Gynae PT complete

Dr Abdullah
INTRODUCTION
TO
GYNECOLOGY
& OBSTETRICS
OBSTETRICS

– is the health profession or medical specialty that deals

with pregnancy, childbirth, and postpartum period
(including care of the newborn). obstetrician are the
professionals in obstetrics.
GYNAECOLOGY

the branch of medical

science that deals with
the health maintenanc
e
and diseases of wome
n, especially of the re
productive organs.
– A gynecologist is devoted only to the reproductive
care of women / A doctor who specializes in the
medical care of women and their reproductive system
(vagina, ovaries and uterus).
– An obstetrician is concerned with women during and
a little after pregnancy. Obstetricians are also
concerned with the health of the fetus. Almost all
modern Gynecologists are also Obstetricians.
 Gynecologist
– Deals with mammograms , uterine or vaginal
infections, fertility problems or contraception, tubal
ligations and hysterectomies. Confirms the pregnancy
and then transfers to the obstetrician.
– Typical procedures performed are: hysterectomy,
oophorectomy, tubal ligation, laproscopy, laprotomy,
cystoscopy
Gynecologist
oophorectomy
hysterectomy
Obstetrician
– A doctor who specializes in the surgical care
of women and their children during
pregnancy, childbirth and post-natal care.
– Pregnancy, post-natal/post-partum care
and delivery.
– Performs regular ultrasounds usually in the
first trimester, at 12th week and 20th week
of pregnancy to determine healthy of the
fetus, identify any complications and
determine gestational period.
– Vaginal and Cesarean deliveries, episiotomy.
 Gynecologist deals with
– They also deal with uterine and vaginal infections or diseases.
– The diseases they typically encounter are cancer of reproductive organs
(ovaries, uterus, fallopian tubes, cervix, vagina and vulva), incontinence,
amenorrhea (absent menstruation), dysmenorrhea (painful
menstruation), infertility, menorrhagia (heavy menstruation), prolapse of
pelvic organs, fungal, bacterial, viral or protozoal infections to
reproductive organs.
– The gynecologist will usually confirm that a woman is pregnant and then
refer her to an obstetrician.
 Obstetricians deals with
– Obstetricians do not treat diseases of the reproductive organs.
– They deal with any complications during childbirth such as
– ectopic pregnancy (embryo in fallopian tubes),
– fetal distress (fetus is compressed in the uterus),
– pre-eclampsia (convulsions due to hypertension),
– placental abruption (patient can bleed to death if not properly
managed),
– shoulder dystocia (one of the fetus' shoulders becomes stuck during
birth),
– uterine rupture, prolapsed cord (causes a risk of fetal suffocation),
obstetrical hemorrhage and sepsis (infection of uterus before or
after childbirth).
Obstetrics and gynecology are
often combined to form a
single medical specialty in
post-graduate medical
training, abbreviated to
OB/GYN. But any
complications with the baby
after delivery is treated by
neo-natal specialists
 History Of
Physiotherapist
s’ Involvement
In Obstetrics
And
Gynecology.

FAIZA AMJAD
LEC 2
• In the late nineteenth century the physiotherapy, nursing and
midwifery professions shared a common rootstock.
DAME ROSALIND PAGET
• In 1886, Dame Rosalind Paget, a
nursing sister at the London Hospital
who was also a midwife, joined the
Midwives Institute, which later became
the Royal College of Midwives (RCM)
• In 1902 she was involved in the
formation of the Central Midwives
Board and appears as number two on
their list of members.
• Also in 1886 Dame Rosalind became
interested in a new therapy – Swedish
massage
DAME ROSALIND PAGET

• She became one of the founding members of

the Society of Masseuses and in 1895 became
its first Chairman of Council.
• Over the years the group prospered,
extended its focus to include remedial
exercise and electrotherapy, and developed
into the Chartered Society of Physiotherapy
(CSP). Dame Rosalind held membership
number one.
• Early in the twentieth century,
Miss Minnie Randell OBE, a
sister at St Thomas’s Hospital
London, had also trained both
as a nurse and a midwife.
• She became interested in both
the massage and the remedial
exercises being propounded by
the Swede, Per Henrik Ling.
• She was appointed as Sister-in-
Charge and then Principal of
the School of Massage and
Medical Gymnastics at St
Thomas’ Hospital
• In 1912, J. S. Fairbairn, a leading consultant
obstetrician at St Thomas’ who believed in
‘preventive obstetrics’, asked Miss Randell to
devise a system of ‘bed exercises’ for his
postnatal patients.
• Because newly delivered women remained in
bed for about 3 weeks at that time,
• The exercises were designed to aid postnatal
physical recovery and to train women to rest
through relaxation.
• Thus Miss Randell was one of the first to bring
the principles of physiotherapy to obstetrics.
• Later, Miss Randell turned her attention to
antenatal instruction, once again urged on by
Mr Fairbairn, who thought that more should
be done preventatively to help pregnant
women
• Randell introduced many of the pelvic- and
lumbar-spine-mobilising exercises which were
based on the movements made by Kashmiri
boatwomen, and encouraged women to
adopt different positions of comfort in labor.
• exercises which were based on the
movements made by Kashmiri boatwomen,
and encouraged women to adopt different
positions of comfort in labor.
• In 1936 Heinemann published a book entitled
Maternity and Postoperative Exercises; written by
Margaret Morris, an ex-ballet dancer, who had
been one of Miss Rendell’s students
• Helen Heardman, who in the 1940s drew together
the threads of relaxation, breathing and
education for childbirth into antenatal
preparatory courses for labor and parenthood
(Heardman 1948)
• Obstetric Physiotherapist’s Association in 1948.
• 1961 became the Obstetric Association of
Chartered Physiotherapists
• Antenatal classes mushroomed through the
1950s, often taken entirely by so called
‘obstetric physiotherapists’, and women were
routinely offered postnatal exercise sessions
and advice postnatally during their 5–7-day
hospital stay.
• Midwives were invited to contribute and
gradually have become the dominant
profession in this aspect of care.
• In the 50 and more years since then, much
has changed in obstetric physiotherapy,
midwifery and obstetrics, and many
dedicated physiotherapists have added their
• In 1963 Laura Mitchell introduced her method of
relaxation, which has been used extensively ever
since.
• In 1978 the Association adopted the title of the
Association of Chartered Physiotherapists in
Obstetrics and Gynaecology (ACPOG)
• In the late 1980s there was further international
pressure to think holistically of women’s health
issues, which led to another change of title in
1994 to the Association of Chartered
Physiotherapists in Women’s Health (ACPWH) and
to physiotherapists employed in the field being
called ‘women’s health physiotherapists
MIDWIVES, HEALTH
VISITORS AND
OBSTETRIC
PHYSIOTHERAPISTS
MIDWIFE
• The role of the midwife is that of the practitioner of
normal midwifery, caring for the woman within the
hospital and community throughout the continuum of
pregnancy, childbirth and the puerperium.
• She has an important contribution to make in health
education, counselling and support.
• In this context her aim is to facilitate the realization of the
woman’s needs, discuss expectations and air anxieties.
• She has the responsibility of monitoring the woman’s
physical, psychological and social wellbeing and is in a
unique position to be able to correlate parent education
with midwifery care.
THE HEALTH VISITOR

• The role of the Health Visitor in this field is to offer advice to the
parents-to-be on the many health, psychological and social implications
of becoming parents and the development of the child.
• She is in a very special position in the family scene to inform them of the
services available and encourage them to use them.
• The health visitor should always have a participatory role within the
team to provide continuity of care to the family.
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 post-natally 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.
• Where necessary she gives specialised treatment e.g. therapeutic
ultrasound post-natally to alleviate perineal discomfort.
• She also assesses and treats musclo-skeletal problems such as
backache and pelvic floor muscle weakness.
• In addition she is a skilled teacher of effective relaxation, breathing
awareness and positioning and thus helps the woman to prepare for
labour.
THE AIMS OF PARENTHOOD
EDUCATION
• To enable parents to develop a confident and relaxed
approach to pregnancy, childbirth and parenthood.
• To enable parents to be aware of the choices in care
based on accurate and up to date information.
• To provide continuity of high quality care as
previously defined to parents by means of team
collaboration and co-operation between
professionals including specialized treatments where
needed
• To ensure that appropriate, consistent and clear
advice is given with full safety factors.
• To promote health and preventative medicine.
• Frequently new methods
of education in
parenthood are
introduced e.g. aqua-
natal and fitness classes.
• In such instances it is
necessary for guidance to
be sought on appropriate
exercises from the local
obstetric physiotherapist
or alternately the
Chartered Society of
Physiotherapy,
 Anatomy

FEMALE PELVIC
 THE PELVIS
• protective shield
• supports the trunk
• pelvis consists of the two innominate bones and the sacrum to
which coccyx is attached
• The innominates and the sacrum articulate at the symphysis
pubis, and at the right and left sacroiliac joints, to form a firm
bony ring.
• The ring of bone is
deeper posteriorly
than anteriorly and
forms a curved
canal.
• The inlet to this
canal is at the level
of the sacral
promontory and
superior aspect of
the pubic bones
• The outlet is formed by the
pubic arch, ischial spines,
sacrotuberous ligaments and the
coccyx.
• The enclosed space between the
inlet and outlet is called the true
pelvis, with the plane of the inlet
being at right angles to the plane
of the outlet.
• The female true pelvis differs from the male in being
shallower, having straighter sides, a wider angle between the
pubic rami at the symphysis and a proportionately larger
pelvic outlet.
 Female Male

Pelvic Inlet

Pelvic Outlet

Pelvic Cavity

Pelvic Arch
• The ideal or gynaecoid pelvis is recognised by its well-rounded
oval inlet
• The inlet has its longest dimension from side to side, whereas
at the outlet the longest dimension is anteroposteriorly
• The foetal skull is longest in its anteroposterior
dimension.
• Most commonly in labour the head enters the
inlet of the maternal pelvis transversely placed
(i.e. long axis to long axis), rotates in mid-
cavity and leaves by the outlet with its longest
dimension lying anteroposteriorly.
Different shapes of pelvic
• Difficulties can be experienced in childbirth from such adverse
features as protuberant ischial spines, a heart-shaped inlet
produced by an invasive sacral prominence, or an
asymmetrical pelvis (e.g. as a result of rickets or trauma).
• It is also possible for the inlet or outlet to be too small to allow
the foetal head to pass through
• It has recently been demonstrated that a narrow suprapubic
arch is associated with a consequential prolonged labour and
postpartum anal incontinence
 sacrum
• The wedge-shaped sacrum is virtually suspended between the
innominates by the exceptionally tough interosseous and
posterior sacroiliac ligaments,
• However, the ventral sacroiliac ligament is less substantial and
is thought to tear during childbirth
• The upper sacrum is stabilized by the illiolumbar ligaments via
its attachment to the fourth and fifth lumbar vertebra and the
lower sacrum by the sacrospinous and sacrotuberous
ligaments attachments to the posterior iliac spines and ischial
tuberosities
 Loading during pregnancy
• Loading of the sacral prominence (e.g. in pregnancy) is often,
but not invariably, accompanied by lumbar lordosis and its
associated adaptations, hip and knee flexion, thoracic kyphosis
and cervical extension with a forward-thrusting chin.
• It should be noted that in this case it is the sacrum that moves
on the ilia and that the pelvis as a whole does not tilt forward
to produce the lumbar lordosis. The pelvic tilt may well remain
constant
 Sacrum rotation
Lumbar lardosis

down and forward

Anterior pelvic tilt

• The range of movement at the two sacroiliac joints and the
symphysis pubis is normally small; however, movement at one joint
can affect the other two joints in a variety of ways.
• During pregnancy, the elevated levels of oestrogen, progesterone
and relaxin play a major role in increasing the laxity of the pelvic
girdle joints . The hormonal levels do return to normal in the weeks
following childbirth, but the time taken will also be affected by
breastfeeding
• . By 3 to 6 months postnatal, the pelvic girdle should return to its
prepregnant state; it may need external stabilization during this
period
PELVIC FLOOR MUSCLES
 OBJECTIVES

• bony land marks of the pelvis

• how the pelvis is orientated when a woman is standing up straight.
• Orientation of different muscles in pelvic diaphragm
• Different structures in the pelvis
• fetal skull and view it from above
 PELVIC FLOOR

• the pelvic floor acts as a dynamic platform that spans the

outlet of the pelvis to support the abdominal and pelvic
organs;
• it is composed of muscle, fascia and ligaments.
• the term the ‘pelvic trampoline’ also sued to describe the
pf
 LAYERS
• Thelayers of the pelvic floor from deepest to superficial
are as follows
• the endopelvic fascia
• the levator ani muscle
• the perineal membrane
• the external genital muscles
• the external genitalia and skin.
Innominate bone
Sacrum
Coccyx
Sacroiliac joint
Sacrococcygeal
joint
Symphysis pubis
Ischial spine
Ileopectineal line
Obturator foramen
Pubic arch
Sacral promontory
Anterior foramina
Anterior superior
iliac spine

Symphysis pubis

Vertical plane
 Ileum

Pubis
Ischium
Acetabulum

Obturator foramen
Sacrotuberous
ligament
Sacrospinous
ligament
Sacrospinous
ligament
Sacrotuberous
ligament
Greater sciatic
foramen

Lesser sciatic
foramen
Piriformis
Piriformis
Obturator internus
Common Iliac A

Internal Iliac A
External Iliac A
Common Iliac V

Internal Iliac V
The Lumbosacral Plexus
Sciatic nerve
Pudendal nerve
Obturator nerve
Sacrotuberous
ligament
Sacrospinous
ligament
Obturator canal
Obturator internus
Muscle
Covered by
Fascia
Pudendal canal
Line of
attachment of
levator ani
Critical pelvic
dimensions

Pelvic inlet
Critical pelvic
dimensions

Pelvic midplane
Critical pelvic
dimensions

Pelvic outlet
 Female Male

Pelvic inlet

Pelvic outlet

Pelvic cavity

Pubic arch
Iliac crest

Pelvic brim

Ischial tuberosity
Rectum
Obturator
Internus
With Fascia
Levator ani

Plus coccygeus
Makes
Pelvic diaphragm
Peritoneum
Subperitoneal
space
Contains:
Pubocervical
Trans cervical
Sacrocervical
Ligaments
 Perineum
everything under
pelvic diaphragm
Ischiorectal fossae
Obturator
membrane
Obturator canal
Pubic arch Symphysis pubis

Inferior pubic
ramus

Ischial ramus
 Ischial tuberosity
Sacrotuberous
ligament

Sacrum / coccyx
Pelvic outlet
Urogenital
triangle

Anal triangle
Bladder
Above the

Cervix Pelvic diaphragm

Rectum
Pubocervical
ligament Above the
Pelvic diaphragm
 Above the
Pelvic diaphragm
Transverse
cervical ligament
 Above the
Pelvic diaphragm

Sacrocervical
ligament
Pelvic diaphragm

Levator ani:
Pubococcygeus
Iliococcygeus
Ischiococcygeus

Coccygeus
Urogenital
diaphragm

Superior layer
of fascia
Urogenital
diaphragm

Sphincter urethrae

Deep transverse
peroneal muscles
Perineal
membrane
Structures in
Superficial pouch

Clitoris & crus

Bulb of vestibule

Vestibular glands
Muscles in
Superficial pouch

Ischiocavernosus

Bulbospongiosus

Supl transverse
peroneal muscles
Perineal body
Labium majus

Labium minus
 Mons pubis

Prepuce of clitoris

Vestibule

vagina

Fourchette
Peritoneum
 Sacrocervical
ligament
Pubocervical
ligament
Pelvic diaphragm
Urogenital
diaphragm
 Rectum

Sacrum

Perineal body Anococcygeal

body
Puborectalis

Deep

Superficial

Subcutaneous
 parietal
coronal eminence
sutures
frontal lambdoid
bones sutures
occiput

anterior
fontanelle
posterior
saggital fontanelle
suture
 PASSENGER

the head flexes as the uterus contracts

the head descends and engages in the pelvis
the leading part approaches the ischial spines
 PASSENGER

the occiput starts to rotate anteriorly

the occiput reaches the pelvic floor (levator ani)
internal rotation continues to achieve an occipito-anterior position
 PASSENGER

the occiput clears the symphysis pubis

the head extends to deliver
 PASSENGER

the head sits on the maternal perineum

 PASSENGER

the fetal head realigns itself with the fetal shoulders -

restitution
 PASSENGER

the shoulders contact the pelvic floor and rotate so that the bisacromial
diameter lies in an anteroposterior orientation
the head therefore continues to rotate - external rotation
THE ABDOMINAL MUSCLES
• The anterior and lateral abdominal wall is formed by the
abdominal muscles
• The deepest of the group is the transversus abdominis muscle,
which lies internally to the internal and external oblique
muscles
• The aponeurosis is reinforced by the two rectus
abdominis muscles, which run in sheaths formed in the
aponeurosis on either side of the linea alba.
• Of particular relevance is the fact that the sheaths are
elastic longitudinally and less so transversely.
• Each rectus abdominis muscle has three transverse
fibrous intersections, which are firmly attached to the
anterior wall of the enclosing sheath.
• The lowest intersection is about the level of the
umbilicus, and the sheaths are deficient posteriorly in
the lowest portion
Anterior wall of the abdomen
 Nerve suply
• The oblique and transversus muscles are innervated by the
lower six thoracic nerves, and the iliohypogastric and
ilioinguinal nerves.
• The recti are innervated by the lower six thoracic nerves
 Visceroptosis
• The shape of the anterior abdominal wall depends on the
tone of its muscles.

• A middle-aged woman with poor abdominal muscles who

has had multiple pregnancies is often incapable of
supporting her abdominal viscera.

• The lower part of the anterior abdominal wall protrudes

forward, a condition known as visceroptosis.

• This should not be confused with an abdominal tumor such

as an ovarian cyst or with the excessive accumulation of fat
in the fatty layer of the superficial fascia.
 Inguinal Canal
• The inguinal canal is an oblique passage through the lower part
of the anterior abdominal wall.
• In the males, it allows structures to pass to and from the testis
to the abdomen.
• In females it allows the round ligament of the uterus to pass
from the uterus to the labium majus.
• The canal is about 1.5 in. (4 cm) long in the adult and extends
from the deep inguinal ring , downward and medially to the
superficial inguinal ring.
• It lies parallel to and immediately above the inguinal ligament.
• In the newborn child, the deep ring lies almost directly
posterior to the superficial ring so that the canal is considerably
shorter at this age.
• Later, as the result of growth, the deep ring moves laterally.
Function of the Inguinal Canal
• The inguinal canal allows structures of the spermatic
cord to pass to and from the testis to the abdomen in the
male. (Normal spermatogenesis takes place only if the
testis leaves the abdominal cavity to enter a cooler
environment in the scrotum.)

• In the female, the smaller canal permits the passage of

the round ligament of the uterus from the uterus to the
labium majus.
 Mechanics of the Inguinal Canal
• The inguinal canal in the lower part of the anterior
abdominal wall is a site of potential weakness in both sexes.

• Except in the newborn infant, the canal is an oblique

passage with the weakest areas, namely, the superficial and
deep rings, lying some distance apart.

• The anterior wall of the canal is reinforced by the fibers of

the internal oblique muscle immediately in front of the
deep ring.

• The posterior wall of the canal is reinforced by the strong

conjoint tendon immediately behind the superficial ring.
• On coughing and straining, as in micturition, defecation,
and parturition, the arching lowest fibers of the internal
oblique and transversus abdominis muscles contract,
flattening out the arched roof so that it is lowered toward
the floor. The roof may actually compress the contents of
the canal against the floor so that the canal is virtually
closed.

• When great straining efforts may be necessary, as in

defecation and parturition, the person naturally tends to
assume the squatting position; the hip joints are flexed,
and the anterior surfaces of the thighs are brought up
against the anterior abdominal wall. By this means, the
lower part of the anterior abdominal wall is protected by
the thighs
INCISIONS OF ABDOMINAL SKIN IN
GYNAECOLOGY

LOWER MIDLINE
SUBUMBILICAL INCISION VERTICAL INCISION
FOR LAPAROSCOPY

PFANNENSTIEL VERTICAL
INCISION INCISION
ANATOMY OF FEMALE
REPRODUCTIVE SYSTEM
Define the terms listed.
Identify the female external
reproductive organs.
Explain the functions and structures of
pelvic floor.
Collectively, the external
female reproductive
organs are called the
Vulva.
Mons Pubis.
Labia Majora
Labia Minora.
Clitoris.
Vestibule.
Perineum
 Is rounded, soft fullness of
subcutaneous fatty tissue, prominence
over the symphysis pubis that forms
the anterior border of the external
reproductive organs.
It is covered with varying amounts
of pubic hair.
The labia Majora are two rounded,
fleshy folds of tissue that extended
from the mons pubis to the perineum.

It is protect the labia minora, urinary

meatus and vaginal introitus.
It is located between the labia majora,
are narrow.
The lateral and anterior aspects are
usually pigmented.
The inner surfaces are similar to vaginal
mucosa, pink and mois.
Their rich vascularity.
The term clitoris comes from a
Greek word meaning key.
Erectile organ.
It’s rich vascular, highly sensitive
to temperature, touch, and
pressure sensation
Is oval-shaped area formed
between the labia minora, clitoris,
and fourchette.
Vestibule contains the external
urethral meatus, vaginal introitus,
and Bartholins glands.
Is the most posterior part of the
external female reproductive organs.
It extends from fourchette anteriorly to
the anus posteriorly.
And is composed of fibrous and
muscular tissues that support pelvic
structures.
Vagina
Uterus
Fallopian tubes
Ovaries
 FALLOPIAN TUBES
The two tubes extended from the
cornu of the uterus to the ovary.
It runs in the upper free border of
the broad ligament.
Length 8 to 14 cm average 10 cm
Its divided into 4 parts.
Which runs into uterine cavity,
passes through the myometrium
between the fundus and body of
the uterus. About 1-2cm in
length.
Which is the narrow part of
the tube adjacent to the
uterus.
Straight and cord like ,
about 2 – 3 cm in length.
Which is the wider part about
5 cm in length.

Fertilization occurs in the

ampulla.
It is funnel or trumpet shaped.
Fimbriae are fingerlike processes, one
of these is longer than the other and
adherent to the ovary.
The fimbriae become swollen almost
erectile at ovulation.
Gamete transport (ovum pickup,
ovum transport, sperm transport).

Final maturation of gamete post

ovulate oocyte maturation, sperm
capicitation.
Fluid environment for early embryonic
development.

Transport of fertilized and unfertilized

ovum to the uterus.
 OVARIES
Oval solid structure, 1.5 cm in thickness,
2.5 cm in width and 3.5 cm in length
respectively. Each weights about 4–8 gm.

Ovary is located on each side of the uterus,

below and behind the uterine tubes
 STRUCTURE OF THE OVARIES

Cortex
Medulla
Hilum
Figure 28–14
Secrete estrogen & progesterone.

Production of ova
 UTERUS
The uterus is a hollow, pear shaped
muscular organ.

The uterus measures about 7.5 X 5

X 2.5 cm and weight about 50 – 60
gm.
Its normal position is anteverted (rotated
forward and slightly antiflexed (flexed
forward)

The uterus divided into three parts

The upper part is the corpus, or body
of the uterus
The fundus is the part of the body or
corpus above the area where the
fallopian tubes enter the uterus.
Length about 5 cm.
A narrower transition zone.
Is between the corpus of the uterus and
cervix.
During late pregnancy, the isthmus
elongates and is known as the lower
uterine segment.
The lowermost position of the
uterus “neck”.
The length of the cervix is about
2.5 t0 3 cm.
The os, is the opening in the cervix that
runs between the uterus and vagina.
The upper part of the cervix is marked
by internal os and the lower cervix is
marked by the external os.
 Perimetrium.
 Myometrium.
 Endometrium.
 1. PERIMETRIUM

Is the outer peritoneal layer of

serous membrane that covers
most of the uterus.
Laterally, the perimetrium is
continuous with the broad
ligaments on either side of the
uterus.
 2. MYOMETRIUM
Is the middle layer of thick muscle.
Most of the muscle fibers are
concentrated in the upper uterus,
and their number diminishes
progressively toward the cervix.
 The myometrium
contains three types of
smooth muscle fiber
Which are found mostly in the
fundus and are designed to
expel the fetus efficiently toward
the pelvic outlet during birth.
These fiber contract after
birth to compress the blood
vessels that pass between
them to limit blood loss.
Which form constrictions where the fallopian
tubes enter the uterus and surround the internal
os
Circular fibers prevent reflux of menstrual blood
and tissue into the fallopian tubes.
Promote normal implantation of
the fertilized ovum by controlling
its entry into the uterus.
And retain the fetus until the
appropriate time of birth.
 3. ENDOMETRIUM
Is the inner layer of the uterus.
It is responsive to the cyclic variations of
estrogen and progesterone during the female
reproductive cycle every month.
 The two or three layers of the endometrium
are:
*Compact layer
*The basal layer
*The functional or Sponge layer this
layer is shed during each menstrual period
and after child birth in the lochia
THE FUNCTION OF THE UTERUS

Menstruation ----the uterus sloughs

off the endometrium.

Pregnancy ---the uterus support

fetus and allows the fetus to grow.
Labor and birth---the uterine
muscles contract and the cervix
dilates during labor to expel the
fetus
 VAGINA
It is an elastic fibro-muscular tube
and membranous tissue about 8 to
10 cm long.
Lying between the bladder
anteriorly and the rectum
posteriorly.
The vagina connects the uterus
above with the vestibule below.

The upper end is blind and called

the vaginal vault.
The vaginal lining has multiple folds, or
rugae and muscle layer. These folds allow
the vagina to stretch considerably during
childbirth.
The reaction of the vagina is acidic,
the pH is 4.5 that protects the vagina
against infection.
To allow discharge of the
menstrual flow.
As the female organs of coitus.
To allow passage of the fetus from
the uterus.
Physiology of pregnancy
 objectives
• Menstruation
• Pregnancy and fetal development
• The physical and physiological changes of pregnancy
• Complications of pregnancy
Menstrual cycle
Hormonal secretions in relation to
menstruation
Hormonal secretions in relation to
menstruation
Billings ovulation method
• Dry days
• 7th or 8th postmenstrual day(peak of
fertility)
• Thick secretions
• Dry days
 Pregnancy
• The state of carrying a developing embryo or fetus within
the female body i.e from conception to birth.
 Calculation
• A human pregnancy is calculated as usually lasting
about 40 weeks or 280 days.
• If the date on which the last menstrual flow
commenced is known, the estimated date of delivery
(EDD) can be calculated by adding 7 days to the date
and then adding 9 months
• This method of calculating the EDD is known as
Naegele’s rule
• For the first 8 weeks it is usual to call the developing baby
an embryo; thereafter to delivery it is called the fetus.
• The fetus grows within a thin semitransparent sac (the
amnion), is bathed in amniotic fluid and is attached to the
placenta by the umbilical cord.
 Placental hormones
1. Protein hormones of the placenta:
chorionic gonadotropin (cHG)– it is maintain the function of
the corpus luteum during early gestation, promote uterine
vascular vasodilation and myometrial smooth muscle
relaxation, relaxin secretion by the corpus luteum, stimulate
thyroid activity, and some more basic forms also stimulate
iodine uptake
human lactogen – its actions include lipolysis and an increase
in the levels of circulating free fatty acids, thus providing a
source of energy for maternal metabolism and fetal
nutrition
2. Steroid hormones of the placenta: estrogens; progesterone.
3. Chorionic adrenocorticotropic and thyrotropin, growth
hormone variant, parathyroid hormone-related protein
(PTH-rP), calcitonin, and relaxin – no significant role has
been established for this substance in normal human
pregnancy.
4. Hypothalamic-like-releasing hormones of the placenta
Role of Estrogen in Pregnancy:

• Increasing blood flow to the uterus by

promoting vasodilation.
• Changing the sensitivity of the
respiratory system to carbon dioxide.
• Softening of the cervix, initiating uterine
activity, and maintaining labor.
• Developing the breasts in preparation
for lactation and secretion of prolactin
by the pituitary gland.
Role of Progesterone in Pregnancy:
• Ready the uterus for implantation.
• Relaxes smooth muscle to prevent
spontaneous abortion.
• Works to prevent a maternal immunologic
response to the fetus.
• Relaxes smooth muscle
– to decrease motility & improve absorption of
nutrients.
– Enlarges the ureters & bladder to increase
capacity.
• Plays a role in development of the alveoli &
ductal system to prepare for lactation.
Metabolic and endocrine changes
1. Relaxin is a hormone secreted by the corpus
luteum. the endocrine body located in the ovary
at the site of the ruptured ovarian follicle.
a. Relaxin softens connective tissue during
pregnancy in preparation for labour and delivery.
when the pelvis must open to allow for the birth of
the foetus. Relaxin. However is not specific to the
pelvis. Other joints can also be affected.
b. Relaxin peaks in early and late pregnancy.
Women with chronic joint instability may notice an
increase in symptoms during these times.
c. Relaxin has also been speculated to
increased in the non pregnant
women after ovulation and throughout
the menstrual period. This may cause
softening of the joints and pain in
affected women.
Edema is present in the hands. feet.
face and eyelids. This is due in part to
sodium and water retention.
Additionally. hormones circulating by
the placenta. ovaries, and adrenal
cortex cause increased capillary
permeability, which contributes to the
edema many pregnant women
experience.
 Cutaneous system
Cutaneous system
Due to overstretching of the skin, the elastic
fiber may rupture together with small blood
vessels and so red streaks appear; known as
striae gravidarum. They are usually more
marked below the umbilicus, on the breasts
and may appear on the buttocks and thighs.
In some women they are not marked or even
don't appear during pregnancy. After labor,
the red striae become pale silvery white due
to fibrosis and are known as (striae
albicantes).
Stria gravidarum
Pigmentation: It is due to suprarenal
changes, it usually begins to appear
after the 4th month. The pigmentation
may appear anywhere but the
commonest sites are:
1. Linea nigra: which is a line of
pigmentation between the umbilicus
and the symphysis pubis.
2. Increased pigmentation of the nipple
as primary areola and appearance of
the secondary areola.
Linea nigra
3. Cloasma gravidarum or mask face of
pregnancy which is butterfly
pigmentation of the forehead, nose,
upper lip and the adjoining parts of the
checks.
This pigmentation may persist but the
cloasma gravidarum usually disappears.
Falling of hairs and brittleness of nails may
occur during pregnancy.
Butterfly pigmentation
Weight Gain During Pregnancy
Changes in Organ Systems
 Uterus and Related Connective
Tissue
Uterus.
• The uterus increases from a pre-pregnant size of 5
by 10 cm (2 by 4 in.) to 25 by 36 cm (10 by 14
in.).
• It increases five to six times in size, 3,000 to
4,000 times in capacity, and 20 times in weight by
the end of pregnancy.
• By the end of pregnancy, each muscle cell in the
uterus has increased approximately 10 times over
its pre-pregnancy length
• Once the uterus expands upward and leaves the
pelvis, it becomes an abdominal rather than a
pelvic organ.
 Connective tissues.
• Ligaments connected to the pelvic organs
are more fibroelastic than ligaments
supporting joint structures.
• The fascial tissues, which surround and
enclose the organs in a continuous sheet,
also include a significant amount of
smooth muscle fibers.
• The round, broad, and uterosacral
ligaments in particular provide
suspensory support for the uterus.
 Urinary System
• Kidneys. The kidneys increase in length by 1 cm (0.5 in.).
• Ureters. The ureters enter the bladder at a perpendicular
angle because of uterine enlargement.
• This may result in a reflux of urine out of the bladder and
back into the ureter;
• therefore, during pregnancy, there is an increased chance
of developing urinary tract infections because of
urinary stasis.
 Pulmonary System
• Hormonal influences.
• Hormone changes affect pulmonary secretions and rib
cage position.
• Edema and tissue congestion of the upper respiratory tract
begin early in pregnancy because of hormonal changes.
Hormonally stimulated upper respiratory hyper-secretion also
occurs.
• Changes in rib position are hormonally stimulated and occur
prior to uterine enlargement. The subcostal angle
progressively increases; the ribs flare up and out. The
anteroposterior and transverse chest diameters each increase
by 2 cm (1 in.). Total chest circumference increases by 5 to 7
cm (2 to 3 in.) and does not always return to the prepregnant
state.
• The diaphragm is elevated by 4 cm (1.5 in.); this is a passive
change caused by the change in rib position.
 Respiration
• Respiration rate is unchanged, but depth of respiration
increases.
• Tidal volume and minute ventilation increase, but total lung
capacity is unchanged or slightly decreased.
• There is a 15% to 20% increase in oxygen consumption; a
natural state of hyperventilation exists throughout pregnancy
to meet the oxygen demands of pregnancy.
• The work of breathing increases because of hyperventilation;
dyspnea is present with mild exercise as early as 20 weeks
into the pregnancy.
Cardiovascular System
• Blood volume and pressure. Blood volume
progressively increases 35% to 50% (1.5 to 2 L)
throughout pregnancy and returns to normal by 6 to 8
weeks after delivery.
• Plasma increase is greater than red blood cell increase,
leading to the “physiologic anemia” of pregnancy, which
is not a true anemia but is representative of the greater
increase of plasma volume.
• The increase in plasma volume occurs as a result of
hormonal stimulation to meet the oxygen demands of
pregnancy.
• Venous pressure in the lower extremities increases
during standing as a result of increased uterine size and
increased venous distensibility.
• Pressure in the inferior vena cava rises in late pregnancy,
especially in the supine position, because of
compression by the uterus just below the diaphragm.
• In some women, the decline in venous return and
resulting decrease in cardiac output may lead to
symptomatic supine hypotensive syndrome.
• The aorta is partially occluded in the supine position
• Blood pressure decreases early in the first trimester.
• There is a slight decrease of systolic pressure and a
greater decrease of diastolic pressure.
• Blood pressure reaches its lowest level approximately
midway through pregnancy and then rises gradually from
mid-pregnancy to reach the prepregnant level
approximately 6 weeks after delivery.
• Although cardiac output increases, blood pressure
decreases because of venous distensibility.
 Heart
• Heart size increases, and the heart is elevated because of
the movement of the diaphragm.
• Heart rhythm disturbances are more common during
pregnancy.
• Heart rate usually increases 10 to 20 beats per minute by
full term and returns to normal levels within 6 weeks after
delivery.
• Cardiac output increases 30% to 60% during pregnancy and
is most significantly increased when a woman is in the left
side-lying position, in which the uterus places the least
pressure on the aorta.
Musculoskeletal System
 Abdominal muscles
• The abdominal muscles, particularly both sides of the
rectus, as well as the linea alba, are all subjected to
significant biomechanical changes and become stretched
to the point of their elastic limit by the end of
pregnancy.
• This greatly decreases the muscles’ ability to generate a
strong contraction and thus decreases their efficiency of
contraction.
• .
 Pelvic floor muscles
• The pelvic floor muscles, in their antigravity position, must
withstand the total change in weight; the pelvic floor
drops as much as 2.5 cm (1 in.) as a result of
pregnancy.
Connective tissues and joints
• The hormonal influence on the ligaments is profound,
producing a systemic decrease in ligamentous
tensile strength.
• Joint laxity has been measured in multiple joints during
pregnancy and postpartum. These changes in joint
stability have been noted as many as 4 months
postpartum.
• The thoracolumbar fascia is lengthened via its
connection to the abdominal wall, which diminishes its
ability to support and stabilize the trunk effectively.
• Joint hypermobility occurs as a result of ligamentous
laxity and may predispose the patient to injury,
especially in the weight-bearing joints of the back,
pelvis, and lower extremities.
 Thermoregulatory System
• Metabolic rate.
• During pregnancy, basal metabolic rate and heat
production increase.
• An additional intake of 300 calories per day is needed to
meet the basic metabolic needs of pregnancy.
• In pregnant women, normal fasting blood glucose levels
are lower than in nonpregnant women.
Changes in Posture and
Balance
 Center of Gravity
• The center of gravity shifts upward and forward because
of the enlargement of the uterus and breasts. This
requires postural compensations to maintain balance and
stability.
• The lumbar and cervical lordosis increase to compensate for
the shift in the center of gravity.
• The shoulder girdle and upper back become rounded with
scapular protraction and upper extremity internal rotation
because of breast enlargement;
• this postural tendency persists in the postpartum period due
to infant care demands.
• Tightness of the pectoralis muscles and weakness of the
scapular stabilizers may be preexisting to or induced by the
pregnancy postural changes.
• A tendency toward genu recurvatum will shift weight
toward the heels in an attempt to counteract the anterior
pull of the growing fetus.
• Changes in posture do not automatically correct after
childbirth, and the pregnant posture may become
habitual. In addition, many child care activities contribute
to persistent postural faults and asymmetry.
 Balance
• With the increased weight and redistribution of body
mass, there are compensations to maintain balance.
• The pregnant woman usually walks with a wider base
of support and increased external rotation at the hips.
• This change in stance, along with growth of the baby,
makes some activities such as walking, stooping, stair
climbing, lifting, reaching, and other activities of daily
living (ADLs) progressively more challenging.
• Activities requiring fine balance and rapid changes in
direction, such as aerobic dancing and bicycle riding,
may become inadvisable, especially during the third
trimester.
 Nervous system
Functional changes may appear especially in
neurotic women as :
-sleepy, depressed
-while others become irritable, excited and
suffer from insomnia.
-The nausea and vomiting may have a
neurotic element.
-Change of appetite such as refusal of some
types of food.
-Neuralgias
Thank you
Questions?
PHYSIOLOGY OF
LABOR AND
PARTURITION
 Parturition
• Definition
– Uterine contractions that lead to expulsion of
the fetus to extra-uterine environment
 Hormonal changes
• Estrogen & Progesterone
– Progesterone inhibit uterine contractility
– Estrogen stimulate uterine contractility
• From 7th month till term
– Progesterone secretion remain constant
– Estrogen secretion continuously increase
– Increase estrogen/progesterone ratio
 Hormonal changes
• Oxytocin
– Dramatic ▲of oxytocin receptors (200 folds)
• gradual transition from passive relaxed to active
excitatory muscle (↑responsiveness).

– Increase in Oxytocin secretion at labor

– Oxytocin increase uterine contractions by
• Directly on its receptors
• Indirectly by stimulating prostaglandin production
 Hormonal changes
• Prostaglandins
– Central role in initiation & progression of
human labour
– Locally produced (intrauterine)
– Oxytocin and cytokines stimulate its
production
 Positive
feedback
mechanism
 Phases of parturition
• Phase 0
– Pregnancy: uterus is relaxed (quiescent)
• Phase 1
– Activation
• Phase 2
– Stimulation: stage 1& stage 2
• Phase 3 = stage 3
– Delivery of the placenta and uterine involution
 Phases of parturition
• Phase 0 (pregnancy)
– Increase in cAMP level
– Increase in production of
• Prostacyclin (PGI2) cause uterine relaxation
• Nitric oxide (NO) cause uterine relaxation

Adapted from Smith, 2007

 Phases of parturition
• Phase 1 (activation)
– Occurs in third trimester
– Promote a switch from quiescent to active
uterus
– Increase excitability & responsiveness to
stimulators by
• Increase expression of gap junctions
• Increase G protein-coupled receptors
– Oxytocin receptors
– Increase PGF receptors
 Phases of parturition
• Phase 2 (stimulation)
– Occurs in last 2-3 gestational weeks
– Increase in synthesis of uterotonins
• Cytokines
• Prostaglandins
• Oxytocin
– Includs 2 stages:
• Stage 1
• Stage 2
 Phases of parturition
• Phase 3 (uterine involution)
– Pulsatile release of oxytocin
– Delivery of the placenta
– Involution of the uterus
• Occurs in 4-5 weeks after delivery
• Lactation helps in complete involusion
 Mechanism of parturition
• Contractions start at the fundus and
spreads to the lower segment
• The intensity of contractions is strong at
the fundus but weak at the lower segment
• In early stages 1 contraction/ 30 minuets
• As labor progress 1 contraction/ 1-3
minutes
• Abdominal wall muscles contract
• Rhythmical contractions allows blood flow
 Onset of labor
• During pregnancy
– Periodic episodes of weak and slow
rhythmical uterine contractions 2nd trimester
• Towards end of pregnancy
– Uterine contractions become progressively
stronger
– Suddenly uterine contractions become very
strong leading to:
• Cervical effacement and dilatation
 Stages of Labor
• Dilation
– Cervix becomes dilated
– Full dilation is 10 cm
– Uterine contractions begin and increase
– Cervix softens and effaces (thins)
– The amnion ruptures (“breaking the
water”)
– Longest stage at 6–12 hours
Cervical effacement and dilatation
Stages of Labor

Figure 16.20 (1 of 3)
 Stages of Labor
• Expulsion
– Infant passes through the cervix and
vagina
– Can last as long as 2 hours, but
typically is 50 minutes in the first birth
and 20 minutes in subsequent births
– Normal delivery is head first (vertex
position)
– Breech presentation is buttocks-first
Stages of Labor

Figure 16.20 (2 of 3)
 Stages of Labor
• Placental stage
– Delivery of the placenta
– Usually accomplished within 15 minutes
after birth of infant
– Afterbirth—placenta and attached fetal
membranes
– All placental fragments should be
removed to avoid postpartum bleeding
Stages of Labor

Figure 16.20 (3 of 3)
New arrival
COMPLICATIONS
OF PREGNANCY
AABCDEGPPP
 ANEMIA
• Anemia is very common in pregnancy, and is accepted to be
significant at a hemoglobin level of less than 10.5 g/100 mL or
less and is due in most cases to an iron deficiency.
• The majority of the depletion of the maternal stores are due to the
increasing demands of the pregnancy hemoglobin levels fall,
pallor, dyspnea and edema
• Severe anemia is said to be present if the hemoglobin levels fall
below 6.5 g/100 mL
 ANTEPARTUM HEMORRHAGE
• Antepartum hemorrhage (APH) is a serious complication,
defined as bleeding from the genital tract at any stage
from 24 weeks’ gestation to the birth.
• Bleeding during labor is often called ‘intrapartum
hemorrhage’
 CARDIAC DISEASE
• Cardiac output increases by 30–50% during pregnancy
• There is also a risk of cardiac decompensation, especially
during labor and in the 4 days following parturition.
• Those with a valve replacement may require
anticoagulant therapy.
 DIBETES MELLITUS
• The total or relative lack of insulin can result in
dehydration, hyperglycemia, ketosis, polyuria and
polydipsia.
• Perinatal death, pre-eclampsia, fetal abnormalities.
• Some are Macrosomic babies
• A macrosomic fetus is at greater risk of birth trauma
especially brachial plexus lesion due to shoulder
dystocia
• some of the babies are very small owing to placental
dysfunction
• C-section delivery
 GESTATIONAL DIABETES
• This is a temporary condition associated with pregnancy.
Those women that develop hyperglycemia (detected with
an impaired glucose tolerance test during pregnancy) may
have an adverse neonatal outcome if left untreated.
 ECTOPIC PREGNANCY
• The fertilized ovum occasionally implants
outside the uterus, most commonly in the
fallopian tube at the ampulla or the
isthmus – the junction of the tube with the
uterus.
• As the pregnancy develops, distension of
the tube results in pain, and if left
untreated, eventual rupture of the tube or
bleeding leads in some patients to shock
and even maternal collapse.
 PLACENTA PREVIA
• Where the placenta has embedded low on the uterine
wall, close to or even across the isthmus and cervix
 OLIGOHYDRAMNIOS &
POLYHYDRAMNIOS
• Oligohydramnios is a rare condition where the liquor
amnion is much reduced and milky
• Fetal abnormalities (e.g. talipes, torticollis) owing to
the lack of space for movement.
• The baby’s skin is very dry and leathery
• Polyhydramnios is the presence of an abnormally
large quantity of amniotic fluid so that the uterus is
tense and distended to a degree inconsistent with the
gestation dates, and it may be impossible to palpate
the fetus
• esophageal atresia,
• open neural tube defect
 PREGNANCY INDUCED HYPERTENSION/ PRE-
ECLAMPSIA
• Pregnancy-induced hypertension is the most common
and potentially serious complication of pregnancy for both
mother and fetus
 BREECH POSITION
• Right before birth, most babies are in a head
down position in the mother's uterus. Sometimes,
the baby is in a bottom first (or feet first)position. When
a baby is in that position before birth, it's called a
breech birth or breech baby.
 ASSOCIATED PATHOLOGY
• Fibroids
• Genital herpes
• HIV
• Intrauterine growth retardation & death
• Multiple pregnancies
 TYPES OF DELIVERY
• Episiotomy
• Forceps delivery
• Vacuum extraction
• Cesarean section
ANTENATAL CARE
 PREGNANCY BACK CARE
• Postural, hormonal and weight changes,
• Ergonomic education involving sitting and working
positions, bending, lifting and household activities
Symphysis pubis dysfunction (SPD)
• Symphysis pubis dysfunction, or SPD,
means the ligaments that normally keep
your pelvic bone aligned during pregnancy
become too relaxed and stretchy too soon
before birth (as delivery nears, things are
supposed to start loosening up). This, in
turn, can make the pelvic joint — unstable,
causing some pretty strange sensations
and sometimes pelvic pain
 Pelvic floor and
pelvic-tilting exercises
• Women who had learnt and practiced PFM contractions
during pregnancy experienced less urinary incontinence
postpartum
Exercises for circulation and cramp
• Ankle dorsiflexion and plantar flexion, and foot
circling carried out for 30
• women should be advised not to cross the knees
when sitting.
• The technique of stretching in bed with the foot
dorsiflexed and not plantar flexed for preventing
and easing calf cramp
• Additionally, cramp relief include avoiding long
periods of sitting, a pre-bedtime walk, calf
stretches, a warm bath, and foot and ankle
exercises in bed before going to sleep
 Cardiovascular
• Both exercise and pregnancy increase:
– Heart rate
– Stroke volume
– Cardiac output
• Theoretical risk: Competing effects on regional blood flow
distribution
– Both glucose and oxygen delivery to placental site is reduced
 Cardiovascular II
• Women who perform regular weight
bearing exercise
– Augment pregnancy associated increases in
plasma volume
– Increase placental volume
– Increase cardiac output
• What does this suggest?
– Increased rate of placental blood flow at rest
– Increase in 24 h glucose & oxygen delivery
Walking

One of the best

cardiovascular exercises
for pregnant women,
walking keeps you fit
without jarring your knees
and ankles. It is safe
throughout the nine months
of pregnancy and can be
built into your day-to-day
schedule.
Swimming

• Healthcare providers and fitness experts

hail swimming as the best and safest
exercise for pregnant women. Swimming is
ideal because it exercises both large
muscle groups (arms and legs), provides
good cardiovascular benefits, and allows
pregnant women to feel weightless despite
the extra weight of pregnancy.
Yoga and stretching

Yoga and stretching can help

maintain muscle tone and keep
you flexible with little if any
impact on your joints.
However, you may have to
augment a yoga regime by
walking a few times a week to
give your heart a workout. Be
careful not to overdo the
stretching. You will be more
supple as a result of the effects
of relaxin, which causes your
ligaments to be more pliable.
Don't hold the stretches for too
long or try to develop your
flexibility too much.
Pilates

Pilates is a form of exercise which combines

flexibility and strength training with body
awareness, breathing and relaxation. The
exercises are based on certain movement
patterns performed with your tummy and pelvic
floor muscules -- known in Pilates as the "stable
core" or base. These muscles are also known as
deep stabilizing muscles. Because Pilates
targets the tummy and pelvic floor muscles and
these muscles can weaken during pregnancy,
Pilates exercises can be useful.
Low-impact aerobics
• One good thing about an
aerobics class is that it's a
consistent time slot when
you know you'll get some
exercise. If you sign up for
a class specifically
designed for pregnant
women, you'll get to enjoy
the camaraderie of others
just like you, and can feel
reassured that each
movement has been
deemed safe for you and
the baby.
Pulmonary disease

Contraindications to Exercise
Contraindications (PPPPP II)
Pregnancy-induced hypertension
Preterm rupture of membranes
Preterm labor during or prior during pregnancy
Placenta previa
Persistent second- or third-trimester bleeding
Incompetent cervix
Intrauterine growth retardation
Relative contraindications (CCTV)
Chronic hypertension
Cardiac disease
Thyroid function abnormality
Vascular disease
Urinary function and dysfunction
continence

• The term ‘continence’ is used to describe the normal ability of a

person to store urine and feces temporarily, with conscious control
over the time and place of micturition and defecation.
• Continence of urine and feces is fundamental to the sociological,
psychological and physical well-being of an individual
• Infants do not have such control, but develop the neurological
maturity and form the habits necessary, usually by 3 or 4 years of age
Incontinence

• ‘Incontinence’ has been defined as the involuntary or inappropriate passing of urine or faeces,
or both, that has an impact on social functioning or hygien.
• This definition applies only after early childhood.
• society places demands that voiding occurs at a time and in a place that is acceptable to the
majority.
• For example, when out for a walk in the countryside, it is acceptable to empty one’s bladder
behind a hedge on the edge of a deserted field, but to do so behind a hoarding in a crowded
street is not acceptable.
• If a person passes urine or feces into clothing, in a bed or chair, on to the ground or into a
receptacle not designated for the purpose the person is likely to be labelled as ‘incontinent’.
• Incontinence of urine or feces is a symptom or a sign with a cause, not a condition or a
specific disease.
• It may be a temporary state associated with a transient cause (e.g. transient
unconsciousness, infection, or drug side-effects), or it may be persistent resulting from
longer-lasting or even permanent causes (e.g. trauma in childbirth, stroke)
• it can lead to isolation, depression, loss of self-esteem, and ill health, for example infections
Prevention of continence problems

• Repetitive coughing, smoking, frequent constipation, obesity, repeated heavy lifting and
poorly controlled diabetes are just some of the factors that can lead to continence problems
and over which an individual has some control
• Following childbirth, it is important to regain pre-pregnancy strength of the pelvic floor
muscles (PFMs) as far as humanly possible
• As a prophylactic measure, every woman should be encouraged from a young age to make a
regular habit of PFM contractions (Wall & Davidson 1992), and it is never too late to start!
• patients with hay fever, asthma, chronic chest conditions, back problems, stroke, multiple
sclerosis, Parkinson’s disease, Alzheimer’s disease, hypertension and diabetes, those
undergoing hip replacement, the elderly, the obese, those on crutches and those confined to
a wheel chair are all at particular risk of developing bladder and bowel dysfunction
NORMAL LOWER URINARY TRACT FUNCTION

• Ureters
• Bladder
• urethra
THE MICTURITION CYCLE
• The micturition cycle consists of two phases:
• bladder filling
• bladder emptying
• During the filling phase, the detrusor muscle is compliant and the detrusor pressure is usually
less than 15 cm H2O
• At a volume of 150–200 ml the first mild desire to void is commonly felt.
• Normally this desire can be postponed, at least to allow for completion of the necessary
preparations for voiding, although more often it is postponed for longer
• Eventually, with increasing stored volume, the pressure within the bladder begins to rise and
the sensation of fullness becomes more consciously apparent and persistent.
• A decision to void is taken, a socially acceptable site is found and necessary preparations are
made.
• The levator ani and urethral sphincter muscles relax and then the detrusor muscle contracts.
• On completion of the void the levator ani and sphincter muscle contract and the detrusor
muscle stops contracting and is ready to store again
STORAGE OF URINE

• The normal bladder’s compliance accommodates and stores the incoming urine without a
significant rise in pressure within the bladder, and without involuntary contractions of the
detrusor even with provocation (e.g. a cough, change of position).
• The actual pressure in the bladder is the sum of intra-abdominal pressure on the bladder
from outside and the pressure produced by the elasticity of the connective tissue and muscle
of the bladder wall.
compliance

• The elastic ability of the bladder to accommodate an increasing volume of fluid without a
rise of pressure is called ‘compliance’,
• Urine is prevented from leaving the stable bladder via the urethra by a considerable closure
pressure, about 50–70 cm H2O in premenopausal women and 40–50 cm H2O for
postmenopausal women
• As filling continues, the limit of distensibility of the bladder wall is
reached and the pressure then begins to rise.
• The average daytime tolerable bladder capacity in women is between
350 and 500 ml; the first void of the day may be greatest and may be
greater than 500 ml.
• Continence is maintained so long as the pressure within the bladder is
lower than the closure pressure of the urethra.
• Even in a normal, healthy person there is a point, as bladder pressure
rises, at which urethral pressure could be overwhelmed and leakage
occur.
VOIDING OF URINE

• Micturition is normally achieved by voluntary, cortically mediated relaxation of the external

urethral sphincter and levator ani muscles, which is followed a few moments later by a
detrusor contraction.
• In the absence of stressful environmental or other factors (e.g. urethral
obstruction), the detrusor contraction, combined with the normal slight
shortening and opening up of the relaxing urethra, empties the bladder
in a continuous steady stream in a short time.
• As women have a short urethra (3–5 cm), the detrusor is not required to
contract very strongly to complement gravity to achieve emptying;
normally it should not be necessary to bear down to empty.
flow rate

• The flow rate, that is, the volume of liquid in millilitres expelled via the urethra per second,
has a strong dependency on the total voided volume
• A normal flowmetry chart will show a smooth bell-shaped curve rising to a peak (maximal
urine flow rate – MUFR) and falling back to zero.
• From such a trace, the average urine flow rate is calculated (AUFR).
• In women with no gynaecological problems the AUFR may vary between 5 and 15 mL/s for a
voided volume of 100 mLand between 12 and 25 mL/s for 400 mL
THE NEUROLOGICAL CONTROL OF CONTINENCE

• Continence is controlled neurologically at three levels – spinal, pontine and cerebral.

Normally these harmoniously interact by means of a combination of somatic and autonomic
pathways – chiefly parasympathetic
• Urine is stored and micturition initiated periodically, usually four to six times a day.
• The bladder wall is richly supplied with stretch receptors whose discharge is proportional to
the intramural tension
• As the bladder begins to fill, parasympathetic afferent fibres convey this information via the
pelvic nerves to sacral roots S2–S4, to the sacral micturition centre
• From there the impulses ascend in the lateral spinothalamic tracts, and are then relayed back
to the pons where there are areas capable of inhibiting or exciting the sacral micturition
centre.
• In the early stages of bladder filling, detrusor muscle contraction is
inhibited by descending inhibitory impulses to the sacral centre
• As the volume of stored urine increases, so does the strength of the
receptor discharges from the bladder wall. This causes them to be
relayed higher to several areas of the cerebral cortex including the
frontal lobe, so that the desire to void may be consciously perceived.
• Thus the cortex now becomes involved in detrusor inhibition and, if
micturition is not to take place, it is usually possible to suppress the
voiding urge to a subconscious level again and postpone bladder
emptying
• In addition, sympathetic afferent input via the hypogastric nerves (T11–L3) from the bladder
wall, trigone and smooth muscle of the urethra is able to stimulate sympathetic efferent
impulses to reduce the bladder’s tendency to contract and to increase urethral pressure
A SUMMARY OF FACTORS WHICH
FAVOUR NORMAL URINARY
FUNCTIONING
• The bladder and urethra are structurally sound and healthy; damage or
pathology, such as infection, will affect function.
• The nerve supply to the bladder, urethra, external sphincter and PFM is
intact; conditions such as multiple sclerosis and diabetes, or
childbearing, can cause disruption.
• The bladder is positioned so the neck is well supported and able to
close, and the urethra is not kinked; the angle made by the urethra with
the bladder may also be of some importance; childbearing can cause
damage to supporting structures.
• The bladder is positioned and supported high enough in the abdominal
cavity that intra-abdominal pressure is transmitted both to it and to the
proximal portion of the urethra; the latter is referred to as the
‘pinchcock’ effect.
• Bladder size and capacity are normal.
• There are no pathological changes in surrounding structures (e.g. fibroids causing pressure
on the bladder).
• The woman has the ability to move sufficiently quickly and freely to a socially acceptable site
in order to void (e.g. such conditions as arthritis may make going upstairs to the toilet too
painful to contemplate).
• The woman is able to adjust clothing and position herself for voiding unaided; anything that
causes difficulty and delay (e.g. inappropriate clothing, mental confusion, heavy doors, or
dependence on others) may dispose to ‘accidents
• An inappropriate diet, reduced fluid intake or inactivity can cause
constipation.
• The woman is in good general physical health, alert, and free from
confusion, depression or serious stress; she does not smoke and is not
obese.
• There is a fluid intake of about 1.5 litres per day, and avoidance of
excess alcohol or caffeine (e.g. coffee, tea, cola, chocolate, Lucozade).
LOWER URINARY TRACT DYSFUNCTION

• Storage symptoms are experienced during the storage phase (e.g. abnormal bladder
sensations, frequency, urgency and leakage of urine).
• Voiding symptoms are experienced during the voiding phase, and include any description or
deviation from a speedy and continuous flow of urine (e.g. a slow or intermittent stream,
hesitancy at the start of micturition, terminal dribble).
• Postmicturition symptoms are experienced immediately after micturition (e.g. a feeling of
incomplete emptying, and postmicturition dribble).
Some useful definitions

• Enuresis means any involuntary loss of urine.

• Nocturnal enuresis is involuntary loss of urine during sleep.
• Nocturia is the complaint that the individual has to wake at night one or
more times to void. Technically this term should be reserved for passing
urine at night as a result of being wake from sleep by a strong desire to
void. It is different from a habit of always waking at a certain time to
void whether one needs to or not, and different from happening to wake
up (or being woken) and deciding to void without real need.
• Increased daytime frequency (pollakisuria) is the complaint by patients
who consider that they void too often during the day. There are also
specific symptoms associated with sexual intercourse .
frequency as the passage of urine seven or more times during the day,
or the need to wake more than twice at night to void.
• Urgency is the complaint of a compelling desire to pass urine which is
difficult to defer.
• A normal desire to void is defined as the feeling that leads a person to
pass urine at the next convenient moment, but voiding can be delayed if
necessary.
• The urinary voiding stream may be described as slow, spitting or
spraying, or intermittent (i.e. stops and starts).
• Hesitancy describes difficulty in initiating flow.
• Dysuria is pain on passing urine.
• A postvoid residual (PVR) is defined as the volume of urine left in the
bladder at the end of micturition.
URINARY INCONTINENCE
 Definition
• UI is the involuntary loss of urine that is
objectively demonstrable and a social or hygienic
problem.

International Continence Society

 Consequences of UI
CSF E
• Cellulitis, Pressure ulcers, UTI
• Costs > $16 billion
• Caregiver burden inc. contributes to institutionalization
• Sleep deprivation
• Social withdrawal, depression
• Falls with fractures
• Embarrassment (50%), interference with activities
 COMMON TYPES OF URINARY
INCONTINENCE
• Extraurethral incontinence
• Detrusor overactivity incontinence (urge)
• Urodynamic stress incontinence
• Nocturnal enuresis
• Giggle incontinence
• Incontinence associated with sexual activity
• Functional incontinence
• Mixed incontinence
 URODYNAMIC STRESS INCONTINENCE
• The symptom. The patient complains of incontinence on stress,
that is, when the intra-abdominal pressure is raised by exertion
or effort (e.g. sneezing, coughing or walking)
• The sign. An involuntary spurt, dribble or droplet of urine is
observed to leave the urethra immediately on an increase in
intra-abdominal pressure (e.g. when coughing).
• This test should be performed with a reasonable amount of
urine in the bladder, and may need to be conducted standing
up, rather than lying down.
• The patient may also be able to demonstrate how a particular
activity such as jumping produces a leak
• The condition. Urodynamic stress incontinence
(USI) is the name coined to denote the
condition in which there is
• involuntary loss of urine , in the absence of a
detrusor contraction, the intravesical
pressure (pressure in the bladder) exceeds
the maximum urethral pressure.
• Essentially the detrusor activity is normal but
the urethral closure mechanism is
incompetent. There may be associated
bladder neck hypermobility.
 CAUSES
• Prolapse of the bladder and urethra, due to damage to
supporting structures or associated with uterine descent,
• prolapse, particularly if it substantially involves the anterior
wall of the vagina
• Atrophy associated with reduced oestrogen and ageing
attacks the elastic and adhesive factors of the urethral wall.
• weakness of the pelvic floor
 Weakness of PFMs
• trauma to muscle or adjacent tissues (e.g. surgery or
childbirth)
• damage to the nerve supply to the sphincter or levator ani
muscle (e.g. from surgery, stretching or tearing at childbirth)
• weakness from underuse (the patient may sit around all day,
perhaps suffering from depression)
• stretching from overuse (e.g. repeated coughing, straining at
the stool because of constipation, heavy lifting or obesity)
 Management of USI
• Identifying the precipitating factors
• The treatment of chest infections or respiratory allergies, stopping of
smoking, reduction in obesity, help with a heavy dependent relative, relief
of constipation, treatment for depression, encouragement to activity and
other general health- and continence promoting advice may be enough to
relieve symptoms
• encouraged to make a daily habit of PFMCs
• Where the PFMs are very weak or the patient is unable to produce a
PFMC, biofeedback with or without electrical stimulation should be offer
• Where there is considerable prolapse with obvious bladder neck descent,
surgery will probably be required
Nocturnal enuresis
• Nocturnal enuresis is urinary incontinence
during sleep, or ‘bed wetting’ at an age when
a person could be expected to be dry – usually
agreed to be the developmental age of 5 years
• It must be differentiated from waking with
urgency and failing to reach the toilet in time
(i.e. detrusor overactivity incontinence)
• It is often associated with daytime leakage
 MANAGMENTS
mnemonic (DmARDS)
• It may be necessary to change Diet to reduce caffeine intake, such
as cola drinks and chocolate.
• Where it is thought that the child sleeps too deeply to be aware of
the desire to void, various Alarm systems can be used.
• Reward charts and scheduled awakening may be tried.
• Antidiuretic drugs may be prescribed, for example desmopressin,
which can be administered as a nasal spray or orally (Glazener &
Evans 2003).
• Specialised bedding products may reduce the need for changes in
the night, and it is never a waste of time to teach PFM contractions,
which may have some inhibitory effect on the detrusor muscle
Giggle incontinence
• It is thought that giggle incontinence is caused by detrusor overactivity
induced by laughter
• treatment is as for detrusor overactivity;
• in severe cases this may include pharmocotherapy.
• Time is well spent explaining exactly why the leakage occurs and teaching
PFM exercise and deferment techniques.
• Not only should the girl practise PFM exercise regularly to build up
strength and endurance but she should be encouraged to develop the
habit of contracting these muscles before and while giggling.
• Continence-promoting advice should include fluid intake and bowel habits
Incontinence associated with sexual
activity
• The urethra and bladder lie in close proximity to the vagina; thus
sexual activity can cause urinary symptoms and lower urinary tract
dysfunction, and this in term may give rise to sexual problems
• dysuria, urgency and urinary tract infections
• Simple advice to empty the bladder prior to intercourse or to
change the coital position may be helpful. Drug therapy may be
prescribed to reduce detrusor overactivity. VPFMC to control
leakage and inhibit the detrusor muscle may also be helpful to
control urgency.
Functional incontinence
• there is involuntary loss of urine resulting from a deficit in
ability to perform toileting functions secondary to physical or
mental limitations.
 Mixed Incontinence
• Features of both urge and stress incontinence.
• Common in older women
• Management: bladder retraining, pelvic muscle exercises,
other pelvic muscle rehabilitative options outlined previously,
pharmacologic agents.
Diastasis Recti
THE ABDOMINAL MUSCLES
• The anterior and lateral abdominal wall is formed by the
abdominal muscles
• The deepest of the group is the transversus abdominis muscle,
which lies internally to the internal and external oblique
muscles
• The aponeurosis is
reinforced by the two rectus
abdominis muscles, which
run in sheaths formed in the
aponeurosis on either side
of the linea alba.
• Of particular relevance is the
fact that the sheaths are
elastic longitudinally and
less so transversely.
• Each rectus abdominis
muscle has three transverse
fibrous intersections, which
are firmly attached to the
anterior wall of the
enclosing sheath.
• The lowest intersection is
about the level of the
umbilicus, and the sheaths
are deficient posteriorly in
the lowest portion
• The oblique and transversus muscles are innervated by the
lower six thoracic nerves, and the iliohypogastric and
ilioinguinal nerves.
• The recti are innervated by the lower six thoracic nerves
Abdominal Layers
 A-fascial layers

1- Superficial layer, referred to as the fatty layer, is a single

layer with varying amounts of fat.
2-Deep fascial layer, known as the membranous layer, is
more membranous and contains elastic fibers.
 B-Anterolateral muscle group

Anterolateral muscle group of the abdomen consist of

four pairs of muscles which include
• 1- External oblique muscle
• 2- Internal oblique muscle
• 3- Transversus abdominis
• 4- -Rectus abdominis
 Rectus sheath

The rectus abdominis is entirely enclosed in a

sheath formed by the aponeuroses of the
muscles of the lateral walls of the abdomen.
 Functions of the abdominal muscles

1- Protect the abdominal viscera and keep them in

their positions
2- Maintain a good erect posture
3- Stabilize pelvis during straight leg raising
4- Help in respiration and defecation
5- Concern with forward flexion of the trunk
6- Help expulsion of the fetus during second stage
of labour.
7- Improving the function of the pelvic floor muscles
 C- The aponeuroses
• which are defined as flat sheets of densely
collagen fibers usually consisting of several
layers with few elastic fibers
 D- The linea alba
• which is the result of the fusion of the right
and left aponeuroses of the three pairs of the
anterolateral abdominal muscles in the
midline from sternum to the pubis.
Diastasis Recti
 Definition
It is the separation of the rectus abdominis muscle which involve
widening of the linea alba with gap greater than the normal
distance between the rectus bellies (2 Cm or 2 fingers above
umbilicus) palpated above, below or at the level of the umbilicus
 Normal development of diastasis recti
• Infants: A diastasis recti looks like a ridge, which runs down the middle of the
stomach from the bottom of the sternum to the belly button. It increases with
muscle straining and is clearly seen when the child tries to sit up. In infants, the
rectus abdominis muscles continue to grow and the diastasis recti gradually
disappears.
• Pregnancy: Pregnant women may develop the condition because of increased
tension on the abdominal wall. The risk is higher if with multiple births or many
pregnancies. Women who are 12 or more weeks pregnant should not do
exercises that stress the abdomen. This may worsen the condition. Often seen
after pregnancy and childbirth but should disappear after a few months.
• Adults: Often seen in patients with strenuous jobs and weak trunk muscles. It
can become very large and increases with muscle straining and is clearly seen
when the patient lifts head to sit up.
• Diastasis recti is a separation between the left and right side of
the rectus abdominis muscle, which covers the front surface of
the belly area.
 Etiology
• Diastasis recti may occur in pregnancy as a result of
hormonal effects on the connective tissue and the
biomechanical changes of pregnancy; it may also develop
during labor, especially with excessive breath-holding
during the second stage.
• It can occur above, below, or at the level of the umbilicus
but appears to be less common below the umbilicus.
• It appears to be less common in women with good
abdominal tone before pregnancy.
• Clinically, a diastasis may be found in women well past their
childbearing years and also in men. Routine assessment for
this condition is highly recommended and can easily be
done in conjunction with abdominal strength testing.
 Significance
• diastasis recti may produce musculoskeletal
complaints, such as low back pain, possibly as
a result of decreased ability of the abdominal
musculature and thoracolumbar fascia to
stabilize the pelvis and lumbar spine.
 Activity limitations.
• Activity limitations can also occur, such as inability to perform
independent supine-to-sitting transitions because of extreme
loss of the mechanical alignment and function of the rectus
muscle.
 Decreased fetal protection
• In severe separations, the remaining midline layers of
abdominal wall tissue are skin, fascia, subcutaneous fat, and
peritoneum.
• The lack of muscular support provides less protection for the
fetus.
 Potential for herniation
• Severe cases of diastasis recti may progress to herniation of the
abdominal viscera through the separation at the linea alba.
• This degree of separation requires surgical repair.
Examination for Diastasis Recti
• Instruct patients to perform a self-test on or after the third
postpartum day for optimal accuracy.
• Until 3 days after delivery, the abdominal musculature has
inadequate tone for valid test results.
 Patient position and procedure
• Hook-lying. Have the patient slowly raise her head and shoulders
off the floor, reaching her hands toward the knees, until the spines
of the scapulae leave the floor. Place the fingers of one hand
horizontally across the midline of the abdomen at the umbilicus
• If a separation exists, the fingers will sink into the gap between the
rectus muscles, or a visible bulge between the rectus bellies may be
appreciated. The number of fingers that can be placed between the
muscle bellies is then documented. Because this condition can occur
above, below, or at the level of the umbilicus, test for it at all three
areas.
 The palpation should assess the
following
1- Width and length of any recti separation
2- Region of the greatest diastasis
3- Bulge of the abdomen on recti contraction
4- The women's ability to activate abdominal
musculature
5- The endurance capacity of the abdominal
musculature.
 Predisposing factors

1-Child bearing especially when there was

succession of pregnancies
2-Hernias, the simplest form of a ventral or
epigasteric hernia is the region of the linea alba
and represents diastasis recti.
4- Conditions that results in a persistent
excessive increase in intra-abdominal
pressure favors the development of a
diastasis such as lifting or carrying heavy
objects or chronic cough.
5- Sudden strain or fall may also be the
starting point of a diastasis
6- Decrease in the tone of the tissues of the
abdominal wall as a result of general
weakness may also predispose to diastasis
development
 Incidence
Diastasis recti are not a condition limited
to pregnant or postpartum women, it also can
be seen in obese males, in patients with
chronic lung disease, and in children (whose
linea alba is wider than the adult)
 Incidence
• Second trimester
• Childbearing period at full term 66%
• Immediate post-partum 50%
• Multiple gestation
• ↓Incidence in women with Good abdominal
tone prior to pregnancy
• Above umbilicus 37% - At umbilicus 52%- Below
umbilicus 11%
INTERVENTIONS
Corrective Exercises for Diastasis Recti
• corrective exercises (head lift or head lift with
pelvic tilt) should be used until the separation
is corrected to 2 cm (two finger widths) or less
 Head Lift
Patient position and procedure:
• Hook-lying with her hands crossed over midline at the level of
the diastasis for support.
• Have the woman exhale and lift only her head off the floor.
• At the same time, her hands should gently approximate the
rectus muscles toward midline
• Then have the woman lower her head slowly and relax
• This exercise emphasizes the rectus abdominis muscle and
minimizes the obliques.
• Some women may not be able to successfully reach over their
abdomens.
• In this case, the use of a sheet wrapped around the trunk at
the level of the separation can be used to provide support and
approximation
 Head Lift with Pelvic Tilt
• Patient position and procedure: Hook-lying. The arms are
crossed over the diastasis for support as before. Have the
patient slowly lift only her head off the floor while
approximating the rectus muscles and performing a posterior
pelvic tilt, then slowly lower her head and relax.
• All abdominal contractions should be performed with an
exhalation so that intra-abdominal pressure is minimized.
Strengthening exercises
 HSC
• Head lift - In a lying down position, knees bent at 90° angle, feet
flat, slowly lift the head, chin toward your chest, (concentrate on
isolation of the abdominals to prevent hip-flexors from being
engaged), slowly contract abdominals toward floor, hold for two
seconds, lower head to starting position for 2 seconds. Complete 10
repetitions.
• Seated squeeze - Again in a seated position, place one hand above
the belly button, and the other below the belly button. With
controlled breaths, with a mid-way starting point, pull the
abdominals back toward the spine, hold for 2 seconds and return to
the mid-way point. Complete 100 repetitions.
• Core contraction - In a seated position, place both hands on
abdominal muscles. Take small controlled breaths. Slowly contract
the abdominal muscles, pulling them straight back towards the
spine. Hold the contraction for 30 seconds, while maintaining the
controlled breathing. Complete 10 repetitions.
 USS
• Upright push-up - A standup pushup against the wall, with feet together
arms-length away from wall, place hands flat against the wall, contract
abdominal muscles toward spine, lean body towards wall, with elbows
bent downward close to body, pull abdominal muscles in further, with
controlled breathing. Release muscles as you push back to starting
position. Complete 20 repetitions.
• Squat against the wall - Also known as a seated squat, stand with back
against the wall, feet out in front of body, slowly lower body to a seated
position so knees are bent at a 90° angle, contracting abs toward spine as
you raise body back to standing position. Optionally, this exercise can also
be done using an exercise ball placed against the wall and your lower back.
Complete 20 Repetitions.
• Squat with squeeze - A variation to the "Squat against the wall" is to place
a small resistance ball between the knees, and squeeze the ball as you
lower your body to the seated position. Complete 20 repetitions.
Diastasis Recti Tape
 Why use tape?
• As a stimulus to assist function and strengthen muscles.
• After application we see and feel the muscle activation and the
space between the muscle decrease.
• The child becomes ‘alert’ and is able to do more
• with the tape on. Adults can perform a given exercise with
more ease. The tape assists in sensory awareness.
Ligament technique
Tulper Techniques
Pregnancy-Induced Pathology
Pregnancy-Induced Pathology
Diastasis Recti Varicose Veins

Posture-Related Back
Joint Laxity
Pain

Sacroiliac/Pelvic Girdle Nerve Compression

Pain Syndromes
Posture-Related Back Pain
 Posture-Related Back Pain

CAUSES 1. The postural changes of pregnancy, Characteristics

2. Increased ligamentous laxity,
The symptoms of low back pain
3. Hormonal influences,
4. decreased abdominal muscle function. usually worsen with muscle fatigue
from static postures .
As the day progresses; symptoms
Incidence •50% to 80% of pregnant women are usually relieved with rest or
• In the postpartum period, with change of position.
prevalence in as many as 68% of Women who are physically fit
women, for as long as 12 months generally have less back pain during
after delivery. pregnancy

Interventions

Low back pain symptoms can be treated effectively with many traditional low back
exercises, proper body mechanics, posture instructions, improvement in work
techniques, along with superficial modality application.
The use of deep heating agents, electrical stimulation, and traction is generally
contraindicated during pregnancy.
Sacroiliac/Pelvic Girdle
Pain
 Sacroiliac/Pelvic Girdle
Pain

Characteristics

Sacroiliac pain is localized to the posterior pelvis and is described as

stabbing deep into the buttocks distal and lateral to L5/S1.
 Sacroiliac/Pelvic Girdle
Pain

Characteristics

Pain may radiate into the posterior thigh or knee but not into the
foot.
 Sacroiliac/Pelvic Girdle
Pain

Symptoms

Symptoms include pain with prolonged sitting, standing

or walking, climbing stairs, turning in bed, unilateral
standing, or torsion activities.
Symptoms may not be relieved by rest and frequently
worsen with activity.
 Sacroiliac/Pelvic Girdle
Pain

Symptoms

Pubic symphysis dysfunction may occur alone or in

combination with sacroiliac symptoms and includes
significant tenderness to palpation at the symphysis,
radiating pain into the groin and medial thigh, and
pain with weight bearing
 Sacroiliac/Pelvic Girdle
Pain

interventions

Activity modification. Exercise modification. External stabilization..

 Sacroiliac/Pelvic Girdle
Pain

interventions

Activity modification.

•Daily activities should be adapted to minimize asymmetrical forces acting on the

trunk and pelvis.
•For example, getting into a car is done by sitting down first, then pivoting both legs
and the trunk into the car, keeping the knees together;
•side-lying is made more symmetrical by placing a pillow between the knees and
under the abdomen;
•and sexual positions are altered to avoid full range of hip abduction.
•Single-leg weight bearing, excessive abduction, and sitting on very soft surfaces
should be avoided.
•In addition, caution patients to avoid climbing more than one step at a time,
swinging one leg out of bed at a time when getting up, or crossing the legs when
sitting.
 Sacroiliac/Pelvic Girdle
Pain

interventions

Exercise modification.

Exercise must be modified so as not to aggravate the

condition.
Avoid exercises that require single-leg weight bearing and
excessive hip abduction or hyperextension.
Teach the patient to activate the pelvic floor and transverse
abdominals when transitioning from one position to another
and with any lifting in order to stabilize the pelvis.
 Sacroiliac/Pelvic Girdle
Pain

interventions

External stabilization

Use of external stabilization such as belts or corsets designed

for use during pregnancy helps reduce posterior pelvic pain,
especially when walking.
Varicose Veins
 Varicose Veins

Varicosities are aggravated in pregnancy by the increased uterine weight,

venous stasis in the legs, and increased venous distensibility.

Characteristics

Varicosities can present in the first trimester and are more prevalent with
repeated pregnancies.
They can occur in the lower extremities, the rectum (hemorrhoids), or vulva.
Symptoms usually include heaviness or aching discomfort, especially with
dependent leg positions;
intensity may become severe as the pregnancy progresses.
In addition, pregnant women are more susceptible to deep vein thrombosis.
 Interventions

Exercise modification. If there is discomfort, exercises may need to be

modified so that minimal dependent positioning of the legs occurs.
External support. Elastic support stockings should be worn to provide an
external pressure gradient against the distended veins, and the woman should
be encouraged to perform lower extremity exercises and to elevate the lower
extremities as often as possible.
Vulvar varicosities may benefit from use of a perineal pad or belt that
provides counter-pressure and support to the tissues.
 Joint Laxity
• Significance
• All joint structures are at increased risk of injury during pregnancy
and during the immediate postpartum period. The tensile quality of
the ligamentous support is decreased, and therefore injury can
occur if women are not educated regarding joint protection. There
is much controversy regarding the impact of postpartum hormone
levels; however, elevated levels have been found 3 to 5 months
after delivery.
• Interventions
• Exercise modification. Teach the woman safe exercises to perform
during the childbearing year, including modification of exercises to
decrease excessive joint stress
• Aerobic exercise. Suggest nonweight-bearing or less stressful
aerobic activities such as swimming, walking, or biking, particularly
for women who were relatively sedentary before pregnancy.
 NERVE COMPRESION SYNDROMES
• Thoracic outlet syndrome
• Carpel tunnel syndrom
TOS
Pregnancy-Induced Pathology
Pregnancy-Induced Pathology
Diastasis Recti Varicose Veins

Posture-Related Back
Joint Laxity
Pain

Sacroiliac/Pelvic Girdle Nerve Compression

Pain Syndromes
Posture-Related Back Pain
 Posture-Related Back Pain

CAUSES 1. The postural changes of pregnancy, Characteristics

2. Increased ligamentous laxity,
The symptoms of low back pain
3. Hormonal influences,
4. decreased abdominal muscle function. usually worsen with muscle fatigue
from static postures .
As the day progresses; symptoms
Incidence •50% to 80% of pregnant women are usually relieved with rest or
• In the postpartum period, with change of position.
prevalence in as many as 68% of Women who are physically fit
women, for as long as 12 months generally have less back pain during
after delivery. pregnancy

Interventions

Low back pain symptoms can be treated effectively with many traditional low back
exercises, proper body mechanics, posture instructions, improvement in work
techniques, along with superficial modality application.
The use of deep heating agents, electrical stimulation, and traction is generally
contraindicated during pregnancy.
Sacroiliac/Pelvic Girdle
Pain
 Sacroiliac/Pelvic Girdle
Pain

Characteristics

Sacroiliac pain is localized to the posterior pelvis and is described as

stabbing deep into the buttocks distal and lateral to L5/S1.
 Sacroiliac/Pelvic Girdle
Pain

Characteristics

Pain may radiate into the posterior thigh or knee but not into the
foot.
 Sacroiliac/Pelvic Girdle
Pain

Symptoms

Symptoms include pain with prolonged sitting, standing

or walking, climbing stairs, turning in bed, unilateral
standing, or torsion activities.
Symptoms may not be relieved by rest and frequently
worsen with activity.
 Sacroiliac/Pelvic Girdle
Pain

Symptoms

Pubic symphysis dysfunction may occur alone or in

combination with sacroiliac symptoms and includes
significant tenderness to palpation at the symphysis,
radiating pain into the groin and medial thigh, and
pain with weight bearing
 Sacroiliac/Pelvic Girdle
Pain

interventions

Activity modification. Exercise modification. External stabilization..

 Sacroiliac/Pelvic Girdle
Pain

interventions

Activity modification.

•Daily activities should be adapted to minimize asymmetrical forces acting on the

trunk and pelvis.
•For example, getting into a car is done by sitting down first, then pivoting both legs
and the trunk into the car, keeping the knees together;
•side-lying is made more symmetrical by placing a pillow between the knees and
under the abdomen;
•and sexual positions are altered to avoid full range of hip abduction.
•Single-leg weight bearing, excessive abduction, and sitting on very soft surfaces
should be avoided.
•In addition, caution patients to avoid climbing more than one step at a time,
swinging one leg out of bed at a time when getting up, or crossing the legs when
sitting.
 Sacroiliac/Pelvic Girdle
Pain

interventions

Exercise modification.

Exercise must be modified so as not to aggravate the

condition.
Avoid exercises that require single-leg weight bearing and
excessive hip abduction or hyperextension.
Teach the patient to activate the pelvic floor and transverse
abdominals when transitioning from one position to another
and with any lifting in order to stabilize the pelvis.
 Sacroiliac/Pelvic Girdle
Pain

interventions

External stabilization

Use of external stabilization such as belts or corsets designed

for use during pregnancy helps reduce posterior pelvic pain,
especially when walking.
Varicose Veins
 Varicose Veins

Varicosities are aggravated in pregnancy by the increased uterine weight,

venous stasis in the legs, and increased venous distensibility.

Characteristics

Varicosities can present in the first trimester and are more prevalent with
repeated pregnancies.
They can occur in the lower extremities, the rectum (hemorrhoids), or vulva.
Symptoms usually include heaviness or aching discomfort, especially with
dependent leg positions;
intensity may become severe as the pregnancy progresses.
In addition, pregnant women are more susceptible to deep vein thrombosis.
 Interventions

Exercise modification. If there is discomfort, exercises may need to be

modified so that minimal dependent positioning of the legs occurs.
External support. Elastic support stockings should be worn to provide an
external pressure gradient against the distended veins, and the woman should
be encouraged to perform lower extremity exercises and to elevate the lower
extremities as often as possible.
Vulvar varicosities may benefit from use of a perineal pad or belt that
provides counter-pressure and support to the tissues.
 Joint Laxity
• Significance
• All joint structures are at increased risk of injury during pregnancy
and during the immediate postpartum period. The tensile quality of
the ligamentous support is decreased, and therefore injury can
occur if women are not educated regarding joint protection. There
is much controversy regarding the impact of postpartum hormone
levels; however, elevated levels have been found 3 to 5 months
after delivery.
• Interventions
• Exercise modification. Teach the woman safe exercises to perform
during the childbearing year, including modification of exercises to
decrease excessive joint stress
• Aerobic exercise. Suggest nonweight-bearing or less stressful
aerobic activities such as swimming, walking, or biking, particularly
for women who were relatively sedentary before pregnancy.
 NERVE COMPRESION SYNDROMES
• Thoracic outlet syndrome
• Carpel tunnel syndrom
TOS
CESAREAN CHILDBIRTH

Lec-16P
 Cesarean Childbirth
• A cesarean section is the delivery of a baby through an incision
in the abdominal wall and uterus rather than through the
pelvis and vagina.
• General, spinal, or epidural anesthesia may be used.
 INDICATIONS
• usually performed when a vaginal delivery is a risk for mother
or baby,
• complications of labor and factors impeding vaginal delivery
:small pelvis,dystocia
cord prolapse
hypertension
placental problems
 abnormal
presentation

macrosomia
• other complications of
pregnancy, preexisting
conditions and
concomittant disease
pre-eclampsia
multiple births
sexually transmitted infections such as genital herpes
 Risk
RISK FOR MOTHER
• associated with risks of post-operative adhesions
• incisional hernias
• wound infections
• severe blood loss
• post spinal headaches
RISK FOR THE CHILD
• neonatal depression
• fetal injury
• breathing problems
 demography
• Cesarean section (C-section) delivery is now at an all-time high
and is the most commonly performed surgical procedure in
the United States.
• In 2007, the total number of C-sections was almost 1.5 million,
for a record high rate of 31.8% .This statistic has fluctuated in
the past three to four decades
INTERVENTIONS
High-Risk Pregnancy
• A high-risk pregnancy is one that is complicated by disease or
problems that put the mother or fetus at risk for illness or
death before, during, or after delivery.
• Conditions may be preexisting, induced by pregnancy, or
caused by an abnormal physiologic reaction during pregnancy.
• The goal of medical intervention is to prevent preterm delivery,
usually through use of bed rest, restriction of activity, and
medications, when appropriate
• Prolonged bed rest can impact not just the musculoskeletal
system but also pulmonary, cardiovascular, and metabolic
functions.
• Although these women may initially be seen in the home, the
deconditioning present continues to create functional
restrictions for the postpartum client in terms of strength and
endurance,
High-Risk Conditions
 Premature onset of labor
• If cervical dilation, effacement, and/or uterine contractions
begin before 37 weeks’ gestation, this is considered preterm
labor.
• Clearly, the health of the baby is of primary concern if these
signs are present. The mechanism for this condition is still
unclear.
 Preterm rupture of membranes
• The amniotic sac breaks, and amniotic fluid is lost before onset of
labor.
• This can be dangerous to the fetus if it occurs before fetal
development is complete.
• Labor may begin spontaneously after the membranes rupture.
• The chance for fetal infection also increases when the protection of
the amniotic sac is lost.
• Leakage of amniotic fluid is an indication for immediate medical
attention
 Incompetent cervix
• An incompetent cervix is the painless dilation of the cervix that
occurs in the second trimester (after 16 weeks’ gestation) or
early in the third trimester of pregnancy.
• This may lead to premature membrane rupture and delivery of
a fetus too small to survive
 Placenta previa
• The placenta attaches too low on the uterus, near the cervix.
As the cervix dilates, the placenta begins to separate from the
uterus and may present before the fetus, thus endangering
fetal life.
• The primary symptom is intermittent, recurrent, or painless
bleeding that increases in intensity.
 Pregnancy-related hypertension or preeclampsia
• Characterized by hypertension, protein in the urine, and
severe fluid retention, preeclampsia can progress to maternal
convulsions, coma, and death if it becomes severe (eclampsia).
• It usually occurs in the third trimester and disappears after
birth. The cause is not understood
 Multiple gestation
• More than one fetus develops.
• Complications of multiple gestations include premature onset
of labor and birth, increased incidence of perinatal mortality,
lower birth weight infants, and increased incidence of maternal
complications (e.g., hypertension).
 Diabetes
• Diabetes can be present before pregnancy or may
• occur as a result of the physiological stress of pregnancy.
• Gestational diabetes, which presents or is first recognized in
pregnancy, affects 7% of pregnant women and usually
disappears after pregnancy; however, as many as 50% of these
women may develop type 2 diabetes within 10 years
Thank you
Guidelines for Managing the Pregnant
Woman
 Proper positioning
• Do not exceed 5 minutes of supine positioning at any one time
after the first trimester of pregnancy
• to avoid vena cava compression by the uterus.
• Educate your patients that compression of the vena cava also
occurs with motionless standing.
• For supine exercise, place a small wedge or rolled towel under the
right hip to lessen the effects of uterine compression on abdominal
vessels and to improve cardiac output. The wedge turns the patient
slightly toward the left
• This modification is also helpful during physical therapy evaluation
and treatment when the patient is positioned supine.
 orthostatic hypotension
• To avoid the effects of orthostatic hypotension, instruct the
woman to always rise slowly when moving from lying down or
sitting to standing positions.
 breath-holding
• Discourage breath-holding, and avoid activities that tend to
elicit Valsalva’s maneuver because this may lead to
undesirable downward forces on the uterus and pelvic floor.
• In addition, breath-holding causes stress to the cardiovascular
system in terms of blood pressure and heart rate
 fluid replenishment
• Break frequently for fluid replenishment.
• The risk of dehydration during exercise is increased in
pregnancy.
• Avoid exercising in high temperature or humidity.
• Increase water intake in proportion to time spent exercising
and as environmental temperature increases.
• Encourage complete bladder emptying before exercise.
• A full bladder places increased stress on an already weakened
pelvic floor.
• Include appropriate warm-up and cool-down activities.
• Modify or discontinue any exercise that causes pain.
• Limit activities in which single-leg weight bearing is required,
such as standing leg kicks.
• In addition to possible loss of balance, these activities can
promote sacroiliac or pubic symphysis discomfort
 Stretching/flexibility
• Choose stretching exercises that are specific to a single muscle or
muscle group; do not involve several groups at once.
• Asymmetrical stretching or stretching multiple muscle groups can
promote joint instability.
• Avoid ballistic movements.
• Do not allow any joint to be taken beyond its normal physiological
range.
• Use caution with hamstring and adductor stretches.
Overstretching of these muscle groups can increase pelvic
instability or hypermobility.
 PRECAUTIONS
• Observe participants closely for signs of overexertion or
complications. The following signs are reasons to discontinue
exercise
• Persistent pain, especially in the chest, pelvic girdle, or low back
• Leakage of amniotic fluid
• Uterine contractions that persist beyond the exercise session
• Vaginal bleeding
• Decreased fetal movements
• Persistent shortness of breath
• Irregular heartbeat
• Tachycardia
• Dizziness/faintness
• Swelling/pain in the calf
• Difficulty in walking
Muscle performance and aerobic fitness.
 Recommendations for Fitness Exercise
• It is strongly recommended for all women to participate in mild
to moderate exercise, for both strength and cardiopulmonary
benefits, 15 to 30 minutes/session, most days of the week.
• Individualized programs, based on prepregnancy fitness level,
are preferable
• Currently, there are no data in humans suggesting that pregnant women
need to decrease their intensity of exercise or lower their target heart
rates, but because of decreased oxygen supply, they should modify
exercise intensity according to their tolerance.
• Conventional (age-based) target heart rate zones may be too aggressive for
the average pregnant patient.
• Use of the Borg scale of perceived exertion is more appropriate in this
population, with exertion between 12 and 14 suggested during
uncomplicated pregnancy.

• When fatigued, a woman should stop exercising, and she should never
exercise to exhaustion
The scale starts with “no feeling of exertion,” which rates a
6, and ends with “very, very hard,” which rates a 20.
Moderate activities register 11 to 14 on the Borg scale
(“fairly light” to “somewhat hard”), while vigorous
activities usually rate a 15 or higher (“hard” to “very, very
hard”)
• Activities to avoid include contact sports,
anything with a high risk of abdominal trauma
or falling, high-altitude activities (greater than
6,000 ft), and scuba diving. The fetus is at
increased risk of decompression sickness
during scuba diving
• Nonweight-bearing aerobic exercises, such as stationary
cycling, swimming, or water aerobics, will minimize the risk of
injury throughout pregnancy and the postpartum period.
• If the woman cannot safely maintain balance because of the
shifting and increasing weight, have her modify exercises that
could result in falling and injuring herself or the fetus.
• Resumption of prepregnancy exercise routines during the
postpartum period should be gradual.
• Initiation of pelvic floor exercises immediately postpartum may
reduce symptoms and duration of incontinence
• Physiological and morphological changes of pregnancy
continue for a minimum of 4 to 6 weeks postpartum— longer if
the woman is breastfeeding. Encourage continued joint
protection.
• Breastfeeding women can be reassured that moderate exercise does not
impair quantity or quality of breast milk or infant growth.
• Lactating women will have slower weight loss in the postpartum period;
an additional 500 calories/day are needed to support production of breast
milk.
• Water intake continues to be important; 12 or more glasses per day are
recommended.
• There may be a short-term increase in lactic acid secreted in breast milk
after high-intensity exercise; if the baby appears to eat less after an
exercise session, this can easily be remedied by nursing before exercise
Precautions and Contraindications to
Exercise
 Absolute Contraindications
PPP MMM IVR
• Placenta previa: placenta is located on the uterus in a position in
which it may detach before the baby is delivered
• Preeclampsia: pregnancy-induced hypertension
• Premature labor: labor beginning before the 37th week of
pregnancy
• Multiple gestation with risk of premature labor
• Maternal heart disease, thyroid disease, or serious respiratory
disorder
• Maternal type 1 diabetes
• Incompetent cervix: early dilation of the cervix before the
pregnancy is full term
• Intrauterine growth retardation
• Vaginal bleeding, especially second or third trimester
• Rupture of membranes: loss of amniotic fluid before the onset of
labor
 Precautions to Exercise
• The woman with one or more of the following conditions
may participate in an exercise program under close
observation by a physician and a therapist as long as no
further complications arise. Exercises may require
modification.
• Gestational diabetes
• Severe anemia
• Systemic infection
• Extreme fatigue
• Musculoskeletal complaints and/or pain
• Overheating
• Extreme obesity or extreme underweight/eating disorder
• Diastasis recti
Thank u
TYPES OF EXERCISES IN PREGNANCY
• Critical Areas of Emphasis and Selected Exercise
Techniques
• Pelvic Floor Awareness, Training, and Strengthening
• Relaxation and Breathing Exercises for Use
During Labor
 TYPES OF EXERCISES IN PREGNANCY

Posture Exercises Modified Upper and Lower

Extremity Strengthening

Pelvic Floor Awareness,

Corrective Exercises for Training, and Strengthening
Diastasis Recti
Relaxation and Breathing
Stabilization Exercises Exercises for Use During
Labor

Dynamic Trunk Exercises

 Posture Exercises

• The growing fetus places added stress on postural muscles as

the center of gravity shifts forward and upward and the spine
shifts to compensate and maintain stability.
• In addition, after delivery, activities involving holding and
caring for the baby stress postural muscles.
• Flexibility and stretching exercises are implemented with
caution
• Resistance exercises are performed at a low intensity.
Selected Stretching and Resistance Exercises During Pregnancy
Stretching (with Caution)
Upper neck extensors and scalenes
Scapular protractors, shoulder internal rotators, and levator scapulae
Low back extensors
Hip flexors, adductors, and hamstrings
CAUTION: women with pelvic instabilities should not overstretch
these muscles.
Ankle plantarflexors
Strengthening (Low Intensity)
Upper neck flexors and lower neck and upper thoracic extensors
Scapular retractors and depressors
Shoulder external rotators
Trunk flexors ( particularly lower abdominals; use corrective exercises
for diastasis recti if present)
Hip extensors
Knee extensors
Ankle dorsiflexors
Corrective Exercises for Diastasis Recti
• Head Lift

• Head Lift with

Pelvic Tilt
 Stabilization Exercises
• The exercises should be initiated and progressed at the
intensity that the woman is able to safely control.
• Slow, controlled breathing is emphasized while developing the
stabilizing function of the muscles.
• As pregnancy progresses, the abdominals will undergo extreme
overstretching. Therefore, exercise must be adapted to meet
the needs of each individual, and periodic reassessment must
be done (approximately every 4 weeks during pregnancy)
 PRECAUTIONS
• Because the trunk muscles are contracting isometrically in
many of the stabilization exercises, there is a tendency to
hold the breath; this is detrimental to the blood pressure
and heart rate. Caution the woman to maintain a relaxed
breathing pattern and exhale during the exertion phase of
each exercise.
• If diastasis recti is present, adapt the stabilization exercises
to protect the linea alba as described in the Corrective
Exercises for Diastasis Recti section. Any progression of
postpartum abdominal strengthening exercises should be
postponed until the diastasis has been corrected to two
finger widths or less.
• Keep in mind the 5-minute time limit for supine
positioning when prescribing abdominal exercises after 13
weeks’ gestation.
Dynamic Trunk Exercises

Pelvic Motion Training

Pelvic tilt exercises

Pelvic clock
 Dynamic Trunk Exercises
Pelvic Motion Training
• These exercises are helpful in cases of
posture-related back pain; they are beneficial
for improving proprioceptive awareness, as
well as lumbar, pelvic, and hip mobility.
 Pelvic tilt exercises
• Begin in quadruped (on hands and knees).
• Instruct the patient to perform a posterior pelvic tilt.
While the patient keeps her back straight, have her
isometrically tighten (imagine drawing in) the lower
abdominals and hold, then release and perform an
anterior tilt through very small range.
• For additional exercise, while holding the abdominals in and
the back straight, have the woman laterally flex the trunk to
the right (side-bend to the right), looking at the right hip, then
reverse to the left.
• Have the woman practice pelvic tilt exercises in a variety of
positions, including side-lying and standing.
 Pelvic clock
• With the woman hook-lying, ask her to visualize the face of a clock
on her lower abdomen. The umbilicus is 12 o’clock and the pubic
symphysis is 6 o’clock. The patient’s legs may move slightly while
performing this exercise.
• Have her begin with gentle movements back and forth between 12
and 6 o’clock (the basic pelvic tilt exercise).
• Then ask her to move back and forth between 3 o’clock (weight
shifted to left hip) and 9 o’clock (weight shifted to the right hip).
• Then move in a clockwise manner from 12 to 3 to 6 to 9 and then
back to 12 o’clock, then reverse.
• With practice, these will become very smooth and rhythmical
movements and will not require such concentration on each
number of the clock.
• Continue relaxed breathing throughout the exercise, and do
not force any part of the movement.
• If the patient has difficulty with the motion, make the clock
“smaller” until coordination improve
 Pelvic clock progressions
• Use the visual imagery of cutting the face of the clock in half so that
there is a right side and a left side or a top half and a bottom half.
Have the woman move her pelvis through the arc on the one side
and back through the middle of the clock, and then move the pelvis
through the opposite side and back through the middle. Initially, the
woman may notice asymmetry when comparing the halves; this will
improve with time.
• Once the patient understands and is able to perform the clockwise
pattern, have her do counterclockwise motions with all of the
activities mentioned previously, and then progress the exercises to
the sitting position.
Modified Upper and Lower Extremity
Strengthening
 Standing Push-Ups
Patient position and procedure:
Standing, facing a wall, feet pointing
straight forward, shoulder-width apart,
and approximately an arm-length away
from the wall. The palms are placed on
the wall at shoulder height. Have the
woman slowly bend the elbows, bringing
her upper body close to the wall,
maintaining a stable trunk and pelvic
position, and keeping the heels on the
floor. Her elbows should be shoulder
height. She then slowly pushes with her
arms, bringing the body back to the
original position.
 Supine Bridging
Patient position and procedure:
Supine in the hook-lying position.
Have the woman perform a
posterior pelvic tilt and then lift
her pelvis off the floor. She can do
repetitive bridges or hold the
bridge position and alternately
flex and extend her upper
extremities to emphasize the
stabilization function of the hip
extensors and trunk musculature
 Quadruped Leg Raising
• Patient position and procedure: On hands
and knees (hands may be in fists or palms
may be open and flat). Instruct the woman
to first perform a posterior pelvic tilt and
then slowly lift one leg, extending the hip to
a level no higher than the pelvis while
maintaining the posterior pelvic tilt
• She then slowly lowers the leg and repeats
with the opposite side. The knee may
remain flexed or can be straightened
throughout the exercise. Monitor this
exercise, and discontinue if there is stress on
the sacroiliac joints or ligaments. If the
woman cannot stabilize the pelvis while
lifting the leg, have her just slide one leg
posteriorly along the floor and return
 Modified Squatting
• Wall slides and supported squatting exercises are
used to strengthen the hip and knee extensors
for good body mechanics and also to help stretch
the perineal area for flexibility during the
delivery process. In addition, if the woman
wishes to use squatting for labor and delivery,
the muscles must be strengthened and
endurance trained in advance.
• Patient position and procedure: Standing with
back against a wall and her feet shoulder-width
apart. Have the woman slide her back down the
wall as her hips and knees flex only as far as is
comfortable, then slide back up.
• Patient position and procedure: Standing with
feet shoulder width apart or wider, facing a
counter, chair, or wall on which the woman can
rest her hands and/or forearms for support. Have
the woman slowly squat as far as is comfortable
Perineum and Adductor Flexibility
• these flexibility exercises prepare the
legs and pelvis for childbirth.
Self-Stretching
• Patient position and procedure: Supine
or side-lying. Instruct the woman to
abduct the hips and pull the knees
toward the sides of her chest and hold
the position for as long as is
comfortable (at least to the count of
10).
• Patient position and procedure: Sitting
on a short stool with the hips
abducted as far as possible and feet
flat on the floor. Have her flex forward
slightly at the hips (keeping the back
straight), or have her gently press her
knees outward with her hands for an
additional stretch.
Pelvic Floor Awareness, Training, and
Strengthening
• Begin pelvic floor exercise
training with an empty bladder.
• Gravity-assisted positioning (hips
higher than the heart, such as
supported bridge ) may be
indicated initially for some
women with extreme weakness
and proprioceptive deficits

Contract-Relax Quick Contractions

“Elevator” Exercise Pelvic Floor

Relaxation
 Contract-Relax
• Instruct the woman to tighten the pelvic floor as if
attempting to stop urine flow or hold back gas.
• Hold for 3 to 5 seconds, and relax for at least the same
length of time.
• Repeat as many as 10 times (if performed with proper
technique).
• With significant coordination dysfunction or fatigue,
substitution with the gluteals, abdominals, or hip adductors
may occur.
• To maximize proprioception and motor learning, it is
important initially to emphasize isolation of the pelvic floor
and avoid the substitute muscle actions.
• In addition, watch for Valsalva’s maneuver; if necessary,
have the woman count out loud to encourage normal
breathing patterns.
 Quick Contractions
• Have the woman perform quick, repeated contractions of the
pelvic floor muscles while maintaining a normal breathing rate
and keeping accessory muscles relaxed.
• Try for 15 to 20 repetitions per set.
• This type II-fiber response is important to develop in order to
withstand pressure from above, especially with coughing or
sneezing.
 “Elevator” Exercise
• Instruct the woman to imagine riding in an elevator.
• As the elevator goes up from one floor to the next, she contracts
the pelvic floor muscles a little more.
• As strength and awareness improve, add more “floors” to the
sequence of the contraction.
• Another way to increase difficulty is to ask the woman to relax the
muscles gradually, as if the elevator were descending one floor at a
time.
• This component requires an eccentric contraction and is very
challenging.
 Pelvic Floor Relaxation
• Instruct the woman to contract the pelvic floor as in the
strengthening exercise, then allow total voluntary release and
relaxation of the pelvic floor. Use of the “elevator” imagery should
also be emphasized, with particular attention to taking the elevator
to the “basement.”
• Pelvic floor relaxation is closely linked with effective breathing and
relaxation of the facial muscles. Instruct the woman to concentrate
on a slow, deep breath and allow the pelvic floor to completely
relax. Relaxation of the pelvic floor is extremely important during
stage 2 of labor and vaginal delivery.
• Chronic inability to relax the pelvic floor muscles may lead to
impairments such as hypertonus, pain with intercourse, or
voiding dysfunction.
• If the patient presents with these symptoms, increase the rest
time between pelvic floor contractions and sets; also use
submaximal contractions to improve awareness of tension
versus relaxation.
Relaxation and Breathing Exercises for
Use During Labor
 Visual Imagery
• Use instrumental music and verbal guidance.
• Instruct the woman to concentrate on a relaxing image such as
the beach, mountains, or a favorite vacation spot.
• Suggest that she focus on the same image throughout the
pregnancy so that the image can be called up to the conscious
level when recognizing the need to relax during labor.
 Muscle Setting
• Have the woman lie in a comfortable position.
• Have her begin with the lower body. Instruct her to gently contract
and then relax first the muscles in the feet, then legs, thighs, pelvic
floor, and buttocks.
• Next, progress to the upper extremities and trunk, then to the neck
and facial muscles.
• Reinforce the importance of remaining awake and aware of the
contrasting sensations of the muscles. Emphasize “softening” of
the muscles as the session continues.
• Add deep, slow, relaxed breathing to the routine.
 Selective Tension
• Progress the training by emphasizing awareness of muscles
contracting in one part of the body while remaining relaxed in
other parts.
• For example, while she is tensing the fist and upper extremity, the
feet and legs should be limp.
• Reinforce the comparison between the two sensations and the
ability to control both tension and relaxation.
• While practicing selective tension, have your client work with a
partner who gently shakes the extremity that is “relaxed” to make
sure there is no tension in it.
 Breathing
• Slow, deep breathing (with relaxation of the upper thorax) is the
most efficient method for exchange of air to use with relaxation
techniques and for controlled breathing during labor.
• Teach the woman to relax the abdomen during inspiration so that it
feels as though the abdominal cavity is “filling up” and the ribs are
expanding laterally. During exhalation, the abdominal cavity
becomes smaller; active contraction of the abdominal muscles is
not necessary with relaxed breathing.
• To prevent hyperventilation, emphasize a slow rate of breathing.
Caution the woman to decrease the intensity of the breathing if she
experiences dizziness or feels tingling in the lips and fingers.
Relaxation and Breathing During
Labor
 First Stage
• As labor progresses, the contractions of the uterus become
stronger, longer, and closer together.
• Relaxation during the contractions becomes more difficult.
• Provide the woman with suggested techniques to assist in
relaxation.
• Ensure the woman has emotional support from the father, family
member, or special friend to provide encouragement and assist with
overall comfort.
• Seek comfortable positions including walking, hands and knees ,lying
on pillows, or sitting on a Swiss ball; include gentle repeated motions
such as pelvic rocking.
• Breathe slowly with each contraction; use the visual imagery, and
relax with each contraction. Some women find it helpful to focus their
attention on a specific visual object. Other suggestions include singing,
talking, or moaning during each contraction to prevent breath-holding
and encourage slow breathing.
• During transition (near the end of the first stage), there is often an
urge to push. Teach the woman to use quick blowing techniques,
using the cheeks, not the abdominal muscles, to overcome the desire
to push until the appropriate time.
• Massage or apply pressure to any areas that hurt, such as the low
back. Using the hands may help distract the focus from the
contractions.
• Apply heat or cold for local symptoms; wipe the face with a wet
washcloth.
 Second Stage
• Once dilation of the cervix has occurred, the woman may become active in the birth process
by assisting the uterus during a contraction in pushing the baby down the birth canal.
• Teach her the following techniques:
• While bearing down, take in a breath, contract the abdominal wall, and slowly breathe out.
This will cause increased pressure within the abdomen along with relaxation of the pelvic
floor.
• PRECAUTION: Tell the woman that if she holds her breath, there will be increased tension
and resistance in the pelvic floor. In addition, exertion with a closed glottis, known as
Valsalva’s maneuver, has adverse effects on the cardiovascular system.
• For maximum efficiency, maintain relaxation in the extremities, especially the legs and
perineum. Keeping the face and jaw relaxed assists with this.
• Between contractions, perform total body relaxation.
Unsafe Postures and Exercises During
Pregnancy
 Bilateral straight-leg raising
• This exercise typically
places more stress on the
abdominal muscles and
low back than they can
tolerate.
• It can cause back injury or
diastasis recti and
therefore should not be
attempted.
 Fire hydrant” exercise
• This exercise is performed on
hands and knees, and one hip
is abducted and externally
rotated at a time
• If the leg is elevated too high,
the sacroiliac joint and
lumbar vertebrae can be
stressed.
• It should be avoided by any
woman who has preexisting
sacroiliac joint symptoms or
women in whom symptoms
develop.
All-fours (quadruped) hip extension
• This exercise can be
performed safely only .
• It becomes unsafe and can
cause low back pain when
the leg is elevated beyond
the physiologic range of hip
extension, causing the pelvis
to tilt anteriorly and the
lumbar spine to hyperextend.
 Unilateral weight-bearing activities
• Weight bearing on one leg (which includes slouched standing with
the majority of weight shifted to one leg and the pelvis tilted down
on the opposite side) during pregnancy can cause sacroiliac joint
irritation and should be avoided by women with preexisting
sacroiliac joint symptoms.
• Unilateral weight bearing also can cause balance problems because
of the increasing body weight and shifting of the center of gravity.
• This posture becomes a significant problem postpartum when the
woman carries her growing child on one hip. Any asymmetries
become accentuated, and painful symptoms may develop.
Exercise Critical to the Postpartum
Period
• After an uncomplicated vaginal delivery, exercise can be
started as soon as the woman feels able to exercise.
 Pelvic floor strengthening
• Exercises should be resumed as soon after the birth as possible.
• These exercises may increase circulation and aid healing of
lacerations or episiotomy.
• Combining pelvic floor contractions with feeding or changing the
baby may help them become integrated into the daily routine.
• When treating a postpartum client in the clinic, emphasize life-long
need for pelvic floor exercise, especially when lifting or with
significant exertion, to allow the pelvic floor muscles to provide
additional trunk support.
 Diastasis recti correction
• The mother should be taught this test and
encouraged to perform it on the third
postpartum day.
• Corrective exercises should continue until the
separation is two finger widths or less.
 Aerobic and strengthening exercises
• As soon as the woman feels able, cardiopulmonary exercise
and light resistance training can be resumed with gradually
increasing intensity.
• A physical examination is suggested before the onset of
vigorous exercise or sport-specific training.
• Stop exercise if there is bleeding & injury(strain)
 TO KNOW THE ANSWERS OF THE FOLLOWING QUESTIONS
 Why male are more Mathematical and Analytical than females ?
 Why females are more Communicative than males ?
 Why females are more prone to Dementia ?
 Why females are more Emotional than males ?
 Why females are more Expressive in their Feelings ?
 Why females are more susceptible to Depression?
 Why Social cognition and interpersonal judgment in more in
females ?
 Why females speak a lot ?
 GENDER
DIFFERENCES
IN
‘‘BRAIN ANATOMY’’
 Size & Weight
 Brain Volume
 Grey Matter vs White Matter
 Hypothalamus
 Anterior Commissure
 Cerebellum
 Corpus Callosum
 Inferior-Parietal Lobule (IPL)
 Amygdala
Several Postmortem and structural Neuro imaging
studies in humans have shown some Morphological
differences that are likely to reflect an interaction
between developmental influences, experience, and
hormone actions on the mature brain.
Experience

Development Hormones
 Size & Weight

 Male : 1260cm3
 Female : 1130 cm3
 The adult human brain weighs on average about 3lb (1.5 kg)
 Male brains are about 10% larger than female brains and
weigh 11-12% more than that of a woman.
 Men's heads are also about 2% bigger than women's. This is due to the larger
physical stature of men. Male’s larger muscle mass and larger body size
requires more neurons to control them.
 New born baby boy and a baby girl will have similar brain sizes.
 Brain Volume

 Women have larger volumes in the

Frontal and Medial Paralimbic Cortices.
 Men have larger volumes in the
Frontomedial cortex
Amygdala
Hypothalamus.
 Grey Matter vs White Matter
 Men have approximately 6.5 times more gray matter in the brain
than women
 Women have about 10 times more white matter than men do
 At the age of 20 a man has around 176,000 km and a woman
about 149,000 km of myelinated axons in their brains.
 Male : gray matter : cognitive performance
 Female : white matter : communication between different areas
of the brain.
 Average number of neocortical neurons
 Female : 19 billion
 Male : 23 billion
10% of all neocortical neurons are lost over the life span in both
sexes between 20-90 years .
 Hypothalamus
 Hypothalamus, where most of the basic functions of life are
controlled, including hormonal activity via the pituitary gland
also shows gender differences.
 The volume of a specific nucleus in the hypothalamus is twice as
large in men as in women .
 Preoptic area : Mating behavior : 2.2 times larger in men .This
enlargement is dependent on the amount of male sex hormones or
androgens.
 Suprachiasmatic nucleus : Circadian rhythms and reproduction
cycles : More enlongated in females.sphere shape in male.
 Lateral and Medial Mamillary Nucleus : Cognition.
 Anterior Commissure

Anterior Commisure : 12 % larger in

women

Cerebellum
Posture and Balance
Control consciousness(pons) : Larger in
men
 Corpus Callosum
 Larger in Left-handed males .
 Among women there was no difference between right-
handers and left-handers.
Inferior-Parietal Lobule (IPL)
 IPL correlates with the mathematical ability.
 This part was larger in the brain of Albert Einstein
 Left IPL : Larger in Males
 Right IPL : understanding relationships and the ability to
sense relationships between body parts
 Left IPL : perception of time and speed, and the ability to
rotate 3-D figures in the brain.
 Amygdala..involved in producing emotional
reactions.

 Amygdala : Emotional events and does so

through interactions with endogenous stress
hormones released during stressful events.
 Male : Right side dominant
 Female : Left side dominant
women more capable of controlling emotional
reactions.
 Why male are more Mathematical and Analytical
than females ?
The male differentiated brain has a thicker right
hemisphere. This may be the reason males tend to
be more analytical and mathematical.
 Why female are more Communicative than males
?
The female left hemisphere, which is important to
communication, is thicker in female oriented
brains.
 Why Women are more prone to dementia ?
Women have a more space between cell bodies,
dendrites and axons That’s the reason women are
more prone to dementia (such as Alzheimer's disease)
than men
 Why female are more Emotional than males ?
The ratio between the orbitofrontal cortex, a
region involved in regulating emotions and the size
of the amygdala involved in producing emotional
reactions is significantly larger in women than men.
 Why female are more expressive in their feelings ?
Females have a more acute sense of smell and on average have a
larger deep limbic system including hippocampus and
anterior commissure, a bundle of fibers which acts to
interconnect the two amygdale than males. Due to the larger
deep limbic brain women are more in touch with their feelings,
they are generally better able to express their feelings than
men. They have an increased ability to bond and are connected
to others.
 Why Females are more susceptible to depression?
On the other hand larger deep limbic system leaves a female
somewhat more susceptible to depression, especially at times
of significant hormonal changes such as the onset of puberty,
before menses, after the birth of a child and at menopause.
That’s the reason Women attempt suicide three times
more than men.
 Why Social cognition and interpersonal judgment in
more in females ?
Straight Gyrus, A narrow band at the base of the
frontal lobe, involved in social cognition and
interpersonal judgment is about 10% bigger in women
than in men.
 Why females speak a lot ?
The two major areas related to speech, Brocas(motor
speech area) Wernicke(sensory speech area)
significantly larger in women.
 Broca’s Area : 23% more than males
 Wernicke's area : 13% more than males.
 CONCLUSION / ANALYSIS
 Sex differences need to be considered as it may raise
the possibility of early diagnosis and precise treatment
and management for neurological diseases, and may
help physicians and physical therapists to discover new
diagnostic tools to explore the brain differences.
Understanding the development of normal brain and
differences between the sexes is important for the
interpretation of clinical imaging studies.
SEX AND GENDER DIFFERENCES: USE AND
RESPONSE TO MEDICATIONS
Gender Based Medicine
 Gender-based medicine or simply gender medicine is
the field of medicine that studies the biological and
physiological differences between the human sexes and
how that affects differences in disease.
 Traditionally, medical research has mostly been
conducted using the male body as the basis for clinical
studies. The findings of these studies have often been
applied across the sexes and healthcare providers have
assumed a uniform approach in treating both male and
female patients.
 More recently medical research has started to
understand the importance of taking the sex in to count
as the symptoms and responses to medical treatment
may be very different between sexes
Medicine

 Medicine is the science and art of healing. It encompasses a

variety of health care practices evolved to maintain and
restore health by the prevention and treatment of illness.
 GENDER DIFFRENCES:USE AND
RESPONSE TO MEDICATION

Women consume a larger number of medications as

compare to men

Women have been under represented in clinical drug

studies
Women responds differently from men to certain
medications
Reasons of differences between men and women in
the response to medication
 Women have Lower body weight as compared with men
 Women have smaller organ size as compared with men
 Women have high proportion of fat compared with men
 Differences in metabolism
 Functional variations in liver, kidneys and slower GI metabolism
 Differences in Hormone level
Gender diffrences:use and response to medication

 A women response to medication may change according to her

stage in life, hormones have been blamed for this.

 Hormonal levels have been implicated in the fact that women are
at increased risk of developing arrhythmias.

 The blood level of certain medications may drop or be elevated

immediately before the menstrual period making the medication
less effective
Gender diffrences:use and response to medication

 During pregnancy, blood volumes expands, which can dilute and

reduce the effects of medications.

 Medications taken with in the first trimester of pregnancy are

associated with the greatest risk of causing birth defects.
Gender diffrences:use and response to medication

 Medication-related problems in older adults including women are widely

experienced.
 The result of aging and the subsequent impact on drug metabolism cause
increase sensitivity to the effects of some medications.
 The aging effects frequently are coupled with concurrent use of multiple
medications because the presence of multiple chronic diseases.
 This leads to an increased risk of developing an adverse drug event, that is any
harmful, unintended, or unwanted effect of a medication that can lead to
illness or the need for hospitalization or a visit to emergency room.
Gender diffrences:use and response to medication

 The concurrent use of multiple medications also increase the risk

of developing interaction between two or more medications.
 Between medications and certain foods or beverages.
 Self medications
 Outdated medicines
 Shared medicines
 Poor medication
Gender diffrences:use and response to medication

 Poor understanding about the treatment plan.

 Limited access to medication.

 Confusion resulting from the use of multiple medications.

 Drug addiction
Gender diffrences:use and response to medication

 Women have multiple roles in society. as a family caregiver and

professionals,

 Women have may have little time to dedicate to themselves as

compared with men.

 Their health issues, including the use of medications may be

sacrificed by increasing responsibilities.
For safe medication ,we should;

 Take responsibility of your own health.

 Be aware that medications can be helpful and harmful.
 Understands the need of each medications
 Be aware about side effects.
 Be aware about potential interactions with other prescriptions
medications.
 Understands the need and stop of taking medications.
For safe medication ,we should;

 Keep track of medications.

 Inform your doctor about the previous medications,
hospitalization and emergency situations.
 Inform your doctor about your allergies to different
medications.
 women should inform the doctor about their monthly cycle.
For safe medication ,we should;

 Read the information available on the medicines.

 Read the integrants of medicines.

 Use reliable source of reference for .medications.

 Know about the prescribed and non prescribed drugs.

 Be wise. what you don’t know can hurt you. prevention is also a
medication.
Physiotherapy
in
Obstetrics & Gynaecology
 Obstetrics concerns itself with
pregnancy, labour, delivary &the care
of the mother after child birth

Gynaecology is the study of disease

associated with women which in effect
means condition involving the female
genital tract.
Normal anatomy of female pelvis
Physiotherapy in obstetrics condition

From the moment of conception pregnancy

profoundly alters the women physiology.
There is change in all body system to fulfill
the requirement of the body.
Therapeutic exercises may be prescribed to
pregnant women for several reasons:

Primary conditioning unrelated to pregnancy.

Impairments related to physiological changes of

pregnancy, such as back pain ,faulty posture, or
leg cramps.

Physical &physiological benefits.

Preventive measures
Physiological changes during pregnancy
Pregnancy wt. gain - 9.70 to 14.55 kg.

Changes in reproductive system.

Urinary system -kidney increases by 1cm.

Changes in pulmonary system.

CVS.
Physiological changes during pregnancy
Musculoskeletal system.
a. Stretching of abdominal muscles

b. Decrease in ligamentous tensile

strength.

c. Hyper mobility of joints due to

ligamentous laxity.

d. Pelvic floor drops as much as 2.5 cm.

 Mechanical changes.

a. COG shifts upwards & forwards.

b. posture –
*shoulder girdle becomes rounded,
*scapular protraction, upper
*limb internal rotation.
*increase in cervical lordosis.
*knee hyperextension.
*increase in lumber lordosis.
c. balance – pt. walks with wider BOS.
 Exercises in pregnancy

1. Prenatal exercises
2. Preparation for labour
3. Postnatal exercises
Prenatal Exercise:

Potential impairments of pregnancy

Development of faulty posture
Upper & lower extremities stress
Altered circulation, varicose vein LL edema
Pelvic floor stress
Abdominal muscle stretch & diastasis recti
Inadequate relaxation skills necessary for
labour & delivery
Development of musculosketal pathologies
General goals & plan for exercise
programs
GOALS PLAN OF CARE

1.Improve posture & 1.Train & strengthen

correct body mechanics postural muscle

2. Teach correct body

mechanics in all position

2.Upper & lower 2. strengthening ex. of UL &

extremities strengthening LL
3. Prepare for circulatory 3. Stockings, stretching ex.
compromise

4. Improve awareness & 4. Pelvic floor muscle

control of pelvic floor strengthen
musculature
5. Maintain abdominal muscle 5. Abd. Muscle strengthen
function & correct diastesis ex.
recti
6. Provide information about 6. Prenatal & postnatal
preg. & associated problem information

7. Improve relaxation skill 7. Relaxation tech.

General Guidelines for Exercise Instruction
Physical examination is must prior to
engaging a pt. in an Exercise Programme.

Each person should be individually evaluated

for preexisting Musculo -skeletal problems,
posture & fitness level

Exercise regularly, at least thrice a week

Avoid ballistic movements & rapid change in

directions.
include warm-up & cool down session

avoid an anaerobic pace.

strenuous activities should be avoided.

avoid prolong period of standing specially in

third trimester.
adequate caloric intake, increase to 300
kcal./day for ex. during preg. & 500 kcal./day
for ex. during lactation.

low resistance & high repetitions ex. is

recommended, avoid valsalva maneuvers.

stop ex. if any unusual symptoms occur.

Contraindications to exercise……….
1. ABSOLUTE CONTRAINDICATIONS

Preg. Induced HTN BP >140/90 mmhg.

Diagnosed heart disease IHD,RHD,CHF.
Premature rupture of membrane.
Placental abruption.
History of preterm delivery.
Recurrent miscarriage.
Persistent vaginal bleeding.
Fetal distress.
IUGR.
Incomplete cervix
Thrombophlebitis &pulmonary embolism.
Pre-eclampsia
polyhydraminos / oligohydraminos
Acute infection
2.RELATIVE CONTRAINDICATIONS
Diabetes
Anemia's or other blood disorders
Thyroid disorder
Dialated cervix
Extreme obesity / underweight
Breech presentation during third trimester
Multiple gastation
Ex. induced asthma
Peripheral vascular disease
Pain of any kind.
Suggested sequence of exercise.
General rhythmic activities to warm-up.
Gentle selective stretching
Aerobic activities for CVS conditioning
UL &LL strengthening ex.
Abdominal ex
Pelvic floor ex.
Relaxation /cool down activities
Educational information [if any] & postpartum ex.
Education.
Selected exercise techniques
Postural exercise.

Abdominal exercise

Stabilization exercise

Pelvic motion training & strengthening.

Modified UL & LL strengthening.

Perineum &adductor flexibility.

Relaxation &breathing exercise

 Posture exercise:

Includes:-

Strengthening exercise

Stretching exercise
STRETCHING EXERCISES

Upper neck extensors & scalenes

Scapular protractors, shoulder internal rotators

& levetor scapulae

Low back extensors

Hip adductors [caution do not over stretch in

women with pelvic instability]

Ankle planter flexor.

Self Scalen streching Scalens stretching by therapist
Low back extensors stretching

Manual Back Stretch

Self Back Stretching
Hip adductor stretching : -

Tailor’s Sitting Position

Strengthening Exercise .

Upper neck flexors lower neck &upper

thoracic extensors

Scapular retractors &depressor

Shoulder external rotators

Hip & knee extensors

Ankle dorsi flexors

Strengthening of Corner Press Out
External Rotators
ABDOMINAL EXERCISES: -
1. Corrective ex. for diastesis recti
Head lift
Head lift with pelvic tilt

Head Lift
2. Trunk curls
3. Leg sliding
Leg Sliding

Hook lying with posterior pelvic tilt

Maintain pelvic tilt as the feet slide along the

floor away from the body
4 Quadruped pelvic tilt ex.
Stabilization Exercises.
These ex are progression for developing
dynamic control of the pelvis &LL .
These may be performed throughout the
pregnancy & postpartum period.
caution – the women to maintain a relaxed
breathing pattern & exhale during the exertion
phase of each ex.
Alternate hip & knee extension with one leg
stationary on a mat.
Progression is alternate hip & knee extension
&flexion with both LL moving.
Pelvic floor exercises: -
Isometric ex. / kegals ex.

Pt position – any position

Instruction - to tighten the pelvic floor as if attempting to stop
urine, &hold for 3 to 5 sec.
This ex is valuable in treating leaky bladder.
Modified Upper Limb & Lower Limb Exercise.

1. Modified push ups /standing pushups

2. Hip extension
a. supine bridging
b. All four leg raising
a.

Quadruple position with posterior pelvic tilt

b.

Leg is raised only until it is in line with the

trunk
3. Modified squatting

These are used

To strengthen the hip &knee extensor.
Stretch the peroneal area.

a. Supported squatting using a chair or wall.

b. Wall slide.
PERINEUM & ADDUCTOR FLEXIBILITY
Self stretching

1. Women's position supine or side lying .

instruct to abduct the hip &pull the knees
towards the sides of her chest & hold the
position for as long as comfortable.

2. Sitting – have the women sit on a short

stool with the hips abducted & feets flat
on the floor.
RELAXATION & BREATHING EX
Relaxation & Breathing exercise.
Are given with the following objectives

1. To obtain rest during preg.

2. To help the mother regain normal health

afterwards by preventing unnecessary
fatigue

3. Most common method of relaxation is

MITCHELLS METHOD.
4. Patient position in kneeling forward on to
one’s arm on a cushion placed on a seat of
a chair.
5. In this position wt. of the fetus lies on the
anterior abdominal wall & pelvic floor relaxes
6. In this position pt. take deep diaphragmatic
breathing.
7. Other methods of relaxation are
a. mental imagery.
b. muscle setting – “Jacobson’s
Method”
 PREPERATION FOR LABOUR
A prog. of labour training consist of

1. Body awareness & labour/ positioning during

labour.

2. Relaxation during labour.

3. Breathing during labour.

4. Massage during labour.

Positioning During Labour
1st stage of labour –
In this stage uterus
anteverts

Forwards leaning
facilitates ante version

Woman should be
encouraged
To change position
during first stage of
labour
Positions attended during
1st stage are
Sitting with head
&shoulder resting on a
table.
Standing leaning against
a wall either facing or with
back support.
Stride sitting across a
chair resting the head &
arms on the back.
On all four on floor
supported by partner,
standing, resting head on
his shoulder.
 KEGALS EX. DURING 1ST STAGE OF LABOUR
These are labour inducing exercise.

In 1st half an hour –supine to sitting every 5 min.

In 2nd half an hour – do supine to sitting every 4

min.
2. POSITIONING
DURING 2ND STAGE
OF LABOUR.
Commonly used positions
are

Lithotomy

Dorsal (recumbent)

Lateral & semirecument

 RELAXATION DURING LABOUR
Once the labour begins, the of contraction of the
uterus progress.
Relaxation during contraction becomes more
demanding.
Provide the women with suggested tech. to assist
in relaxation.

1.Moral support from family members.

2.Seek comfortable position including lying on pillows,

gentle motions such as pelvic rocking.
3.Slow breathing with each contraction.

4.Visual imagery.

5. During transition there is often an urge to push . Use quick

blowing tech. using the cheeks during push.

6. Local heat/ cold application.

7. Gentle touch provides relaxation.

BREATHING DURING LABOUR
according to Williams & Booth (1985)
1st stage Transitional 2nd stage
stage
Easy Breathing to 1 or 2 deep breaths
prevent
breathing- a pushing in & out, then hold
little slower & “fairly deep making the
deeper then breathing” diaphragm “piston
usual. to move the go down” repeat
diaphragm
up &down when breath runs
together out, after a gulp of
with a sharp air.
blow out
through
relaxed lip
BREATHING & PUSHING
ask the mother to place her index finger over
epigastrium, take a breath in & feel the expansion in
this area.

fix the ribs & increase the intrathoracic pressure,

with inspiration bear down & diaphragm will then act
as a piston directed downwards towards the fundus.

place the other hand on the waist feel it expand

sideways & become aware of the forward bulging of
the lower abd.muscle & the relaxation of the pelvic
floor.”open the door for the birth of baby”
Relaxation of the jaws should explain to the
patient.

The direction of the push is downward under the

pubic bone.

Breath hold for only 6-7sec. To minimize any

adverse effect on the fetus due to a prolonged
pushing maneuver.

several pushes may be necessary during

contraction. b/w contraction sigh out, rest &
relax.
MASSAGE DURING LABOUR
It is helpful in pain relief during labour.
soothing effect of massage activates “gate
closing” mechanism at spinal level.
tissue manipulation stimulates the release of
endogeneous opiates.
massage is applied over-
1. BACK MASSAGE
2. ABDOMINAL MASSAGE
3. LEG MASSAGE
4. PERINEAL MASSAGE
 BACK MASSAGE

1. It is helpful in prolong 1st stage of labour or

when the fetus is in the occipito post. Position.

2. Back pain experienced in lumbosacral region.

3. Stationary kneading is applied slowly & deeply

to the painful area.

4. Effleurage from sacrococcygeal area up &

over the iliac creast

5. Longitudinal stocking from occiput to coccyx.

6. Kneading with clenched fist directly over the SI

joint for severe pain.
 ABDOMINAL MASSAGE
1. Pain experienced over the lower half of the
abdomen in the suprapubic region.
2. light finger stroking over the site of pain.
LEG MASSAGE
1. Occasionally labour pain may be perceived in the
thighs & cramps in the calf or foot.
2. effleurage or kneading relieve pain.
PERINEAL MASSAGE
1. It is done in 2nd stage of labour to encourage
stretching of skin & muscle to prevent tearing/
episiotomy.
EXERCISES THAT ARE NOT SAFE DURING
PREGNANCY
Bilateral SLR.
“Fire hydrant” ex.- this should be avoided by
any women who has pre existing SI joint
symptoms.
Unilateral wt. bearing activities.
Several activities that have potential for high
velocity impact may cause abdominal
trauma should be avoided.1.horse riding &
driving.
2. Heavy wt. lifting.
3. Ice skating, etc.
POSTNATAL EXERCISES
1. Ex. Can be started as soon as after delivery as
the women feels able to ex.
2. All prenatal ex. Can be performed safely in
postpartum period.
3. Before starting ex. Proper assessment of
position & consistency of the fundus of the
uterus should be done.
4. Assessment of perineum & lochia.
5. Monitoring of lower limb edema, varicosities.
6. Care & advise on breast feeding & baby care.
 POSTNATAL EXERCISES

1. Initial postnatal exercises.

2. Early postnatal ex. - Include proper positioning.

 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
EARLY POSTNATAL EX.

sitting standing

feeding
others

lying
 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 Breathing ex. Coughing
function & decrease the &huffing.
risk of pneumonia
2.Decrease incisional 2. Postnatal TENS
pain associated with support incision with
coughing hands when coughing.
3. Friction massage &
3. Prevent postsurgical scar mobilisation.
adhision formation
4.Prevent postsurgical 4.Active leg ex. ,early
vascular complication ambulation
5.Correct posture & 5.Postural instruction
protected activities of &positioning for ADL
daily living
6. Pelvic floor ex.
6. Prevent pelvic floor
dysfunction
7. Abdominal ex.
7. Develop abdominal
strength
SUGGESTED ACTIVITIES FOR THE PT. WITH A CS.
.1. Exercises
All prenatal ex. Should be done.
The women should be instructed to begin
preventive ex. As soon as possible during
recovery period.
Ankle pumping activities &early ambulation to
prevent venous stasis.
Pelvic floor ex. Kegals ex. &pelvic tilting ex.
Abdominal ex. Should be progressed more
slowly.
Deep diaphragmatic breathing
Women should wait at least 6 to 8 wk before
resuming vigrous ex.
2. COUGHING & HUFFING
huffing is a forceful outward breath using the
diaphragm rather then abdominal to push air out of
lungs.
The abdominals are pulled up &in rather then
pushed out causing decreased abdominal pressure
& less strain on the incision.
Support the incision with pillows or hands during
cuffing or huffing.& say “HA” forcefully while pulling
in abdominal muscle.
3. EX TO RELIEVE INTESTINAL GES PAINS
Abd. Massage or kneading while lying on the left
side.
Pelvic tilting ex.
4.SCAR MOBILISATION
 HIGH RISK PREGNANCY
A pregnancy that is complicated by disease or
problem that put the mother or fetus at risk for
illness or death . Condition may be preexisting be
induced by pregnancy or an abnormal
physiological reaction during preg.

The goal of medical intervention is to prevent

preterm delivery, usually through use of bed rest,
restriction of activity &medications when
appropriate.
 GOAL PLAN OF CARE
1. Decrease stiffness 1. Positioning instruction
,joint motion at available
ROM.
2. Maintain muscle length & Stretching &
bulk to improve 2.
strengthening ex. Within
circulation. limits imposed by
physician.
3. Improve proprioception
3. Movement activities for
many body parts as
4. Improve posture within possible.
available limits.
4. modified posture
5. Stress management & instruction.
enhance relaxation .
5. relaxation tech.
6. Enhance postpartem
recovery. 6. Ex instruction &home
program for postpartum
period.
 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 .
- shoulder , elbow , fing. Flex. & extn. , reach to
ceiling, arm circle.
- unilateral SLR in supine & side lying position.
- bilateral active ROM in diagonal pattern for UL &
LL
-pelvic tilt, bridging, isometrics for pelvic floor
muscle.
Sitting [may not be allowed]
- all UL joint movement in available ROM.
-cervical movement in available ROM.
4. RELAXATION TECHNIQUE
5. BED MOBILITY & TRANSFER ACTIVITIES
moving up down side to side in bed.
rolling
supine to sitting assisted by arms.
6.PREPRATION FOR LABOUR
Relaxation tech.
Modified squatting supine, sitting or side lying
with knee to chest.
Breathing
PREGNANCY INDUCED PATHOLOGY
PATOHLOGY PT MANAGEMENT
1. diastesis recti 1.Modified abdominal muscle
ex. With crossed hand
over the abdomen.
2. Lower back pain & pelvic
2.In acute condition bed rest
pain.
do’s or don’t
gentle heat & massage
pelvic tilting in croock lying
TENS if indicated
3. SI dysfunctioN 3. Modified ex. For SI pain
4. Nerve compression 4. Splinting
syndrome ice packs
- Carple tunnle syndrome elevation of the limb
TENS
- Brachial pluxus pain
- Meralgia paraesthetica
Posterior tibial nerve
-

compress
5.Circulatory problem 5. –prolonged standing
avoided
varicose vein of leg
ankle ex. ,calf stretching
vulval varicose vein
- raising foot end of standing
leg cramps should bed.
-thrombosis & deep kneading massage
- thromboembolism - stocking & breathing ex.
6. Stress incontinence 6. pelvic floor ex

7. Postural backache 7. postural correction

8. coccydynia 8. Ice packs ,heat, US,

TENS,
use of rubber ring to
relieve pressure in
sitting.
Sitting posture in coccydynia
PHYSIOTHERAPY IN GYNAECOLOGICAL
CONDITIONS
 INDICATIONS PT MANAGEMENT
1. INFECTIONS 1. in acute phase
-vulvitis -chemtherapy.
-vaginitis in chronic phase
- cervicitis pulsed or cont SWD
- salphingitis
- PID
2. CYST & NEW GROWTH 2. pulsed SWD /US for
softning of painful abd.
adhesion.
3..STRESS INCONTINENCE 3. pelvic floor ex.
4.GENITAL PROLAPSE 4. pelvic floor strength
-cystocele, urethrocele, - ening ex.
-rectocele, enterocele,
- uterine prolapse
5. MENSTRUAL DISORDER 5. primary type
-primary / spasmodic type pain coping strategies
- sec. /congestive

- dysmennoria relaxation & breathing

tech. & TENS
6. BACKACHE & ABD. 6. TENS
PAIN
THANKS
What Is Female Athlete Triad
 Sports and exercise are part of a balanced,
healthy lifestyle. People who play sports are
healthier; get better grades; are less likely to
experience depression; and use alcohol,
cigarettes, and drugs less frequently than
people who aren't athletes.
 But for some girls, not balancing the needs
of their bodies and their sports can have
major consequences
 Some girls who play sports or exercise
intensely are at risk for a problem called
female athlete triad.
 Female athlete triad is a combination of
three conditions:
1. disordered eating,
2. amenorrhea,
3. osteoporosis.
 A female athlete can have one, two, or all
three parts of the triad.
Female athlete triad
Disordered Eating

 Includes a wide spectrum of unhealthy eating

behaviors
 Skipping meals or limiting calorie intake
 Restricting certain foods such as those high in fat or
protein
 Diet pills, laxatives, diuretics
1. Anorexia nervosa
2. bulimia nervosa
Disordered Eating

 May be intentional or unintentional

 Lose a few pounds before an event
 failing to balance energy expenditures with adequate energy intake”
Amenorrhea

 Primary amenorrhea
 Absence of menstruation by age 16 in a girl with secondary sex
characteristics

 Secondary amenorrhea
 Absence of 3 or more consecutive menstrual cycles in a girl who has begun
menstruating

 Amenorrhea associated with exercise is hypothalamic in origin

Etiology

 In the 1970’s low body weight or low body fat was thought to
be the primary cause of amenorrhea
 Exercise-stress hypothesis
 Deficit in energy availability
Hypothalamic Dysfunction

 Disruption of
hypothalamic-pituitary-
ovarian axis
 Decrease in pulsatile GnRH
disrupts pituitary secretion
of LH and FSH
 Disruption of LH and FSH
pulsatility shuts down
stimulation to the ovary,
ceasing production of
estradiol
Prevalence

 Prevalence of secondary amenorrhea in adult female athletes

reported at 3-66% compared to 2-5% of the general population

 Only 3 studies have examined all 3 disorders using direct measures

of BMD in female athletes (DEXA)
 These studies indicate that the number of athletes with all 3 disorders
simultaneously is relatively small however the number of athletes with
disordered eating and menstrual dysfunction was large enough to warrant
concern
 What causes hypothalamic
dysfunction?

 Deficit in energy availability

Energy Availability

 Definition
 Dietary energy intake minus exercise energy expenditure OR
 The amount of dietary energy remaining after exercise training to support
physiological processes

 Energy balance
 Occurs in young adults at an energy availability of 45 kcal per kilogram of
fat-free mass per day (kcal/kg FFM daily)
 In exercising women, LH pulsatility is disrupted below 30 kcal/kg FFM per
day
Energy Availability
 Energy availability-hypothalamic
dysfunction
 Mechanism by which a deficit in energy
availability disrupts GnRH is currently
unknown but research suggests plasma
glucose plays a role via glucose-sensing
neurons in the brain
 Glucoregulatory hormones do not
maintain normal plasma glucose
concentrations below energy
availability of 30 kcal/kg FFM per day
Energy Availability

 The bone connection

 Estrogen suppresses osteoclast activity so bone loss in amenorrheic
women was originally attributed to hypoestrogenism
 However, estrogen replacement has not fully restored bone density in
clinical trials
 Low energy availability may have a direct effect on bone
Energy Availability

 “Do athletes need to take special care to avoid low energy

availability?”
 Food deprivation increases hunger however the same deficit produced by
exercise energy expenditure does not
 Hunger appears to be mediated by oral and GI rather than metabolic
mechanisms
 Appetite is NOT a reliable indicator of energy requirements
 Athletes must learn to eat by discipline not by appetite
Menstrual Dysfunction

 Despite differences, menstrual dysfunction is more prevalent .

 Menstrual dysfunction is NOT a normal part of training!

Osteoporosis

 “Disease characterized by low bone mass and microarchitectural

deterioration of bone tissue leading to enhanced skeletal fragility and
increased risk of fracture”

 Principal cause of premenopausal osteoporosis in active women is decreased

ovarian hormone production and hypoestrogenemia

 Athletes may be at risk for fractures during their competitive years and
premature osteoporotic fractures in the future
Who is at Risk?

 “Potentially all physically active girls and women could

be at risk for developing one or more components of the
Triad”

 Sports that emphasize low body weight

 Subjective scoring of performance (figure skating)
 Endurance sports (distance running)
 Body contour-revealing clothing (track, cheerleading)
 Weight categories (wrestling, horse racing)
 Emphasis on prepubertal body habitus (gymnastics)

 Male athletes are also at risk for disordered eating and

anorexia nervosa
figure skating
distance running
cheerleading
wrestling
Gymnastics
IMPORTANT FACTORS
1. Alone or in combination, Female Athlete Triad disorders can decrease
physical performance and cause morbidity and mortality

2. Internal and external pressures placed on girls to achieve unrealistically low

body weight underlies development of these disorders

3. Sports medicine professionals need to be able to recognize, diagnose, and

treat or refer women with any component
4. Women with one component should be screened for the others
• Screening for the Triad can be done at the preparticipation exam or during clinical
evaluation of any associated complaint

5. All sports medicine professionals including coaches and trainers should learn about
preventing and recognizing the Triad
• Should not pressure girls to lose weight and should know basic nutrition information
• Have referral sources for nutritional counseling and medical and mental health evaluation

6. Parents should not pressure their daughters to be thin and should be educated about
Triad warning signs
7. Sports medicine professionals, athletic administrators, officials of sport
governing bodies share a responsibility to prevent, recognize and treat the
Triad
• Support development of educational programs

8. Physically active girls and women should be educated about proper nutrition,
safe training practices, and warning signs of the Triad

9. Further research is needed into the prevalence, causes, prevention,

treatment, and sequelae of the Triad
Bone Health

 Spectrum of bone health

 Low bone mass
 Stress fractures
 Osteoporosis
 Bone strength is characterized by bone mineral content and
density as well as quality of bone
 Bone quality refers to the process of bone turnover
Diagnosis of low bone mass and
osteoporosis in athletes
 DEXA is currently the most accepted diagnostic tool
Bone Health

 Female athletes have higher BMD than nonathletic counterparts UNLESS

they have menstrual dysfunction
 Bone density declines in proportion to the number of menstrual cycles missed
 Myburgh and colleagues showed a direct correlation between time spent
amenorrheic and number of stress fractures in 1990
 Low bone mineral density may be irreversible resulting in a lifetime lower
bone density
 Risk of stress fractures is two-four fold higher in athletes with menstrual
disturbances compared to those without
Bone Health

 Females gain more than 50% of

skeletal mass during adolescence
and reach peak bone mass between
18 and 25 years of age
 Young women menstrual
dysfunction during these years are
at risk for losing 2% of bone mass
annually instead of gaining 2-4%
Evaluation

 History and physical

 Vital signs
 Thyroid
 Signs of virilism
 Visual fields and cranial nerves
 Pelvic exam
Laboratory Evaluation

 CBC, ESR,
 EKG and/or echocardiogram if abnormal cardiac exam
 TSH
 LH, FSH to rule out premature ovarian failure
 Prolactin to rule out pituitary tumor
 Consider imaging
 If hirsutism, free testosterone, 17-hydroxy-progesterone to screen for adrenal
or ovarian tumors
Bone Density

 Bone density
 Consider DEXA for the
following: (ABD)
 Amenorrheic > one year
 BMI < 18
 Documented history of stress
fracture
Warning Signs
 Food restriction  Constipation
 Chronic dieting  Chronic diarrhea
 Skipping meals  Frequent weight
 Fasting fluctuations
 Laxative use  Fatigue
 Diet pill use  Muscle weakness
 Obsessive training  Muscle cramps
 Low self-esteem  Dehydration
 Dry skin and hair  Delayed puberty
 Frequent restroom
visits after meals
Treatment Goal

 Restore reproductive and metabolic hormones by increasing

energy availability
 Increase energy intake
 Reduce energy expenditure
 Weight gain of 1-2 kilograms (or 2-3%) or 10% decrease in exercise load
in either duration or intensity is often sufficient to reverse reproductive
dysfunction!
Treatment is Multidisciplinary
 Behavioral change
 Nutritional interventions: development of personalized nutrition plan
 Exercise interventions: exercise prescription or recommendations
 Example: one day off each week
 Supplements recommended
 Calcium 1500 mg daily, vitamin D 400-800 IU daily
 Psychological
 Cognitive behavioral therapy has been shown to be most efficacious therapy for eating
disorders
 Treatment for depression if present
Hormone Therapy

 In women who have not responded to non-pharmacological

treatment, initiate therapy with low-dose oral contraceptive to
raise estrogen concentrations and prevent further bone loss

 Minimal bone increases have been noted in women with

hypothalamic amenorrhea on oral contraceptives but increases in
BMD of 6-17% have been seen with spontaneous reversal of
amenorrhea
PREVENTION!

 Educational programs targeting coaches, athletes, parents,

athletic trainers, school administrators
 Currently there is a lack of such programs

 Nutrition education
 Emphasis should be placed on concept of food as energy for training and
recovery rather than on body weight
 ACSM and American Dietetic Association published a joint position
statement entitled “Nutrition and Athletic Performance” in 2000
Physician Knowledge

 240 health care professionals (physicians, medical students, physical

therapists, athletic trainers and coaches) were surveyed to
determine their knowledge and comfort in treating the condition

 Results
 48% of physicians, 43% of therapists, 38% of trainers, 32% of medical
students and 8% of coaches could identify all 3 components
 When divided into specialties, 69% of PM&R physicians, 63% of
orthopedic surgeons, 53% of family physicians, 36% of pediatricians, 17%
of gynecologists identified all 3 components
 Only 9% of physicians felt comfortable treating the disorder

 Conclusion: While recognition of the Triad has increased

significantly, knowledge of treatment is still lacking among
physicians and medical personnel
The End

Thanks

ASK???
BREAST CANCER & LYMPH OEDEMA
 Structure and Function
of the Lymphatic System
• The primary function of the lymphatic system is to collect
and transport fluid from the interstitial spaces back to the
venous circulation
• This is accomplished with a series of lymph vessels and
lymph nodes.
• The lymphatic system also has a role in the body’s immune
function
• When the lymphatic system is compromised either by
impairment of lymphatic structures or by an overload of
lymphatic fluid, the result is swelling in the tissue spaces.
• Edema is a natural consequence of trauma to and
subsequent healing of soft tissues. If the lymphatic system
is compromised and does not function efficiently,
lymphedema develops and impedes wound healing.
• Lymph edema is an excessive and persistent accumulation of
extravascular and extracellular fluid and proteins in tissue
spaces
• It occurs when lymph volume exceeds the capacity of the
lymph transport system, and it is associated with a
disturbance of the water and protein balance across the
capillary membrane. An increased concentration of proteins
draws larger amounts of water into interstitial spaces, leading
to lymphe dema.
• Furthermore, many disorders of the cardiopulmonary system
can cause the load on lymphatic vessels to exceed their
transport capacity and subsequently cause lymph edema.
 Anatomy of the Lymphatic System
• The lymphatic system is an open system.
• The lymphatic capillaries are situated close to the blood capillaries
and are responsible for pulling the fluid into the lymphatic
circulation
• Once inside the lymphatic vessels, the fluid is transported from
lymph nodes to lymphatic trunks.
• The end result is the collection of the lymphatic fluid at the venous
angles.
• In total, the body has 600 to 700 lymph nodes with the largest
grouping found in the head and neck, around the intestines, and in
the axilla and groin.
 Physiology of the Lymphatic System
• The main components of lymphatic fluid are water and protein found in the extracellular
spaces.
• In a normal state, the lymphatic system transports this fluid back to the venous circulation.
• The amount of fluid transported is the lymphatic load, and the amount of fluid the
lymphatic system can transport is the transport capacity.
• When the balance in the interstitium is disrupted, whether by an increased lymphatic load
or a decreased transport capacity, lymphedema can develop.
• Lymphatic load is increased when the venous system is unable to transport the required
amount of fluid, which can occur in a patient with a venous insufficiency.
• Transport capacity is affected when the structures of the lymphatic system are impaired,
for example, following surgery to remove lymph nodes in a patient with cancer.
 Types of Lymph edema
• Lymph edema can be classified as primary, meaning there is an
inherent problem with the structures of the lymphatic system, or
secondary, meaning there is an injury to lymphatic structures.
• This injury may be in the form of surgery, radiation, trauma, or
infection.
• Lymphedema can also be caused by a combination of lymphatic-
venous dysfunction commonly seen in patients with chronic
venous insufficiency.
• Remember, lymphedema is not a disease but rather a symptom of
a malfunctioning lymphatic system.
 Primary Lymph edema
• Primary lymphedema, although uncommon, is the result of
insufficient development (dysplasia) and congenital
malformation of the lymphatic system.
• Primary lymphedema can be divided into the age of
presentation
■ Congenital: presents at birth and is sometimes known as
Milroy’s disease
■ Praecox (early): develops prior to 35 years of age
■ Tarda: develops after 35 years of age
• Primary lymphedema typically affects more females than
males and presents more often in the extremities, more so in
the lower than upper extremities
 Secondary Lymphedema
• Most of the patients seen by healthcare practitioners for management of
lymphedema have secondary lymphedema
• By far, the most common causes of secondary lymphedema are related to
the comprehensive management of cancers of the breast, pelvis, and
abdomen.
• Secondary lymphedema is classified by the cause of the injury to the
lymphatic structures including:
■ Surgery
■ Inflammation and infection
■ Obstruction or fibrosis
■ Combined venous-lymphatic dysfunction (chronic venous insufficiency)
Clinical Manifestations of Lymphatic
Disorders
 Clinical Manifestations of Lymphatic
Disorders
• Lymph edema
• Location. When lymph edema develops, it is most often apparent in
the distal extremities, particularly over the dorsum of the foot or
hand.
• The term dependent edema describes the accumulation of fluids in
the peripheral aspects of the limbs, particularly when the distal
segments are lower than the heart.
• In contrast, lymphedema can manifest more centrally, for example,
in the axilla, groin, or even the trunk.
• Thorough assessment of the entire limb and regional area is
important to define the extent of swelling.
• Severity.
• The severity of lymph edema may be described quantitatively
or qualitatively.
• Lymph edema is described by the severity of changes that
occur in skin and subcutaneous tissues. The three categories—
pitting, brawny, and weeping edema
 Increased Size of the Limb
• As the volume of interstitial fluid in the limb increases, so does
the size of the limb (weight and girth).
• Increased volume, in turn, causes tautness of the skin and
susceptibility to skin breakdown.
• Descriptors, such as mild, moderate, and severe, sometimes
are based on how much larger the size of the edematous limb
is compared to the non involved limb
• However, there are no standard definitions associated with
size and severity
 Sensory Disturbance
• Paresthesia (tingling, itching, or numbness) or occasionally a
mild, aching pain may be felt, particularly in the fingers or toes.
• In many instances the condition is painless, and the patient
perceives only a sense of heaviness of the limb.
• Fine finger coordination also may be impaired as the result of
the sensory disturbances.
 Stiffness and Limited Range of Motion
• Range of motion (ROM) decreases in the fingers and wrist or
toes and ankle or even in the more proximal joints, leading to
decreased functional mobility of the involved segments
 Decreased Resistance to Infection
• Wound healing is delayed; and frequent infections
(e.g.,cellulitis) may occur.
• Early recognition and treatment of cellulitis has shown to be
important in reducing further tissue damage.
Examination and Evaluation
of Lymphatic Function
 History and Systems Review
• Note any history of infection, trauma, surgery, or radiation
therapy. If a patient has a history of cancer and received
chemotherapy, a review of the treatment and duration of the
chemotherapy treatment is also important.
• The onset and duration of lymphedema, delayed wound healing,
or previous treatment of lymphedema are pertinent pieces of
information.
• Identify the occupation or daily activities of the patient,
• and determine if long periods of standing or sitting are required.
Specific questioning to determine a pattern to the swelling can also
aid in treatment planning
 Examination of Skin Integrity
• Visual inspection and palpation of the skin provide
information bout the integrity of the skin. The location of the
edema should be noted.
• When the limb is in a dependent position, palpate the skin to
determine the type and severity of lymph edema and changes
in skin and subcutaneous tissues.
• Describe the thickness and density of the tissue in each area of
the limb.
• Areas of pitting, brawny, or weeping edema should be noted.
 Stemmer sign
• A positive Stemmer sign, an
indication of Stage II or III
lymphedema, may be identified
during palpation
• It is considered positive if the
skin on the dorsal surface of the
fingers or toes cannot be
pinched or is difficult to pinch
compared with the uninvolved
limb.
• A positiveStemmer sign can be
indicative of a worsening
condition
 Girth Measurements
• Circumferential measurements of the involved limb should be
taken and compared with the noninvolved limb if the problem
is unilateral.
• Identify specific intervals or landmarks at which
measurements are taken so measurements during subsequent
examinations are reliable.
• Use of circumferential measurements at anatomical landmarks
has been shown to be a valid and reliable method of
calculating limb volume
 Volumetric Measurements
• An alternative method of measuring limb size is to immerse
the limb in a tank of water to a predetermined anatomical
landmark and measure the volume of water displaced.
• Although this method also has been shown to be valid and
reliable, for routine clinical use, it is more cumbersome and
less practical than girth measurements.
Management of Lymph edema
Comprehensive Regimens and Components
• Decongestive lymphatic therapy.
• Treatment typically is divided
into two phases. Phase I is the
intensive treatment phase;
Phase II is the maintenance
phase. The goal of Phase I
treatment is reduction, whereas
the goal of Phase II treatment is
longterm management.
 Manual lymphatic drainage
• Manual lymphatic drainage (MLD) involves slow, very light
repetitive stroking and circular massage movements done in a
specific sequence with the involved extremity elevated
whenever possible
Breast Cancer-Related
Lymphatic Dysfunction
• Current treatment for breast cancer involves a multimodality
approach.
• Surgery, chemotherapy or hormonal therapy, and radiation
may be employed
• Axillary dissection and removal of lymph nodes interrupt and
slow the circulation of lymph, which in turn can lead to
lymphedema
• Radiation therapy can cause fibrosis of tissues in the area of
the axilla, which obstructs the lymphatic vessels and
contributes to pooling of lymph in the arm and hand
 Surgical Procedures
• Surgical treatment of breast cancer falls into two broad
categories—mastectomy and breast-conserving surgery
 Mastectomy
• Mastectomy involves removing the entire breast.
• In addition, a mastectomy may involve removing the fascia
over the chest muscle.
• With late-stage, invasive disease, a radical mastectomy in
which the pectoralis muscles also are excised may be required,
leading to significant muscle weakness and impaired shoulder
function.
 Breast-Conserving Surgery
• Options for resecting the tumor and preserving a portion of
the breast include lumpectomy, which involves excision of the
mass and a margin of healthy surrounding breast tissue, or
• segmental mastectomy (also known as quadrectomy), which is
excision of the affected quadrant of the breast.
• Rather than mastectomy, these procedures are being used
increasingly in combination with adjuvant therapy for patients
with stage I or II tumors.
Managements guidelines
Thank you