Professional Documents
Culture Documents
Ekta modi
2nd MPT in Rehab
Maternal health 1
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.
Maternal health 2
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
Maternal health 3
• 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)
Maternal health 5
Pelvic diameters:
Maternal health 6
•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
Maternal health 8
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
Maternal health 9
• 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
Maternal health 10
• 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)
Maternal health 11
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
Maternal health 12
• 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.
Maternal health 13
The abdominal muscles
Maternal health 15
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.
Maternal health 16
• 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.
Maternal health 17
Reproductive tract
Maternal health 18
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.
Maternal health 19
• After ovulation follicle collapses and
become corpus luteum which
secretes oestrogens and
progesterone.
Maternal health 20
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.
Maternal health 21
• 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.
Maternal health 22
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.
Maternal health 23
• 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.
Maternal health 24
• 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.
Maternal health 25
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.
Maternal health 26
• Urethra embedded in anterior vaginal
wall is vulnerable to trauma during
childbirth, pelvic surgery and
occasionally during intercourse.
Maternal health 27
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
Maternal health 28
• 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.
Maternal health 29
• 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.
Maternal health 30
• Two other bands of fascia-
uterosacral ligaments- connect cervix
and upper part of vagina to lower
portion of sacrum.
Maternal health 31
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.
Maternal health 32
• 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.
Maternal health 33
• 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.
Maternal health 34
• 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.
Maternal health 35
Physiological changes in pregnancy
Maternal health 37
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.
Maternal health 38
• 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)
Maternal health 39
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
Maternal health 40
• Urethral tone reduced : stress
incontinence
• In blood vessels: lowered diastolic
pressure.
Maternal health 41
4. Development of breasts milk
producing glands.
Maternal health 42
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.
Maternal health 43
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)
Maternal health 44
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.
Maternal health 45
Average fundal heights,
Maternal health 46
• 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
Maternal health 47
Cardiovascular system
Maternal health 49
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
Maternal health 50
Supine hypotension
• reason
• Moving the women into sidelying gives relief
(Kinsella et al 1994)
Maternal health 51
Peripheral vasodilatation
• Occurs because of effect of
progesterone.
• Women with raynaud’s disease
experience relief.
• Epistaxis, haemangioma, palmar
erythma, vascular spiders may occur
Maternal health 52
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.
Maternal health 53
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.
Maternal health 54
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.
Maternal health 55
• Subcostal angle increase from
68degrees to 103degrees
Maternal health 56
Immune system
Maternal health 58
Breasts
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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.
Maternal health 62
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.
Maternal health 63
• 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)
Maternal health 64
Nervous system
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Urinary system
Maternal health 68
Musculoskeletal system
Maternal health 69
• 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.
Maternal health 70
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.
Maternal health 71
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.
Maternal health 72
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
Maternal health 73
‘After pains’: throbbing or cramping
kind of pain of moderate to severe
intensity.
Maternal health 74
• Sign of involuting uterus: can be
palpated.
On 1st postpartum day: above
umbilicus
By 6 days: midway
By 10 days: dissapeared down
behind symphysis
Maternal health 75
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.
Maternal health 76
• 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.
Maternal health 77
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)
Maternal health 78
• 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.
Maternal health 79
Prevention of back pain:
• Ostgaard et al (1994) found pain was
reduced by early individual education.
Maternal health 80
• 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.
Maternal health 81
• Sitting:
on chair, follow the criteria:
Maternal health 83
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:
Maternal health 84
• Objective examination:
a) Positioning:
standing
prone
supine
b) Routine observation:
c) Functional assessment:
Maternal health 85
• Treatment:
Gentle heat and massage.
TENS if pain continues.
Exercise programme, to maintain
results.
Corsets for lumbar spine.
Maternal health 86
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.
Maternal health 87
• Osteitis condensans ilii, seen on X-
ray after childbirth.
Disappears in few months.
Maternal health 88
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.
Maternal health 89
• 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.
Maternal health 90
Symphysis pubis dysfunction
Maternal health 92
Thoracic spine pain
Maternal health 93
Treatment :
• mobilisation.
• Posture correction
• Rib lifting techniques:
• Hot water bottle or ice pack
Maternal health 94
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)
Maternal health 95
Examination for diastasis rectii:
patient position and procedure:
Maternal health 96
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.
Maternal health 97
Nerve compression syndromes
Maternal health 98
Ultrasound
Splinting limiting wrist flexion.
Modify position of wrist in prone
kneeling exercises.
Maternal health 99
Brachial plexus pain:
treatment: exercises, stretching,
elevation
Meralgia paraesthetica:
TENS is helpful ( Fisher et al 1987)
Chondromalacia patellae:
avoid full squat
Treatment:
• Warmth or cold
• Massaging or stroking
b) Diagonal curls:
5. Scapular retraction:
In sitting or standing.
3. Visual imagery:
Payne 1998, encourage the person to
think in pictures as opposed to words.
Touch relaxation:
Kitzinger (1987) discusses this concept,
where women relaxes to the touch of
her partner.
Imagery :
Teaching techniques:
3 phases of contraction,
Preparatory phase
Action phase
Recovery phase.
labour compared to sea and explain
the mother.
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.
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.
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
3. Ice:
Its pain relieving effect is well
documented. ( knight 1989,
palastanga 1988)
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.
3. Urinary retention
Causes:
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.
3. Thoracic pain:
Relieved with active exs and hot or ice
packs.
2. Oedema:
4. Pulmonary embolism:
5. Haemorrhoids:
2. Puerperal psychosis:
More severe condition.
Mother lose contact with reality, have
delusions, mood swings, anxiety,
agitation.
3. Postnatal depression:
Begin early in postpartum period.
Mother sad, depressed, worry for
herself and baby.
In severe PND, mother feel suicidal.
Emergency CS
Obstructed labour
Foetal & maternal distress
Ante partum haemorrhage
Placental abruption
Prevention:
Application of stockings
Early mobilization
Avoid sitting with knees acutely flexed
Lower limb movements, deep breathing exs
5. Back pain:
6. Dependent edema:
1. Extraurethral incontinence:
loss of urine through channels other than
urethra.
May be due to congenital
abnormality.eg:aberrant ureter draining into
vaginal vault
Management:
Removal of cause if possible.
Pharmacotherapy.
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.
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.
2. electromyography:
Computerised EMG equipment:
Vaginal electrode is used.
Periform is popular because of its ellipsoid
shape.
8. menstruation:
9. Neurological conditions:
Maternal health 349
10. Pain with anal fissure:
12. Prolapse:
5. Endoanal ultrasonagraphy:
360 degrees rotating transducer
introduced in anal canal, gain image
of both IAS and EAS.
Diet
Bowel retraining:
Toiletting 20-30 mins after meal, to
utilize gastrocolic response.
Four stage holding programme for
bowel urgency and frequency.
3. biofeedback:
Via anal pressure probe or EMG
electrodes.
5.Neuromuscular stimulation:
Anal electrode should be used.
Freq: 35-40 Hz
Pulse duration: 250 microsec.
7. Anal plugs:
Disposable anal plugs are inserted in
upper part of canal. Useful on
occassional basis.
Maternal health 367
Maternal health 368