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OBSTETRICS Objectives: The student should be Physical Therapy in Women’s able to: Health Care • Understand the roles and responsibilities of the physical therapist in working with obstetrical patients during and after pregnancy and Carol Figuers, PT, EdD childbirth Professor • Recognize physical therapy interventions for Doctor of Physical Therapy Division pregnancy & postpartum Duke University School of Medicine

Hormonal Changes & Pelvic Girdle PT Interventions – Back Pain • Instability of joints • Symmetrical body movements • SI dysfunction main cause of • Small ranges of motion “back pain” in women* • “Baby Hugger” belts • Isometric exercises around pelvis and stabilization • Body mechanics Boissonnault JS, Klenstinski JU, Pearcy K. The role of *Garras et al. Single‐leg‐stance (flamingo) radiographs to assess pelvic instability: How exercise in the management of pelvic girdle and low much motion is normal? J Bone Joint Surg Am. 2008. back pain in pregnancy: A systematic review of the literature. JOWHPT, 2012.

Transverse abdominis Check for Diastasis Recti strengthening

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Transversus Abdominis strengthening Tips for Managing Back Pain

• Posture & Body Mechanics – Avoid carrying objects on one hip (assymmetry) – Avoid crossing legs – Carry loads in middle – Change positions frequently – Get muscles “ready” to move – Support lumbar spine – Watch body mechanics with ADL’s

Tips for Managing Back Pain Suggestions for Healthy Exercise

• Dealing with pain • Mild to moderate exercise at least 3 times/week – Have partner massage back • Modify INTENSITY of exercise – not to – Use moist heat for 30 min. at a time or exhaustion less • ACOG* recommends using Borg scale – Ice the area for 10 min. 4-5times/day of perceived exertion level: (especially irritated SI) 12 – 14 (somewhat hard)

*American College of Obstetrics & Gynecology

Exercise Precautions During Postpartum Pregnancy • Do not start a NEW, aggressive routine • Time frame • Avoid extremes of “range of motion” • When to start • Avoid excessive stress to joints such as exercise? ankles, sacroiliac, pubic symphysis • Need medical • Be sure to replace fluids and calories clearance? (300kcal/day more) • Areas to rehabilitate Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion. American College of Obstetricians and Gynecologists. Number 650. December 2015.

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Education PELVIC FLOOR DYSFUNCTION Objectives: The student should be able to: • Recognize the types, causes and symptoms of urinary incontinence • Identify the most common types of female pelvic pain • Describe the role of the physical therapist in evaluation and intervention for pelvic floor dysfunction

Types of Urinary Pelvic Floor Dysfunction – Urinary Incontinence Incontinence & Pelvic Pain Type Possible Mechanism Symptoms Stress Incontinence Urethral hypermobility Leaking with cough, laugh, Pelvic floor damage sneeze, movements Chronic stress to pelvic floor Urge Incontinence Detrusor muscle instability Leaking with ”trigger” (key in door, water sounds) Frequent urination Mixed Incontinence Combined mechanisms of Combined cues stress and urge Overflow Incontinence Decreased contractility of Chronic dribbling of urine detrusor muscle Urinary frequency Urethral obstruction

**Figuers 2009

Major Types of Incontinence Major Types of Incontinence

• STRESS • URGE

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Prevalence of Urinary Documented Risk Factors Incontinence Associated with Incontinence • Affects more than 13 million • Immobility • High impact physical Americans • Diminished cognition activities • 85% of these are women • Medications • Diabetes • 2-16% of young, nulliparous women • Smoking • Stroke • 30% of women over 65 years old • Fecal impaction • Estrogen depletion • 1 in 4 women with UI never • Pelvic muscle discussed with provider • Low fluid intake/dehydration weakness • Prostate gland enlargement and surgery may pose risk • Environmental • Pregnancy, labor, barriers delivery

Physical Therapy Examination Physical Therapy Examination

• Modified pelvic exam to isolate pelvic floor muscles • Coach on avoiding substitution of gluteal, abdominal and hip adductor muscles • Test for pelvic floor muscle strength (0-5) and endurance (seconds)

Biofeedback Assessment Interventions • EMG electrodes • Prompt patient to • Home program of pelvic floor perform contraction and relaxation of the muscle exercises (Kegels) pelvic floor • Functional Kegels • Quick flicks • Baseline work/rest • Healthy bladder habits session to calculate • Urge suppression drill work and rest averages in microvolts

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Pelvic Pain – Acute vs. Chronic Pelvic Floor Muscle Trigger Point

• CHRONIC PELVIC PAIN = pain in the • Palpate levator ani pelvic area lasting for at least 6 • Obturator internus months • Radiating • Recurrent pelvic pain = episodic symptoms ailments such as dysmenorrhea or dyspareunia • Acute pelvic pain = pain lasting less than one month

Pelvic Pain Interventions References

• Figuers, C. Physical therapy management of pelvic floor dysfunction. In Women’s • Stretching Health Care in Physical Therapy: Principles and Practices for Rehabilitation Professionals, Glenn Irion and Jean Irion (eds), Philadelphia, PA. Lippincott Williams • Pelvic floor muscle & Wilkins. 2009. • Figuers, C. Physical therapy management of pelvic pain. In Women’s Health Care in exercise (increase Physical Therapy: Principles and Practices for Rehabilitation Professionals, Glenn Irion and Jean Irion (eds), Philadelphia, PA. Lippincott Williams & Wilkins. 2009. circulation; • Boissonnault J, Klestinski J, Pearcy K. The Role of Exercise in the Management of Pelvic Girdle and Low Back Pain in Pregnancy:A Systematic Review of the Literature. downtrain) Journal of Women’s Health Physical Therapy, Volume 36 • Number 2 • May/August 2012. • Desensitization • Nygaard I. Idiopathic Urgency Urinary Incontinence. N Engl J Med 2010;363:1156- (dilators) 62. • Skin care • Relaxation

Case Study #1 Obstetrics Case Study #2 Pelvic Floor

• 32 y/o female, 28 weeks IUP • 45 y/o female G3P3 with chief c/o presents for evaluation and stress urinary incontinence which treatment of “back pain”. She impacts her daily activities (she works F/T as a lab research won’t leave the house on bad days) assistant. She c/o pain in right buttock/side, difficulty with sit to • She lives with her children (ages 8- stand, pain in prolonged sitting, 12) and husband and carpools, stair climbing manages the house, but changes • Palpation, pain provocation tests, her clothes “a lot” due to urinary gait analysis suggest hypermobility accidents of right sacroiliac joint and unstable • Internal manual muscle testing of pelvic girdle. Asymetrical levator ani reveals strength of 3/5 movements (e.g. stairs) reproduce pain with endurance hold for 3 seconds • Treatment consisted of instruction in • Home pelvic floor exercise program home exercise program of pelvic of 10 repetitions (hold 3, rest 6) 4 girdle stabilization exercises, separate times/day education on body mechanics, • Patient education including healthy wearing maternity binder when bladder habits, avoiding val salva active or at work to prevent pain

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Questions?

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