Women’s Health & Physical Rehabilitation

By
Arham Shamsi
 History of Physiotherapists’ Involvement in
Obstetrics and Gynaecology
1. In the late nineteenth century the physiotherapy, nursing and
midwifery professions shared a common rootstock.
2. In 1902, Dame Rosalind Paget, established Central Midwives
Board .
3. Extended its focus to include remedial exercise and electrotherapy,
and developed into the Chartered Society of Physiotherapy (CSP).
1. Miss Randell was one of the first to bring the principles of physiotherapy to
obstetrics

2. The exercises were designed to aid postnatal physical recovery and to train women
to rest through relaxation

3. Later turned her attention to antenatal instruction that more should be done
preventatively to help pregnant women.
 Apart from incorporating squatting into her antenatal programme as a
preparation for labour, Miss Randell introduced many of the pelvic
and lumbar spine mobilising exercises
 In 1936 Heinemann published a book entitled Maternity and
Postoperative Exercises; written by Margaret Morris, an ex-ballet
dancer wrote “women should be encourage, in the puerperium were
encouraged to practise repeated ‘pelvic floor tensing’, trying ‘to invert
the sphincters
1. In the 1930s Dr Grantly Dick Read his theory of the fear
tension pain cycle in labour.
2. Fearful women who expected to feel pain became tense as
labour began. This led to tension in their minds and, in their
cervices too. This, he claimed, gave rise to more pain,
which in turn increased their fear. He encouraged his
labouring mothers to relax and breathe deeply through their
contractions.
1. Obstetric Physiotherapist’s Association in 1948
2. in 1961 became the Obstetric Association of Chartered
Physiotherapists
3. In 1978 the Association adopted the title of the Association
of Chartered Physiotherapists in Obstetrics and
Gynaecology (ACPOG)
Gynecologists Obstetricians
• Gynecologists deal with • Obstetricians deal with all
female care throughout a aspects of pregnancy care
woman's life, from her first
sexual encounter to well
after menopause.
 Women Health Screening
Women Should be Reminded of Following Screening guidelines

1. Breast Self Examinations > Feeling for Lumps and looking for
any change in Shape and Size and Color.
2. Pap Smear Test > To Diagnose pre cancer cells lining the
cervix.
3. Speculum >
 Female Athlete Triad
Includes >>>
1. Anorexia Nervosa > Eating disorder which leads to weight at least 15% less
than Normal
Bulimia Nervosa > Binge Eating
2. Amenorrhea > Women of Child bearing age fails to Menstruate . Two Types.
i. Primary >Delayed Puberty, Common in Girls Who are Very thin and Very
Athletic, Fat are absent to Initialize Menstruation.
ii. Secondary > Previously Menstruating Females fails to menstruate for 3
consecutive . Caused naturally by Pregnancy, Breast feeding and
Menopause.
Oligomenorrhea > Infrequent and very light Menstruation caused by Physical
and Emotional Stress, Chronic Illness and Tumors which Secrets Estrogen,
Poor Nutrition. Females Athletes Often Develop Oligomenorrhea due to their
restriceted Diet.
3. Osteoporosis > Osteoporosis is a bone disease that occurs
when the body loses too much bone, makes too little bone, or
both. As a result, bones become weak and may break from a
fall or, in serious cases, from sneezing or minor bumps. As
Bone mainting properties of Estrogen are gone.
Treatment > 1200-1500 mg/day Calcium Supplement
Reduced use of Oral Contraceptives
Dietary > 3 glass of Skim milk and Resistance training
ERT > Estrogen Replacement Therapy
 Changes With Pregnancy
• Changes are Vital for The process of Pregnancy but Often
Women Will develop discomfort because of them .
• In order to create more Space for enlarged Uterus the
Rib Cage Expands which allow Diaphragm to Elevate up
to 4 cm, leads to stress on Rib cage(rib and Thoracic
spine Articulation leads to Back ache.
• Elevated Hormones(estrogen, Progesterone and Relaxin
causes Laxity of Ligaments and Joints, Growth of Breast
and Retention of Fluids. these elevated levels do not
return to baseline for several Months after baby is Born.
1. Relaxin also affects Tissues after Conception, reaching its Peak around 3
months. Also leads to Sacroiliac Hyper mobility.
2. Many changes in Musculo skeleton are due to weight change.
3. Average weight gain 27.5 Pounds.
4. Abdomen Enlargement causes forward weight shift which leads to
Lordosis in Lumbar Spine and Kyphosis in Thoracic Spine.
5. Diastais Recti is another problem(Separation of Rectus Abdominus)
6. Increased in Breast Size puts extra Stress on Thoracic Spine.
7. Sacroiliac Dysfunction may Leads to Sciatica.
8. Pubic Symphysis Separation occur around 2 to 32 week of gestation. As
Pubic Symphysis widens approx 4 to 7 cm.
9. Round Ligament Pain results from Stretching of Lateral aspect of uterus
causes sharp pain in Groin and Vagina.
10. Pelvic Muscle Weakness ( The Three S’s) Sphincteric, Supportive and Sexual.
These Muscles forms A sling. If weak Bladder and Bowl Function will be
Impaired, resulting in incontinence.
11. Increased Subtalar pronation
12. Increased Knee hyper extension
13. Lympedema
14. By the end of Pregnancy Women retain 3 liters of Extra Fluid > CTS, Thoracic out
let syndrome, Ilio inguinal nerve entrapment, Intercostal Neuralgia and Bells
Palsy.
15. Oxygen Consumption Increases by 14%. Half going to Fetus & Placenta and rest
half to Uterine Muscles & Breast Tissues.
16. Blood Volume Increases by 40 to 50% leads to an eventual increase in Cardiac
output to 50%
17. But over all BP decreases in Pregnancy due to Smoot Muscle Relaxation.
 The Obstetric physiotherapist
• The role of the Obstetric Physiotherapist is to promote
health throughout the childbearing period and to help the
woman adjust advantageously to the physical and
psychological changes of pregnancy and the post-natal
period so that the stresses of childbearing are minimised.
Antenatally and postnatally she advises on physical
activity associated with both work and leisure and is a
specialist in selecting and teaching appropriate exercises
to gain and/or maintain fitness including pelvic floor
education.
 The program offers innovative treatments and
therapies, helping women regain their well-being
through our Inner Strength Initiative and once again
enjoy active, satisfying lives. The care focuses, but
not limited to, on pregnancy/post partum, pelvic
floor dysfunction and breast and pelvic cancer
rehabilitation. Special attention Paid to particular
groups of women like adolescents, female athletes
and women with complex conditions.
 Areas of Expertise
1. Prenatal Discomfort 11. Defecatory Dysfunction
2. Pelvic Floor Weakness 12. Post-Gynecological Surgery
3. Chronic/Myofascial Pelvic Pain 13. Post-Abdominal Surgery
Syndromes
14. Coccyx Disorders / Tailbone Pain
4. Post-Partum Discomfort and
15. Perimenopausal& Menopausal
Reconditioning
Concerns
5. Pelvic Girdle Pain
16.Endometriosis
6. Urinary Incontinence
17.Osteoporosis
7. Fecal Incontinence
8. Breast Cancer 18.Lymphedema

9. Chronic Constipation 19.Posture Training

10. Pelvic Organ Prolapse 20.Correct Lifting Methods
 Techniques Utilized
1. Lamaze
2. Kegel’s Protocol
3. Dr Glazer’s Protocol
4. Dr Stein’s Protocol
5. Relaxation Therapy > Jacob’s & Mitchell Method
6. Manual therapy > CTM
7. Wurn Technique > Adhesions
8. Yoga
 Technology Used
1. Aquaflex Cones
2. Interferential Currents
3. Perineometer
4. EPI NO Delphine plus
5. The Educator
6. Bio feed back
7. Cross Fire Treatment
8. TENS
9. Cold Compressions
•Regular mild to moderate exercise sessions, at least three times
a week, are safer than intermittent bursts of activity.
Mild exercise appropriate to the various stages has several
advantages.It helps to strengthen the pelvic muscles,reduces
mood swings that expectant mothers commonly experience and
also keeps the circulatory system healthy.If done in the proper
manner exercise can also help lessen the severity of
backaches,improve sleep and daily stretching helps keep the
joints more flexible and firm.
• A Moderate work out helps to release endorphins
that elevate the mood and help to burn up the
anxious energy leading to more relaxed sleep
patterns. It also helps to strengthen the back, thigh
and buttock muscles that improve posture and
relieve pregnant women of headaches.
• The exercises in particular that are appropriate to
most expectant mothers are swimming ,spinning and
pelvic straightness.
 Contraindications
• Competitive and contact sports, and activities such
as horse riding, skiing, waterskiing and scuba diving
carry far greater risks when a woman is pregnant.

• Jerky, bouncing, ballistic movements and activities

should be avoided
 Contraindications
to vigorous exercise in Pregnancy
• Absolute • Relative
1. Cardiovascular disease
2. Acute infection
1. Women unused to high levels of
3. A history of recurrent spontaneous
4. abortion (miscarriage)
2. exertion
5. Preterm labour in current or previous Pregnancy 3. Blood disorders such as sickle cell
6. Multiple pregnancies disease and anaemia
7. Vaginal bleeding or ruptured membranes 4. Thyroid disease
8. Incompentent cervix 5. Diabetes – however, a carefully
9. Pregnancy-induced hypertension supervised programme of
10. Suspected IUGR or foetal distress gentleexercising may actually
11. Thrombophlebitis or pulmonary embolism benefitsome patients
12. Chronic hypertension, active thyroid,
13. cardiac, vascular or pulmonary disease
14. Diabetes type 1 uncontrolled 6. Extreme obesity or underweight
7. Breech presentation in third trimester
 INITIAL POSTNATAL EX
Breathing Ex. Deep breathing for circulatory &
relaxing effect

Leg exercise Foot ankle leg exercise

Abdominal exercise In crook line position combined with

expiration

Pelvic tilting exercise Crook lying position

Tilt Relax Tilt Relax Exercise
 CESAREAN CHILDBIRTH

• It is an operative procedure whereby the fetuses after the end of 28th wk.
are delivered through an incision on the abdominal & uterine wall.

• Impairments /Problem Due To Cs

1. Risk of pneumonia
2. Postsurgical pain.
3. Risk of adhesion.
4. Formation at incisional site.
5. Risk of vascular complication.
6. Faulty posture.
7. Pelvic floor dysfunction.
8. Abdominal weakness
GOAL PLAN OF CARE

1.Improve pulmonary function & Breathing ex. Coughing &huffing.

decrease the risk of pneumonia

2.Decrease incisional pain associated 2. Postnatal TENS support incision

with coughing with hands when coughing.

3. Prevent postsurgical adhision 3. Friction massage & scar

formation Mobilisation.

4.Prevent postsurgical vascular 4.Active leg ex. ,early ambulation

complication
5.Correct posture & protected 5.Postural instruction &positioning
activities of daily living for ADL

6. Prevent Pelvic floor dysfunction 6. Pelvic floor Ex.

7. Develop Abdominal Strength 7. Abdominal Ex.

EX. PROGRAM FOR HIGH RISK PREGNANCY

1 POSITIONING INSTRUCTION
• Left side lying position to prevent vena cava
compression, enhance COP & lower extrimity edema.
• Pillow to support body parts & enhance relaxation.
• Supine position for short period with wedge placed
under the rt. Hip to decrease IVC compression.
2. ROM INSTRUCTION
Slow active full ROM of all the joints.
Teach movement in gravity eleminated position.
 3. SUGGESTED EX.
 Lying
 Supine or side lying with alternate knee to chest .
 Ankle pumping .
 Unilateral SLR in supine & side lying position.
 Pelvic tilt, bridging, isometrics for pelvic floor
muscle.

 Sitting ,may not be allowed

PREGNANCY INDUCED PATHOLOGY
1>SI Dysfunction 1>Modified Exercises for Si Joint
2>Nerve compression syndrome 2> Splinting
ice packs
3>Circulatory problem varicose elevation of the limb
vein of leg TENS
vulval varicose vein 3> prolonged standing
Leg cramps avoided
Thrombosis & Ankle ex. ,calf stretching
Thromboembolism Raising foot end of standing
should bed.
Deep kneading massage
stocking & breathing ex.
4> Stress incontinence 4>Pelvic floor ex

5> Postural backache 5>Postural correction

6> Ice packs ,heat, US,

TENS,
6> Coccydynia Use of rubber ring to
relieve pressure in sitting.
 References

1. Prevention Practice, A physical Therapist’s Guide to

Health , Fitness and Wellness
By Catherine Rush Thompson.
2. Physiotherapy in Obstetrics and Gynaecology
By Jill Mantle Second Edition