alcohol use, substance abuse, smoking)
identified and addressed.
• Pharmacologic and non-pharmacologic
methods of addressing depression and other
mental health issues should be offered to
women.
• Counseling and psychotherapy will be helpful
for women before, during and after pregnancy.