OBSTETRIC PHYSICAL THERAPY

3 (2+1)Credit Hours

(MS - WHPT)

Dr.Hafiza Neelam Muneeb

Senior Lecturer
RCR & AHS Lahore
Women health physiotherapist
03204097476
hafiza.neelam@riphah.edu.pk
Antenatal care
1. Diagnosis and presumptive manifestations
2. Pregnancy tests
3. Gestational age
4. Initial examination
5. Examination in subsequent visits
6. Drugs during pregnancy
• Contraindications for use of physical agents in pregnancy
• Medication usage in pregnancy
1.Diagnosis and presumptive manifestations

• Presumptive signs and symptoms of pregnancy are those signs and

symptoms that are usually noted by the patient, which impel her to
make an appointment with a physician.

• These signs and symptoms are not proof of pregnancy but they will
make the physician and woman suspicious of pregnancy.
Early symptoms of pregnancy
Some symptoms of pregnancy are especially noticeable early on, including:

1. a missed period
2. feeling exhausted
3. urinating more than normal
4. sensitive, swollen breasts
5. Nausea & vomiting

• If you notice any of these symptoms, talk to your doctor, especially if you’ve
recently had unprotected sex.
 Amenorrhea (Cessation of Menstruation).
(1) Amenorrhea is one of the earliest clues of pregnancy.
The majority of patients have no periodic bleeding after the onset of pregnancy.
However, at least 20 percent of women have some slight, painless spotting during early
gestation for no apparent reason and a large majority of these continue to term and
have normal infants.
(2) Other causes for amenorrhea must be ruled out, such as:
(a) Menopause.
(b) Stress (severe emotional shock, tension, fear, or a strong desire for a pregnancy).
(c) Chronic illness (tuberculosis, endocrine disorders, or central nervous system
abnormality).
(d) Anemia.
(e) Excessive exercise.
Nausea and Vomiting (Morning Sickness).
1) Usually occurs in early morning during the first weeks of pregnancy.

2) Nausea and vomiting are unreliable signs of pregnancy since they may
result from other conditions such as:

(a) Gastrointestinal disorders (hiatal hernias, ulcers, and appendicitis).

(b) Infection (influenza and encephalitis).
(c) Emotional stress, upset (anxiety and anorexia nervosa).
(d) Indigestion.
 Frequent Urination.

• Frequent urination is caused by pressure of the expanding uterus on

the bladder.

• Frequent urination is not a definite sign since other factors can be

apparent (such as tension, diabetes, urinary tract infection, or
tumors).
Breast Changes

In early pregnancy, changes start with a slight, temporary enlargement

of the breasts, causing a sensation of weight, fullness, and mild
tingling.
Fatigue.

• This is a common complaint by most patients during the first

trimester.

• Fatigue may also be a result of anemia, infection, emotional stress, or

malignant disease.
2.Pregnancy tests

• Home pregnancy tests

• Clinical urine test
• Blood test
Pregnancy tests

• Pregnancy tests work by checking your urine for a hormone called human
chorionic gonadotropin (HCG).

• Your body only makes this hormone if you’re pregnant.

• HCG is released when a fertilized egg attaches to the lining of your uterus —

when pregnancy begins.

• If your pregnancy test results are positive, it means you're pregnant. If they’re
negative, it means you’re not pregnant.
Home pregnancy tests

• A home pregnancy test (HPT) can be used on the first day of your
missed period. Some very sensitive tests can be used even earlier.

• These tests work by detecting the hormone human chorionic

gonadotropin (hCG) in your urine.

• A chemical in the stick changes color when it comes into contact with
this hormone.
 Blood test
Blood tests can detect hCG earlier than urine tests. Blood tests are usually more
expensive than home tests, and you have to wait longer for your results.
There are two types of pregnancy blood tests:

Qualitative hCG blood test: This test checks to see whether any hCG is being produced
in the body. It gives a simple yes or no answer as to whether you’re pregnant.

Quantitative hCG blood test: This test measures the specific level of hCG in the blood
Quantitative hCG blood tests are very accurate because they measure the exact
amount of hCG in the blood. They can detect smaller amounts of the hormone than a
qualitative hCG blood test or a urine test.
3. Gestational age
• Gestational age, length of time that a fetus grows inside the mother’s uterus.
• Gestational age is related to the fetus’s stage of growth as well as its cognitive and
physical development. 
• For example, at the gestational age of 7 to 8 weeks, all the vital organs have begun to
form, along with the bones and cartilage.
• By the gestational age of weeks 9 to 13, the genitalia have formed, and the entire
fetus weighs about 1 oz (0.06 pounds).
• By weeks 21 to 23, the fetus’s eyes have developed, and the fetal heartbeat can be
heard by stethoscope
• By 40 weeks, fetal development is complete.
• Hence, a normal pregnancy has a gestational range of 38 to 42 weeks, with 40
weeks generally considered full-term pregnancy
3. Gestational age

Week
First
Trimester   1
1 2 3 4 5 6 7 8 9 10 11 12
3
Second Week
Trimester 14 15 16 17 18 19 20 21 22 23 24 25 26 2
7
Third Week
Trimester 28 29 30 31 32 33 34 35 36 37 38 39 40 4
1
3. Gestational age
• Gestational age should be documented by the clinician as a numeric
value between 1-50. Gestational age (written with both weeks and
days, eg. 39 weeks and 0 days) is calculated using the best obstetrical
Estimated Due Date (EDD) based on the following formula:
• Gestational Age = (280 - (EDD - Reference Date)) / 7 
Duration of the gestation
• Duration of the gestation may be calculated using one of the following
methods

1. Menstrual History
2. Date Of Quickening
3. Hegar,s Sign
4. Pregnancy Test
5. Ultrasound Scanning
1. Menstrual History
• Gestational Age (GA), or menstrual age, is a clinical term usually given in weeks
and days to describe human development timed from the first day of the last
menstrual period (LMP).
• In general, gestational age is measured by the number of weeks that have passed
since the first day of the mother’s last menstrual period
• Naegele,s rule: add 280 days ( roughly 9 months and 7 days) to the first day of
LMP

• For example:
• Date /LMP 1st September 2020
• EDD +7 +9
• EDD 8 June 2021
2. Date Of Quickening
• The first natural sensation of quickening may feel like a light tapping, or
the fluttering of a butterfly.
• These sensations eventually become stronger and more regular as the
pregnancy progresses. Sometimes, the first movements are mis-
attributed to gas or hunger pangs

• Usually, quickening occurs naturally at about the middle of a pregnancy.

• A woman pregnant for the first time typically feels fetal movements at
about 18–20 weeks, whereas a woman who has given birth at least
once will typically feel movements around 15–17 weeks
3. Hegar's sign
• Hegar's sign is a non-sensitive indication of pregnancy in women — its
absence does not exclude pregnancy.
• Pregnancy causes progressive softening of uterus, which typically
begins at the level of isthmus. This softening of isthmus occurs while
the body uterus and cervix still firm , make the cervix and body of
uterus to move independent to each other on bimanual examination
• This sign is demonstrable between 6th-8th weeks of pregnancy
• As before this isthmus is firm and after this softening of uterus is more
generalized .
Parts of uterus

The narrow portion situated between body

and cervix is known as the isthmus
5.Ultrasound Scanning

• Ultrasound uses the size of the fetus to determine the gestational age
(the time elapsed since the the first day of the last menstrual period)

• The American College of Obstetricians and Gynecologists

recommends that ultrasound-established dates should take
preference over menstrual dates when the discrepancy between
ultrasound dating and LMP is exist
1.Gestational sac:
• From start of pregnancy up to 9 weeks the gestation is calculated by
measurement of the size of gestational sac.
2. Crown rump length (CRL)
• CRL is reliable between 9 to 12 weeks and measure the duration of
gestation with the range of +/- 3 days
3. Measurements between 12-24 weeks

1. BPD (bi parietal dimeter )

2. FL ( femur length )
3. HC ( head circumference)
4. AC ( abdominal circumference)

• BPD, FL, HC and AC all can be use to calculate the duration of gestation

• BPD is more reliable

Determining the Estimated Due Date
• The estimated due date (EDD or EDC) is the date that spontaneous
onset of labor is expected to occur. The due date may be estimated by
adding 280 days ( 9 months and 7 days) to the first day of the last
menstrua
• Use of the LMP to establish the due date may overestimate the
duration of the pregnancy, and can be subject to an error of more
than 2 weeks [5-7].l period (LMP)
4. Measurements After 24 weeks

• Only FL is reliable tool other tools lose their accuracy

• Only FL can be use to calculate the duration of gestation

 The Booking Visit
• A. HISTORY
1. General Information (name, age ,address, occupation year since married )
2. Past Medical And Surgical History (UTI, blood reactions, allergy,diabetes,HTN)
3. Family History (D.M, HTN, congenital and inherited disorders)
4. Past Obstetrical History ( most relevant topic of history taking)
5. Social history ( social habits, condition of home and work)
6. Gynecological history ( menarche, LMP, any abnormality of menses)
7. Current pregnancy
Past Obstetrical History
• Total Number of pregnancies and their progress is noted.
• In case of pregnancy loss , the type of abortion ,the need for evacuation, detail
about an ectopic or molar pregnancy are recorded.
• Pregnancy complication like pregnancy induced hypertension,, intrauterine
growth retardation, antepartum hemorrhage etc. are noted.
• The information related to delivery , gestation at delivery, onset of labor, mode of
delivery, place of delivery, level of surgeon, complication of puerperium,
assistance required to the baby, birth weight, APGAR score, congenital
malformation and current status of health of living children and immunization .
Current pregnancy

• Duration of gestation at booking visit is calculated (GA, EDD etc)

• The progress of pregnancy regarding vaginal bleeding , pregnancy

symptoms, general illness, drug intake and exposure to radiation etc is
noted
Initial examination
1. General physical examination
2. Abdominal examination
General physical examination
• Height and weight
• Hands for cyanosis, jaundice, anemia
• Anemia ( presence of pallor in palmer crease and koilonychias (spoon
shaped nails) and is feature of chronic anemia
• Pulse , temperature and Blood pressure
• Eyes are examined for pallor, jaundice and exophthalmos
• Teeth , gums and oral cavity are examined for general hygiene
• Neck examined for thyroid enlargement and lymphadenopathy
• Breast is examined for lump discoloration or secretion
• Legs are examined for varicose veins and oedema
Abdominal examination

• First empty urinary bladder

• Uterus is in pelvis abdominal contour is normal
• May seen previous abdominal scars, pigmentation and striae
gravidarum ( whitish or silvery marks)
• Abdomen is palpated for organomegaly esp liver and spleen
• Percussion and auscultation is not required in first trimester at first
visit
Examination in subsequent visits
• How frequent they should be?
• What care is to be provided at each visit?
Frequency of subsequent visit
• We in Pakistan currently following the UK 1929 model of antenatal
care i.e.

• 4 weekly visit till 28th weeks

• 2 weekly visits till 36 weeks
• Weekly visits there after till birth

for all pregnant women irrespective of the parity

Care provided at each subsequent visits
• The usual protocol of Care provided at each subsequent visits
comprises of the following steps
• 1.History:
• Discussion about diet, sleep, fetal movements, vaginal bleeding or
discharge, feeling of fainting, GIT symptoms, headache or visual
disturbance.
• 2.Examination:
• General and abdominal examination
• General BP, weight oedema, pallor etc.
Abdominal examination at each subsequent visits

1.Inspection

2.palpation
• A. Assessment of fundal height
1. Palpatory method
2. Measurement method
• B. Assessment of fetus
1. First Manoeuvre
2. Second Manoeuvre
3. Third Manoeuvre
4. Fourth Manoeuvre

3.Auscultation
Assessment of fundal height: Palpatory method
Assessment of fundal height:
Palpatory method
 Assessment of fundal height:
Measurement method
• Fundal height is measured with a measuring tape from the top of symphysis pubis
along the midline over the uterine curve to the top of uterine fundus. Measure
this distance in centimetres from the symphysis pubis to the top of the fundus.
This is the symphysis-fundus height.

• Feel carefully for the top of the fundus and for the upper border of the symphysis
pubis. Place the tape measure on the symphysis pubis and, using a tape measure
with the centimetre marks face down, measure to the top of the fundus.Turn the
tape measure over and read the measurement
• The mean fundal height measures approximately 20 cm at 20 weeks and increases
by 1 cm per week so that at 36 weeks the fundal height should be approximately
36 cm.
Assessment of fundal height:
Measurement method
A large SFH raises the possibility of:
• A multiple pregnancy.
• Macrosomia.
• Polyhydramnios.

A small SFH raises the possibility of:

• FGR.
• Oligohydramnios.
B. Assessment of fetus: First Manoeuvre

• To determine the fetal part occupying the uterine fundus

Assessment of fetus: Second Manoeuvre

• Lateral palpation
• Determine the sides on which the fetal back lies
• The palm of the hand are placed on either side of the abdomen, on
one side smooth part of the back is felt, while other side nodular area
i.e limbs
Assessment of fetus: Third Manoeuvre

• This determine the presenting part

• Pawlike grip
Assessment of fetus: Fourth Manoeuvre

• Determine the attitude of the fetal head

• Head flexed or extended
Drugs during pregnancy

• Folic acid before and during pregnancy

• Vitamin D in pregnancy
• Iron in pregnancy
• Vitamin C in pregnancy
• Calcium in pregnancy (Calcium is vital for making your baby's bones
and teeth.)
Folic acid before and during pregnancy

• You should take a 400 micrograms folic acid tablet every day before
you're pregnant and until you're 12 weeks pregnant.

• Folic acid can help prevent birth defects known as neural tube
defects, including spina bifida.

• If you did not take folic acid before you conceived, you should start as
soon as you find out you're pregnant.