Physiotherapy in Obstetrics and Gynaecology 2nd Edition
Physiotherapy in Obstetrics and Gynaecology 2nd Edition
Physiotherapy in Obstetrics and Gynaecology 2nd Edition
Note
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Dedication
This second edition of Physiotherapy in Obstetrics and Gynaecology is dedicated to the memory of Margaret
Polden, co-author of the first edition, who tragically died in 1998 just as work on this second edition
began.
Margie was renowned internationally for her passion for the promotion of the health and well-being
of women, for her clinical excellence, particularly in the obstetric field, and for her easy style of writing.
The Council of the Chartered Society of Physiotherapy formally recognised this by awarding her the first
posthumous Fellowship in 1999.
Through the first edition of Physiotherapy in Obstetrics and Gynaecology the essential essence of Margie’s
knowledge, wisdom and experience was made available to physiotherapists internationally. The
contributors to this second edition all knew Margie and were influenced by her. They have sought to
revise the text in the light of contemporary evidence, as Margie would have wished, and they offer this
volume as a tribute to her – a true friend, colleague and outstanding human being.
Contributors
Sue Barton MSc DipEd MCSP DipTP DipRG&RT Jill Mantle BA FCSP DipTP
DipTHRF SRP Senior Visiting Fellow, University of East London,
Health Senior Lecturer, School of Health Studies, London, England, UK
University of Bradford, England, UK
Pauline Walsh MCSP SRP
Teresa Cook GradDipPhys MCSP SRP Clinical Specialist Physiotherapist in Obstetrics and
Clinical Specialist, Physiotherapist in Women’s Gynaecology, Mount Alvernia Hospital, Guildford,
Health, James Paget Hospital, Great Yarmouth, Surrey, England, UK; Royal Surrey County Hospital
Norfolk, England, UK NHS Trust, Guildford, Surrey, England, UK
Jo Fordyce GradDipPhys MCSP SRP
Clinical Specialist, Physiotherapist in Women’s
Health, St George’s Hospital, London, England, UK
Jeanette Haslam MPhil GradDipPhys MCSP SRP
Senior Visiting Fellow, University of East London,
London, England, UK
ix
Since 1995 it has been a great pleasure, privilege family is complete and she is fit and willing to
and honour to serve as the President of the undergo surgical intervention.
Association of Chartered Physiotherapists in All women with lower urinary tract problems
Women’s Health (ACPWH). This has enabled me to and pelvic organ prolapse benefit from the advice
attend council meetings as well as the Annual of a physiotherapist who can not only provide the
Meeting of the Association on several occasions. appropriate exercises to strengthen the pelvic floor
The ACPWH is an active, enthusiastic group of spe- but can advise on life style interventions in order to
cialist physiotherapists who promote the impor- improve symptoms and help individual women to
tance of physiotherapy in all aspects of obstetrics lead a normal lifestyle. Unfortunately, at present,
and gynaecology. there are not enough physiotherapists trained in
It is well recognised that antenatal education women’s health to take care of the needs of all those
facilitates easier childbirth and a faster return to women who would benefit from such advice and
‘normal’ in the post partum period. However treatment.
many under estimate the value of physiotherapy The second edition of Physiotherapy in Obstetrics
throughout a woman’s life in the promotion of and Gynaecology is an excellent book written by
good health by preventing or ameliorating a wide dedicated women’s health physiotherapists specifi-
range of physical problems. For example urinary cally for physiotherapists. However it will also be
incontinence and pelvic organ prolapse are exceed- of use to all midwives, health visitors, obstetricians
ingly common with a life-time risk of approxi- and gynaecologists and others who are involved in
mately 11% requiring surgery for one or other of the care of women before, during and after preg-
these conditions, a third of whom will require nancy and who share the management of women
re-operation. Thus a huge proportion of the adult with the common sequelae of childbearing. The
female population suffer from symptoms which, text has been written in an ‘easy to read’ style and is
although not life threatening, undoubtedly signifi- well referenced and will, I am sure, be used as a ref-
cantly impair quality of life and lead to embarrass- erence book for many of us dealing with problems
ment and inability to perform routine activities of related to women’s health. I am sure that this book
daily living. Approximately two thirds of women will continue to be the authoritative work on the
with urinary incontinence will benefit from physio- subject until the third edition of Physiotherapy in
therapy and, whilst this may not provide a com- Obstetrics and Gynaecology is published!
plete cure, it is likely to avoid or defer the need for
surgery until a suitable time e.g. when a woman’s Linda Cardozo, 2004
xi
The physiotherapist has been an important member On a personal note I am happy to say that
of the maternity team for years, in fact since at least throughout my professional life in obstetrics and
1912. Then, the physiotherapist Minnie Randall gynaecology I was always conscious of the contri-
together with the obstetrician J. S. Fairbairn at St. bution physiotherapists could bring to our work.
Thomas’ Hospital developed special interests in I was privileged to know and to work with Helen
the management of pregnancy, labour and the puer- Heardman who did so much to promote prepar-
perium. Later the scope was extended to gynaeco- ation for childbirth and the relief of discomfort.
logical cases. The obstetric physiotherapist was always a valued
Out of this has grown the Association of member of the team attending teaching rounds and
Chartered Physiotherapists in Obstetrics and of course conducting antenatal classes for mothers,
Gynaecology. Its special contribution was recog- and fathers. They have a special role which cannot
nised in the joint statement by the Royal College of be properly undertaken by others not trained in
Midwives, the Health Visitors’ Association and their methods.
the Chartered Society of Physiotherapy. I am therefore very glad to welcome this
This recognition makes this new book espe- book with all the care and effort that has gone into
cially timely. The training of a physiotherapist its production, not least in the excellent illustr-
does not necessarily include the role in obstetrics ations and the bibliography which follows each
and gynaecology. The book is a definitive state- chapter and which makes it an excellent work of
ment. It therefore includes chapters on all aspects reference.
of the physiotherapist’s role in obstetrics and The book has a scope and interest far beyond its
gynaecology, from the basic sciences through to authors’ intention.
incontinence, a symptom which causes great dis-
tress and restriction of life to so many women and Dame Josephine Barnes, 1990
one which can so often be helped by the skills of
the physiotherapist.
xiii
It gave Margie and me great pleasure to receive aware of progressions in knowledge, so once again
many assurances from colleagues that our ‘off- we set to work in Margie’s kitchen. Receiving the
spring’ was proving useful. As we travelled the news of Margie’s tragic and untimely death on
world we were encouraged by the sight of well- Monday the 16th March 1998 is etched into the
thumbed copies in departments and libraries, and memory bank of many. All writing ceased and the
we heard our book referred to as ‘the bible’ more second edition went on hold. It has been gradually
than once. resurrected with encouragement from Margie’s
When in 1994 the publishers first mooted the husband, Martin and the family, and from col-
desirability of a second edition, we were exercised leagues. It has only been actually realised with an
as to what to recommend and advise, especially enormous amount of help from colleagues, in par-
with respect to physiotherapy in obstetrics. The ticular Jeanette Haslam, Sue Barton, Jo Fordyce,
publication in 1993 by the Department of Health Pauline Walsh, Teresa Cook, Elizabeth Crothers,
(DoH) of the report of the Expert Maternity Group, Morag Thow, Margaret Brownlee, and Deborah Fry,
entitled Changing childbirth, was followed by a very but also there are many others who responded to
unsettled period within the UK Maternity Services our queries. To all these people I offer my heartfelt
as a variety of new service models were tried. We thanks. May this edition enable the memory of
were dismayed by the absence of any mention Margie to continue to inspire colleagues to holistic,
within the report of the obstetric physiotherapist up-to-date best practice in this specialty.
and, in the light of an acute shortage of midwives,
we considered the emphasis upon each pregnant Jill Mantle London, 2004
woman having a named midwife to support her
throughout each entire childbearing episode to be
unrealistic.
By 1997, publisher pressure mounted, the book Reference
was still selling well but Butterworth Heinemann DoH 1993 Changing childbirth, Part 1 Report of the Expert
wanted an upgrade and we were increasingly Maternity Group. HMSO, London.
xv
This book was conceived in a coach travelling our offspring will be received. We very much hope
between Bristol and Bath, and the first cell divisions that it will prove to be a useful and valued contri-
occurred in the humid atmosphere of the Roman bution to society.
Baths and the Regency Pump Room. Implantation We would like to thank all those who gave their
of the developing morula took place in the offices of time so freely to answer the numerous queries that
Heinemann Medical Books, then in London, and arose in our efforts to make sure that information
the pregnancy was subsequently confirmed. in the book is accurate and up to date; our thanks
The gestation proved to be much longer than also to Shona Grant, our illustrator, for her patience,
originally anticipated. About the length of two ele- Ricky Hoole, Margaret Nokes and Sarah Polden,
phant’s pregnancies, and a period we will certainly our long-suffering typists, and most particularly,
never forget! The physical stresses – writer’s our dear husbands who have endured our raised
cramp, aching bottoms and backs – have been catecholamine levels over an extended period.
great, but in no way did they approach the psycho- They have suffered, like many pregnant fathers,
logical and emotional traumas to ourselves and our and are undoubtedly hoping that life will now ‘get
nearest and dearest. We have used every known back to normal’ – whatever that might mean.
coping strategy and invented several more to cope
with the labour necessary to give birth. Margaret Polden, Jill Mantle London, 1990
Now in the postpartum period, we are, like all
new mothers, relieved but apprehensive as to how
xvii
Introduction
Jill Mantle
At the start of a new edition, it is inspiring to should not be confused with those of ‘ill repute’,
review briefly the history of physiotherapists’ she became one of the founding members of the
involvement in obstetrics and gynaecology. It is Society of Masseuses and in 1895 became its first
also prudent to take stock of relevant changes in Chairman of Council. Over the years the group
policy and practice within society and the National prospered, extended its focus to include remedial
Health Service since the publication of the first edi- exercise and electrotherapy, and developed into
tion, and to reconsider the purpose of this book the Chartered Society of Physiotherapy (CSP).
and the important issues for physiotherapists in Dame Rosalind held membership number one.
the specialty now. Early in the twentieth century, Miss Minnie
In the late nineteenth century the physiother- Randell OBE, a sister at St Thomas’s Hospital
apy, nursing and midwifery professions shared a London, had also trained both as a nurse and a
common rootstock. In the UK, educating more midwife. She became interested in both the mas-
than just a few privileged women was a new phil- sage and the remedial exercises being propounded
osophy, and formal and accredited training for by the Swede, Per Henrik Ling. She was appointed
occupations thought suitable for women, such as as Sister-in-Charge and then Principal of the
nursing and midwifery, was at best elementary. In School of Massage and Medical Gymnastics at St
addition, professional bodies were only just being Thomas’ Hospital. In 1912, J. S. Fairbairn, a lead-
formed. Women who wanted to work outside the ing consultant obstetrician at St Thomas’ who
home and were inclined to care for people took believed in ‘preventive obstetrics’, asked Miss
whatever training was offered, first in one aspect Randell to devise a system of ‘bed exercises’ for
of caring, then in another. his postnatal mothers. Because newly delivered
In 1886, Dame Rosalind Paget, a nursing sister women remained in bed for about 3 weeks at that
at the London Hospital who was also a midwife, time, many problems that are rarely seen today
joined the Midwives Institute, which later became were rife. The exercises were designed to aid post-
the Royal College of Midwives (RCM). In 1902 she natal physical recovery and to train women to rest
was involved in the formation of the Central through relaxation. Thus Miss Randell was one of
Midwives Board and appears as number two on the first to bring the principles of physiotherapy to
their list of members. Also in 1886 Dame Rosalind obstetrics. Later, Miss Randell turned her atten-
became interested in a new therapy – Swedish tion to antenatal instruction, once again urged on
massage. She, and others like her, underwent by Mr Fairbairn, who thought that more should
training and then returned to their hospitals to be done preventatively to help pregnant women
teach the techniques to their colleagues. However, (Fairbairn 1923). She was greatly influenced by Dr
through her insistence on high standards and her Kathleen Vaughan who had noticed, while work-
anxiety that properly trained, reputable masseuses ing in Kashmir, that women who had a sedentary,
xviii INTRODUCTION
confined and inactive lifestyle frequently had more It was another physiotherapist, Helen Heardman,
difficult labours and deliveries than the boat- who in the 1940s drew together the threads of
women and peasants who led much more active relaxation, breathing and education for childbirth
lives. Dr Vaughan believed that heredity was not into antenatal preparatory courses for labour and
the only factor that determined the shape of the parenthood (Heardman 1948). Before her tragic
pelvis and the mobility of its joints and those of the death in 1949, she was instrumental in gathering
lower spine – the way women used their bodies in together the group of like-minded physiothera-
their everyday lives was also an important influ- pists from around the UK who formed the
ence. Apart from incorporating squatting into her Obstetric Physiotherapist’s Association in 1948. It
antenatal programme as a preparation for labour, was one of the first special interest groups of the
Miss Randell introduced many of the pelvic- and CSP, and in 1961 became the Obstetric Association
lumbar-spine-mobilising exercises which were of Chartered Physiotherapists. Antenatal classes
based on the movements made by Kashmiri boat- mushroomed through the 1950s, often taken
women, and encouraged women to adopt different entirely by so called ‘obstetric physiotherapists’,
positions of comfort in labour. and women were routinely offered postnatal exer-
In 1936 Heinemann published a book entitled cise sessions and advice postnatally during their
Maternity and Postoperative Exercises; written by 5–7-day hospital stay. Midwives were invited to
Margaret Morris, an ex-ballet dancer, who had been contribute and gradually have become the domi-
one of Miss Rendell’s students. It is of interest that, nant profession in this aspect of care.
in it, women in the puerperium were encouraged to In the 50 and more years since then, much has
practise repeated ‘pelvic floor tensing’, trying ‘to changed in obstetric physiotherapy, midwifery and
invert the sphincters … until it becomes habitual’; it obstetrics, and many dedicated physiotherapists
was recommended that this be performed to the have added their expertise to the specialty. In 1963
strains of Schubert’s waltzes 16, no. 2 (Morris 1936). Laura Mitchell introduced her method of relaxation,
In her book, Fearless Childbirth published by which has been used extensively ever since. In 1977
Churchill in 1948, Minnie Randell explained that Dorothy Mandelstam was invited to be the first non-
the purpose of the tensing was to prevent and treat medical member of the International Continence
symptoms of urine leakage and prolapse (Randell Society and her name will always be associated with
1948). It is important to appreciate that in the early the ending of the taboo on incontinence. Together
part of the twentieth century far fewer books were with Shelia Harrison, she worked tirelessly through
published than today and women authors were the 1970s to encourage OACP members to expand
rare. Yet these pioneers started a tradition that has the field to include gynaecology and the treatment
continued, and has promoted and enriched the spe- of incontinence. In 1978 the Association adopted the
cialty down the years. title of the Association of Chartered Physiothera-
In the 1930s Dr Grantly Dick-Read was a further pists in Obstetrics and Gynaecology (ACPOG). In
notable source of influence on Miss Randell with the late 1980s there was further international pres-
his theory of the fear–tension–pain cycle in labour. sure to think holistically of women’s health issues,
Fearful women who expected to feel pain became which led to another change of title in 1994 to
tense as labour began. This led to tension in their the Association of Chartered Physiotherapists in
minds and, according to Grantly Dick-Read, in Women’s Health (ACPWH) and to physiotherapists
their cervices too. This, he claimed, gave rise to employed in the field being called ‘women’s health
more pain, which in turn increased their fear. He physiotherapists’.
encouraged his labouring mothers to relax and The Association is one of the largest clinical
breathe deeply through their contractions, a system interest groups in the CSP and, down the years, it
which Miss Randell built into her antenatal classes. has played the lead role in developing postregis-
In the late 1930s, Margaret Morris, suggested to tration courses for physiotherapists wishing to
Miss Randell that women should actually rehearse specialise in the field. It is regrettable that, despite
labour antenatally in the same way that dancers the fact that half the UK population is female and
rehearse for a performance. childbearing is the norm for the majority, the basic
Introduction xix
physiotherapy training contains very little specific statement, negotiated by ACPOG with the RCM
material to prepare physiotherapists to assist and the HVA, and endorsed by the CSP in March
women in pregnancy and the puerperium. Neither 1987, and further confirmed in 1994, entitled
does it enable them to take informed account of Working Together in Psychophysical Preparation for
the effects of childbearing when treating patients Childbirth. This statement was endorsed by the CSP
with pathologies. There is also a deficit in basic at its Council meeting on 11 March 1987. It was
training regarding the promotion of continence revised in 1994 and is published by CSP as
and the treatment of incontinence. This is largely Information paper no. PA13:
due to the fact that obstetric, gynaecological and
Midwives, Health Visitors and Obstetric Physio-
urogynaecological placements for students are
therapists all have important specialist contribu-
optional and there are very few university staff
tions to make in preparation for childbirth and
with expert knowledge of these areas. It is also
parenthood. This contact with parents also pro-
true that few physiotherapy managers have in-
vides a valuable opportunity for more general
depth specialist knowledge or experience of the
health promotion, health education and preven-
specialty. Consequently it has fallen to the specific
tative medicine. In the delivery of such a service
interest group to provide appropriate training and
in a locality, it is important that the professional
this responsibility it has faithfully discharged for
team demonstrates a flexible approach and takes
more than half a century, often with tutors giving
account of the views and needs of all parents.
their time gratis. Today there are courses accred-
ited and run by universities and shorter courses
organised by ACPWH and by individuals – see The midwife
contact details at the end of the chapter. Fortu- The role of the midwife is that of the practitioner
nately it is now more widely recognised by other of normal midwifery, caring for the woman
health professionals that specialist physiothera- within the hospital and community throughout
pists are to be preferred throughout obstetrics, the continuum of pregnancy, childbirth and the
gynaecology and urogynaecology. puerperium. She has an important contribution
This book was designed to assist the following to make in health education, counselling and
categories: support. In this context her aim is to facilitate the
realization of the woman’s needs, discuss expec-
• physiotherapy students making their first con- tations and air anxieties. She has the responsibility
tact with this field or whose training has failed
of monitoring the woman’s physical, psycho-
to include needed information
logical and social wellbeing and is in a unique
• newly qualified physiotherapists on obstetric
position to be able to correlate parent education
and gynaecological rotations
with midwifery care.
• physiotherapists embarking on relevant spe-
cialist postregistration training
The health visitor
• physiotherapists who are actively involved in
The role of the Health Visitor in this field is to offer
the specialty (as a resource book).
advice to the parents-to-be on the many health,
The Association is fortunate to count among its psychological and social implications of becoming
members, both past and present, many women parents and the development of the child. She is in
who have reached the top of their profession a very special position in the family scene to
as specialist clinicians, educators, authors and inform them of the services available and encour-
researchers. They have gained the respect, not only age them to use them. The health visitor should
of their colleagues, but also of the members of the always have a participatory role within the team
midwifery, health visitor and medical professions. to provide continuity of care to the family.
This mutual respect among individuals led ACPOG
into increasing dialogue and collaboration with the The obstetric physiotherapist
RCM and the Health Visitors’ Association (HVA). The role of the Obstetric Physiotherapist is to
The result was the publication of the following promote health throughout the childbearing
xx INTRODUCTION
period and to help the woman adjust advanta- • To ensure that appropriate, consistent and
geously to the physical and psychological changes clear advice is given with full cognisance of
of pregnancy and the post-natal period so that safety factors.
the stresses of childbearing are minimised. Ante- • To promote health and preventative medicine.
natally and post-natally she advises on physical
activity associated with both work and leisure Frequently new methods of education in parent-
and is a specialist in selecting and teaching hood are introduced e.g. aqua-natal and fitness
appropriate exercises to gain and/or maintain classes. In such instances it is necessary for guid-
fitness including pelvic floor education. Where ance to be sought on appropriate exercises from
necessary she gives specialised treatment e.g. the local obstetric physiotherapist or alternately
therapeutic ultrasound post-natally to alleviate the Chartered Society of Physiotherapy, and fur-
perineal discomfort. She also assesses and treats ther training may be required.
musclo-skeletal problems such as backache and
pelvic floor muscle weakness. In addition she is Since the publication of the first edition of this
a skilled teacher of effective relaxation, breathing book in 1990 there have been several government-
awareness and positioning and thus helps the funded developments of relevance to the specialty
woman to prepare for labour. and the demand, particularly within the conti-
nence services, for specialist physiotherapists has
risen steeply. In 1992, the Continence Foundation
Liaison
was established as an umbrella organisation that
In order for the services of the team to be of max-
has provided a focus for all those individuals and
imum benefit to parents there should be a close
organisations concerned to improve the quality and
liaison between members. Liaison, planning and
availability of services for sufferers with contin-
shared learning sessions help to ensure that tech-
ence problems. The Foundation, initially govern-
niques and advice are consistent, up to date,
ment funded but now a charity, seeks to raise
related to current practice and meet the needs
awareness, foster education and research, provide
of parents. This is particularly important when
information, advice and expertise and influence
there is no available member of one of the spe-
policy makers and providers.
cialist professions. Where this is the case, advice
As the result of much collaboration and lobbying
should be sought from the relevant professional
at all levels of government, a great deal has been
body. To enhance continuity of care, new mem-
achieved in 10 years. Conferences and literature, for
bers of the team must always have a period
example, Guidelines for Continence Care (ACA 1993),
of inter-disciplinary induction. The Midwife,
Incontinence: Causes, Management and Provision of
Health Visitor and Obstetric Physiotherapist
Services (RCP 1995), raised awareness. This culmi-
should be in regular contact and operate an effec-
nated in 1998 in the formation of a multidisciplinary
tive referral system.
expert working group (including a physiothera-
pist), by the Parliamentary Under Secretary of State
The aims of parenthood education for the Department of Health (DoH). The brief of
• To enable parents to develop a confident and the working group was to look at continence serv-
relaxed approach to pregnancy, childbirth ices and advise on how they might be improved.
and parenthood. Their report Good Practice in Continence Services was
• To enable parents to be aware of the choices published in 2000, highlighting the problems and
in care based on accurate and up to date making strong recommendations. Although not
information. mandatory, it clearly maps out the envisaged serv-
• To provide continuity of high quality care as ice, the professionals needed to provide the serv-
previously defined to parents by means of ice and the priority groups to be served. The
team collaboration and co-operation between Continence Foundation speedily published two
professionals including specialised treatments supporting publications Incontinence: a Challenge
where needed. and an Opportunity for Primary Care (CF 2000a) and
Introduction xxi
Making the Case for Investment in an Integrated and were prepared for the birth and the care of the
Continence Service (CF 2000b) designed to raise baby. The committee recommended that women
awareness of the government guidelines and of should be able to book with a midwife for the
the need for better services. In 2001/2 research, entire episode of care, including delivery. There
jointly funded by the Continence Foundation and followed a very unsettled period, particularly for
the Royal College of Nursing, took place to survey midwives, as a variety of service provision models
continence service commissioning and provision were tested. There was much talk of ‘informed
across England. A further aim of this research was choice’ for and ‘empowerment’ of mothers-to-be.
to encourage those engaged in the management of The combination of an acute shortage of midwives,
people with incontinence to work towards provid- most pregnant women also being employed, and
ing the best possible services (CF 2002). the need to hold down NHS costs, made these rec-
In 1997 the report of the Pennell Initiative for ommendations virtually impossible to achieve. As
Women’s Health, funded jointly by the government two leaders in the midwifery field wrote:
and by the pharmaceutical company Wyeth and
It is almost impossible for women to have a
chaired by Dame Rennie Fritchie, was published.
decent discussion on options … in a one off visit,
The objective was to gain an overview of what was
with a stranger they may never see again, in a
known about women’s health in later life (45–105⫹)
busy maternity clinic … While we espouse the
and to explore the positive steps that could be taken
right of informed choice, we are giving the
to improve every woman’s prospects of living well
women of Britain a clear message; it is alright for
into a healthy old age. Recommendations were
you to have informed choice so long as you
made for policy makers, for health-care profession-
choose hospital birth, caesarean section, epidural
als, and for women and representative organisa-
anaesthesia and active management.
tions. The recommendations prioritised education,
(Page & Penn 2000)
better early preventative care and prompt assess-
ment and treatment of problems as they arose. The concern with the rising caesarean section rate
The National Service Framework for Older People continues with the 2000/1 figure for England and
(DoH 2001) reflects thinking from the Pennell Wales at 21.3% (DoH 2002), and questions are now
report (1998) and Good Practice in Continence Services being asked as to whether women are made aware
(DoH 2000) requiring identification of those with of the risks and disadvantages of caesarean
osteoporosis and those at risk of falls, and setting section. Statistics are now being collected of the
the target for an integrated continence service by number of ‘normal births’, that is, spontaneous
2004. In addition, the requirement for evidence- onset, and without regional anaesthesia, augmen-
based practice throughout the National Health tation of labour or episiotomy. Data prepared by
Service (NHS) has produced a plethora of research, BirthChoiceUK.com (Dodwell 2002) from DoH
especially related to continence care. ‘Quality of statistics for England suggest a patchy picture and
life’ has become a valued outcome measure. a fall in ‘normal births’ from 60% in 1999 to 41.5%
Conservative treatment has returned to favour as in 2001. The debate regarding home delivery as an
the first line of treatment for many with continence option for mothers-to-be is being clouded by the
problems and consequently specialist physiothera- unaffordable insurance premiums being demanded
pists have been in greater demand. of independent midwives.
Progress in the maternity services has been less Changing Childbirth failed to mention physio-
positive. In 1993 the DoH published the report of therapists, and did not address the health needs of
an expert committee entitled Changing Childbirth. mothers in the puerperium and beyond. These
The committee, which did not include a physio- needs were powerfully exposed by MacArthur et al
therapist, was chaired by Julia Cumberlege, (1991). Many of the problems highlighted could
Under-Secretary of State for Health. In essence, possibly be prevented by early intervention by a
the recommendations were that the service should physiotherapist specialising in women’s health
ensure that the woman and her partner felt sup- and, if problems arise, would probably benefit
ported and fully informed throughout pregnancy from assessment and treatment by one. To cut costs
xxii INTRODUCTION
and to reduce the risk of hospital-based infections collaborated to produce this second edition is a
being passed to mother or infant, women now are deep conviction that thorough and effective phys-
discharged within 1–4 days of delivery into the iotherapy is essential in this field, and that physio-
hands of community midwives. Shortages of mid- therapists are the most appropriate professionals
wives, holidays, sickness and urban road conges- to carry it out. There is no better forum for health
tion make this service problematical. More recently education, in its widest sense, than is offered by the
the fact that postnatal women are not happy with contact between the whole obstetrical health-care
their care has been raised (Singhe & Newburn 2000). team and women experiencing pregnancy, labour
Women now work through pregnancy, often right and the puerperium; and the benefits go on and
up to delivery. Antenatal class attendance is poor, on, into later years. The knowledge so gained radi-
and early discharge after delivery leaves physio- ates out, like the ripples from a stone tossed into a
therapists struggling to deliver an effective service, pool, and influences whole families and the wider
even to those at risk. community. The physiotherapist has a great deal to
Support from research and expert opinion for offer in this field, particularly in terms of fitness,
providing routine input to modern maternity care coping with stress, wise back care and the promo-
by women’s health physiotherapists is weak; that tion of continence.
for prevention, assessment and treatment of condi- We have tried not to perpetuate information
tions like symphysis pubis dysfunction and incon- that has been stated and restated in other textbooks
tinence is stronger (Fry 1992, Morkved 2001, Reilly without proper testing, and have been very careful
et al 2002). Attempts to show benefit from antenatal not to dictate prescriptions for treatment, as careful
class attendance has been disappointing. To deal educated assessment is the key to appropriate ther-
with this uncertainty, a well-constructed body of apy. In a book of this size we have had to set limits
research is needed. This is unlikely to be of interest on what is included and the depth at which it is
to obstetricians and midwives. Women’s health covered; some knowledge is assumed. We have
physiotherapists are the affected group and those tried to write clearly and simply, with a minimum
in post must take up the challenge. The collabora- of jargon, explaining underlying physiology and
tive multicentre approach and carefully planned the reasoning behind certain approaches. We
auditing would provide first stage evidence on include references for further reading in each
which to base more detailed studies. aspect of the subject. Cross-references have been
When preparations for the first edition of this used extensively, but, in places, material has been
book were under way, physiotherapists in urogyn- repeated to avoid an irritating break in the reader’s
aecology felt they were struggling and were under- train of thought caused by having to turn to
valued. What a dramatic change has occurred! another page. We hope that other physiotherapists
Now it is those in obstetrics who are constantly will be infected by our enthusiasm for the spe-
being required to argue their case for existence. cialty, and will enjoy, as we do, working with our
Hopefully this book will offer support, informa- midwifery, health visitor and medical colleagues,
tion and ideas. The motivation of those who have for the benefit of women of all ages.
References
ACA (Association for Continence Advice) 1993 Guidelines CF (Continence Foundation) 2002 Good, better and best
for continence care. ACA, London. Practice. Continence Foundation, London.
CF (Continence Foundation) 2000a Incontinence: a challenge CSP (Chartered Society of Physiotherapy) 1994
and an opportunity for primary care. Continence Working together in psychophysical preparation
Foundation, London. for childbirth. Information paper no. PA13. CSP,
CF (Continence Foundation) 2000b Making the case for London.
investment in an integrated continence service. Dodwell M 2002 BirthChoiceUK.com: introduction to birth
Continence Foundation, London. statistics. New Digest, August, p 8–9.
Introduction xxiii
DoH (Department of Health) 1993 Changing childbirth, part controlled trial of primiparous women. International
1 and 2. HMSO, London. Urogynecology Journal 12:S1.
DoH (Department of Health) 2000 Good practice in Morris M 1936 Maternity and postoperative exercises.
continence services. DoH, London. Heinemann, London, p 109–111.
DoH (Department of Health) 2001 The national service Page L, Penn Z 2000 Informed choice has become a hollow
framework for older people. DoH, London. phrase. New Generation, June: 12.
DoH (Department of Health) 2002 NHS maternity statistics, Pennell Initiative 1998 The Pennell Report on Women’s
England and Wales. 1998–99 to 2000–01. Stationery Health 1998. Health Service Management, University of
Office, London. Manchester, Manchester, p 64–65.
Fairbairn J S 1923 Introduction. In: Liddiard M The Randall M 1948 Fearless childbirth. Churchill, London.
mothercraft manual, Churchill, London. RCP (Royal College of Physicians) 1995 Incontinence: causes,
Fry D 1992 Diastasis symphysis pubis. Journal of the management and provision of services. RCP, London.
Association of Chartered Physiotherapists in Obstetrics Reilly E T C, Freeman R M, Waterfield A E et al 2002
and Gynaecology 71:10–13. Prevention of post partum stress incontinence in
Heardman H 1948 A way to natural childbirth. Livingstone, primigravidae with increased bladder neck mobility; a
London. randomised controlled trial of antenatal pelvic floor
MacArthur C, Lewis M, Knox E 1991 Health after childbirth. exercises. British Journal of Obstetrics and Gynaecology
HMSO, London. 109:68–76.
Morkved S, Salvesen K A, Scheil B et al 2001 Prevention of Singhe D, Newburn M. 2000 Women’s experiences of
urinary incontinence during pregnancy – a randomised postnatal care. National Childbirth Trust, London.
Further reading
Continence Foundation 2000a Incontinence: a challenge and DoH (Department of Health) 1993 Changing childbirth, part
an opportunity for primary care. Continence Foundation, 1 and 2. HMSO, London.
London. DoH (Department of Health) 2000 Good practice in
Continence Foundation 2000b Making the case for continence services. DoH, London.
investment in an integrated continence service. DoH (Department of Health) 2001 The national service
Continence Foundation, London. framework for older people. DoH, London.
Continence Foundation 2001 Good, better and best practice. NCT 2002 Evidence based briefing. Caesarean section – Part 1.
Continence Foundation, London. New Digest Edition 19, National Childbirth Trust, London.
Useful websites
Association of Chartered Physiotherapists in Women’s Health – International Continence Society – www.ics.org.com
www.womensphysio.com Royal College of Midwives – www.rcm.org.com
Association for Continence Advice – www.aca.uk.com Royal College of Obstetricians and Gynaecologists –
Chartered Society of Physiotherapy – www.csp.org.uk www.rcog.org.com
Continence Foundation – www.continence.foundation.org.uk Royal College of Physicians – www.rcplondon.ac.uk
Chapter 1
Anatomy
Jeanette Haslam
CHAPTER CONTENTS
The pelvis 1 The breast 12
The pelvic floor and muscles of the pelvis 5 The reproductive tract 13
The perineum 10 The urinary tract 18
The abdominal muscles 11 The anorectal region 22
THE PELVIS
The pelvis provides a protective shield for the important pelvic contents;
it also supports the trunk, and constitutes the bony part of the mechanism
by which the body weight is transferred to the lower limbs in walking,
and to the ischial tuberosities in sitting. The pelvis consists of the two
innominate bones and the sacrum to which the normally malleable coc-
cyx is attached. The innominates and the sacrum articulate at the symphy-
sis pubis, and at the right and left sacroiliac joints, to form a firm bony
ring. They are held together by some of the strongest ligaments in the
body (Fig. 1.1). 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. The ideal or gynaecoid pelvis
is recognised by its well-rounded oval inlet and similarly uncluttered
outlet (Fig. 1.2c).
2 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Iliolumbar ligament
Sacrospinous ligament
Sacrotuberous ligament
(a)
Sacral prominence
Anterior superior iliac spine
Anterior sacroiliac ligament Anterior longitudinal ligament
Inguinal ligament
Sacrospinous ligament
Sacrotuberous ligament
Pectineal ligament
Symphysis pubis
(b)
Promontory of sacrum
Sacrotuberous ligament
Tip of coccyx
Body of pubis Pelvic outlet
Pubic arch Ischial tuberosity
(c)
Figure 1.1 The pelvis: (a) posterior view; (b) anterior view; (c) side view.
Anatomy 3
The inlet has its longest dimension from side to side, whereas at the
outlet the longest dimension is anteroposteriorly (Table 1.1). 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 (see p. 63).
Some other possible pelvic shapes are shown in Figure 1.2. Difficulties
can be experienced in childbirth from such adverse features as protuber-
ant 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 (cephalopelvic disproportion, see p. 77).
It has recently been demonstrated that a narrow suprapubic arch is
associated with a consequential prolonged labour and postpartum anal
incontinence (Frudinger et al 2002).
The wedge-shaped sacrum is virtually suspended between the innom-
inates by the exceptionally tough interosseous and posterior sacroiliac
ligaments, which in the cadaver detach themselves from their periosteal
junction rather than tear when the bones are forcibly separated (Meckel
1816, Sashin 1930). However, the ventral sacroiliac ligament is less sub-
stantial and is thought to tear during childbirth (Shelly et al 2002). The
upper sacrum is stabilised by the illiolumbar ligaments via its attachment
to the fourth and fifth lumbar vertebra and the lower sacrum by the
4 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Axis of rotation
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. Zacharin (1980) used the term the ‘pelvic
trampoline’ to suggest the characteristics of the pelvic floor. The layers of
the pelvic floor from deepest to superficial are as follows:
• The levator ani muscles (Fig. 1.4), otherwise known as the pelvic
diaphragm or pubovisceralis (pubococcygeus) and iliococcygeus, are
6 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Anterior
vaginal
wall Arcus tend.
Rectum fasc. pelv.
Levator ani muscle
Urethra
External
anal sphincter Perineal membrane
Clitoris
Urethral meatus
Ischiocavernosus muscle
Vagina
Bulbospongiosus muscle Urogenital diaphragm
Superficial transverse
Perineal body
perineal muscle
Anus
Levator ani muscle
External anal sphincter
muscle Gluteus maximus muscle
anterior and lateral sides of the coccyx. The iliococcygeus originates from
the arcus tendineus and passes inferiorly to the midline to interdigitate
in front of the anococcygeal raphe. At other times the pubovisceral
muscles are known as the puboperineus and pubococcygeus (Lawson
1974, Peschers & DeLancey 2002).
Other muscles that are intimately concerned with the PFM are the
ischiococcygeus, obturator internus and piriformis. However, none of
these muscles has any direct connection with the vagina or anal sphincter.
The ischiococcygeus (sometimes known as coccygeus) finds its origin on the
spine of the ischium and sacrospinous ligaments and travels medially to
insert into the lower sacrum and upper coccyx. They both provide pelvic
contents support and assist in the stability of the sacroiliac joint. The coc-
cygeus has been largely dismissed in the past as having a passive role.
However, its importance is increasingly known as it has been shown that
PFM activity can influence the sacroiliac joint (Tichy et al 1999), and this
joint may be implicated in urinary symptoms (Dangaria 1998).
The obturator internus and piriformis are the major muscles of the
pelvic side-walls. The obturator internus finds its origin in the bony mar-
gins of the obturator foramen, the obturator membrane and rami of the
pubis and ischium to converge into a tendon, leaving the pelvis via the
lesser sciatic foramen to be inserted into the greater trochanter of the femur.
The piriformis helps to form the posterior boundary originating from the
anterolateral sacrum, travelling through the greater sciatic foramen and
also finding insertion in the greater trochanter.
8 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
The arcus tendineus fascia of the pelvis (ATFP) is a linear fascial thick-
ening of the obturator fascia attached anteriorly to the pubic bone and
posteriorly to the ischial spine and is believed to be of great importance
in the continence mechanism as a connection between the iliococcygeus
and the endopelvic fascia. The endopelvic fascia surrounds the vagina
and finds its attachment laterally to the ATFP. The endopelvic fascia is
also thought to act as a connection between the bladder neck and urethra
to the ATFP. As the iliococcygeus also finds its origin at the ATFP, during
a contraction of the iliococcygeus, it is proposed that force is transmitted
through the endopelvic fascia and anterior vaginal wall to assist in sup-
porting the urethra and bladder neck (Freeman 2002). This ‘hammock
hypothesis’ was first proposed by DeLancey (1994b) (Fig. 1.4).
There have been many names given to the component parts of the
levator ani, and the reader must be aware of these when reading the litera-
ture. The levator ani were subdivided by Ashton-Miller & DeLancey
(2002) into the puboperineus, the pubococcygeus, the puborectalis and
the iliococcygeus. The puboperineus is that part arising lateral to the
pubic symphysis and inserting into the perineal body in front of the rec-
tum. The pubococcygeus and puborectalis both arise from the pubic bone
either side of the midline. The puborectalis has some attachment to the
lateral vaginal walls, and inserts partially into the rectum between the
internal and external sphincter while other fibres continue to form a sling
by passing behind the anorectal junction. The pubococcygeus inserts
partially into the anal canal, behind the rectum and into the coccyx.
Contraction of these medial fibres pulls the rectum, vagina and urethra
forward toward the pubic bones thus compressing their lumens. Fur-
thermore, the loop behind the rectum forms a sling which, by its resting
tension, results in the rectum joining the anal canal at a 90° angle. This
angle is considered to be a factor in the maintenance of faecal continence.
As the variety of names given to the constituent parts of the levator ani
muscles can be confusing, Figure 1.6 has been constructed in an attempt
to assist the reader. If both strong and coordinated, the levator ani
muscles, enveloped in fascia on both surfaces, form an efficient muscular
sling or ‘trampoline’ giving caudal support and adapting appropriately to
posture, position and activity.
The levator ani is a somatic muscle, so has the possibility of voluntary
control, and is supplied by the perineal branch of the pudendal nerve
(S2–S4). However, recent observations on fresh-frozen female cadavers
suggest that the female levator ani muscles are not innervated by the
pudendal nerve but rather by an innervation originating from the sacral
nerve roots (S3–S5) travelling on the superior surface of the levator ani
(Barber et al 2002).
Histochemical and electron microscopic examination of levator ani
muscle (Gilpin et al 1989, Gosling et al 1981) showed that it was made
up of large diameter type I (slow twitch) and type II (fast twitch) striated
muscle fibres, with muscle spindles observed. Type I fibres are highly
fatigue resistant and consequently can produce contraction over long
periods although the power of the contraction tends to be of a relatively
low order. Muscle activity may be recorded by electromyograph (EMG)
Anatomy 9
Pubic symphysis
Iliococcygeus
Ischiococcygeus
(also known as coccygeus)
Piriformis
Coccyx
from the levator ani muscle ‘at rest’ and even in sleep; presumably the
type I fibres are responsible for this. By contrast, type II fibres are highly
fatiguable but produce a high order of power on contraction. All these facts
support the contention that the levator ani muscle is a skeletal muscle
adapted to maintain tone over prolonged periods and equipped to resist
sudden rises in intra-abdominal pressure, as for example on coughing,
sneezing, lifting or running. It has been shown that there is reflex activity
such that a fast-acting contraction occurs in the distal third of the urethra,
which contributes to the compressive forces of the proximal urethra during
raised intra-abdominal pressure (Constantinou & Govan 1982).
It has been reported that there are two subgroups of fast twitch fibres
IIa and IIx (previously known as IIb), where IIa are fast twitch oxidative
fibres and are relatively more fatigue resistant but produce slightly less
power than IIx (fast twitch glycolytic). A reason for lack of standardisa-
tion of exercise may be individual differences in response to that exercise,
perhaps due to genetic factors (Bruton 2002). Further research needs to be
done to determine any more exacting principles regarding optimal load,
frequency or repetitions in the exercise prescription to maintain normal
function or improve it (Bruton 2002). Table 1.2 shows the percentage of
type II fibres found by Gilpin et al (1989) in the pubococcygeus muscle.
The perineal membrane (Fig. 1.4) lies superficially (i.e. inferior to
the levator ani muscle) and spans the pelvic outlet anteriorly between the
descending ischiopubic rami. It is a fibrous layer and the urethra and
vagina pass through it. It is intimately connected with the distal portion
of the urethra and its musculature, with the medial side-walls of the
vagina and with the perineal body. It is reinforced by some smooth and
10 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
THE PERINEUM
The external genitalia are shown in Figure 1.7. At either side of the entry
to the vagina (introitus) are the Bartholin’s glands, which are activated
mainly in sexual arousal to produce mucoid secretions; they are normally
about the size of a pea. The skin and structures of the perineum are sup-
plied by the pudendal nerve (S2–S4). It has been shown in a study of 224
primagravid women going into spontaneous labour that a short peri-
neum of less than 4 cm resulted in significantly more episiotomies, peri-
neal tears and instrumental deliveries (Rizk & Thomas 2000).
Anatomy 11
Level of external
urethral opening
Labium minus
Level of Vaginal introitus
Bartholin's
glands
Fourchette
Perineum
Anus
Rectus Transversus
abdominis abdominis
muscle muscle
Linear
Umbilicus alba
Obliquus
externus
abdominis Obliquus
muscle internus
abdominis
muscle (cut)
part. However, there is still more work necessary to demonstrate all the
muscle interactions (Sapsford 2001). The PFM timing of recruitment
when there is any rise in intra-abdominal pressure may be considered
crucial (Deindl et al 1993) and as such it is essential to consider any other
muscle groups that may be involved.
THE BREAST
The female breast (Fig. 1.9) consists of fat and glandular tissue, overlying
the pectoralis major muscle. It is roughly circular with an axillary tail
extending up and laterally to the axilla. The breasts undergo two bursts
of hormonally mediated growth: one in puberty, the second in preg-
nancy. In addition, many women notice fullness and tenderness directly
related to stages in the menstrual cycle.
It has always been believed that the breast has 15–25 secreting lobes
each composed of very many lobules. Each lobe has its own duct with an
opening on to the nipple area. Just proximal to each opening there is a
widened portion in the duct (the lactiferous sinus), which, when milk is
being produced, acts as a temporary reservoir. The nipple is said by some
to be the origin of 15–25 lactiferous ducts (Tot et al 2002), but others believe
that there are far fewer, many of the previously quoted ducts being seba-
ceous glands (Love 2000). It is not disputed that the nipple has some
muscle to form erectile tissue when cold, sexually stimulated or breast-
feeding. The surrounding loose, pigmented skin is known as the areola
and has modified sweat glands that present as small swellings known as
Montgomery’s tubercules. They may enlarge during pregnancy and
breastfeeding. The nipples are normally slightly raised but in some women
they are flat or even inverted. A baby may experience difficulty suckling
where the nipples are inverted but with skilled help this can be overcome.
Anatomy 13
Rib
Adipose tissue
Intercostal
muscles
Lactiferous Pectoralis
duct major
Lactiferous muscle
sinus
(ampulla)
Nipple Lobule
Areola
Around the time of the menopause or earlier the breast tissue under-
goes involution; this results in a decrease in number of lobules and ducts.
The fibrous or fatty involution may be in varying combinations (Tot et al
2002). It is the decreasing density of breasts that make them more amenable
to mammographic examination. Hormone replacement therapy (HRT)
can confound the interpretation of mammograms by increasing the
breast tissue density but this is rapidly reversible when HRT is discon-
tinued (Silva & Zurrida 2000).
The blood supply to the breast is via the axillary, internal thoracic and
second to fourth intercostal arteries; the breast is drained by accompany-
ing veins. The lymphatic drainage is of some importance because of the
possible development of carcinoma in breast tissue and its subsequent
dissemination via the lymphatic system. There is an anastomosing net-
work of channels, 95% of which drain to the anterior axillary nodes
(Bundred et al 2000), but the medial part of the tissue is drained to the
internal thoracic nodes. The nerve supply is from the anterior and lateral
cutaneous branches of the fourth to sixth thoracic nerves.
Fallopian tube
Fimbria
Fundus of uterus
Ovary
Broad ligament
Isthmus of uterus
Internal os
External os
Vault of vagina
Figure 1.10 The reproductive
tract – left half in cross section.
OVARIES The ovaries produce ova, and also secrete oestrogens and progesterone
under the direction of the anterior pituitary gland. In the cortex of these
two pinkish-grey structures the size and shape of almonds, lie thousands
of primary follicles, each consisting of an immature ovum and a single
layer of stroma cells. At birth the ovaries contain about 2 million follicles;
by 7 years of age there has been some wastage and weeding out of imper-
fect cells to reduce this number to about 300 000, a process that con-
tinues throughout life. From puberty through the reproductive years, a
number of follicles develop but usually only one follicle ripens fully
every month.
The ovum in this follicle develops in size and in maturity and the
stroma cells differentiate so as to be able to secrete oestrogens and pro-
gesterone in increasing amounts. At ovulation the ovum is ejected from
the surface of the ovary into the peritoneal cavity, to be directed by the
fimbria into the fallopian tube. After ovulation the follicle collapses and
undergoes a further phase of development to become a corpus luteum, so
called because it is yellow in appearance. It continues to produce oestro-
gens and progesterone and then, if fertilisation of the ovum does not
occur, shrivels after about 10 days. If pregnancy occurs the corpus luteum
enlarges and continues to be active for 4 months; it probably then degen-
erates. Thus, over the years the initially smooth ovarian surface becomes
increasingly wrinkled and puckered, and in a woman in her late 40s there
are just a few hundred follicles left at most.
Anatomy 15
FALLOPIAN TUBES The two fallopian or uterine tubes connect the ovaries with the uterus. The
outer end of the tube is funnel shaped and fimbriated; one fimbria is
longer than the others and is attached to the ovary. The tentacle-like
processes of the fimbria are able to move, apparently stimulated in some
way to search for and facilitate the passage of ova into the tube. The prox-
imal end gains access to the uterine cavity either side of the uterine fun-
dus. The tubes themselves are about 10 cm long. A coat of smooth
involuntary muscle, consisting of an outer longitudinal layer and an inner
circular layer, is responsible for peristaltic waves, which pass towards the
uterus; the lining of the tubes is both ciliated and secretory. Thus, once in
the tube, an ovum is not only propelled but also nourished as it passes
along. It seems likely that conception most commonly occurs in the vicin-
ity of the junction of the distal third and the proximal two-thirds of the
relevant tube. The tubal secretions contain the essential ingredients
to condition the sperm and ovum for fertilisation, a process known as
capacitation. An ectopic pregnancy occurs when the fertilised ovum is
implanted outside the uterine cavity, usually in the fallopian tube.
UTERUS The uterus (womb) consists of the fundus, the body, the isthmus (which
is no more than 5 mm in depth but develops into the lower segment
during pregnancy) and the cervix (neck). The uterus is the shape of an
inverted pear and in the nulliparous adult it measures approximately
9 cm long, 6 cm wide and 4 cm thick; it weighs about 50 g. It is a poten-
tially hollow organ with a thick muscular wall (myometrium) lined with
lush, highly vascular endothelium (endometrium), whose thickness varies
with the menstrual cycle but is approximately 1.5 mm. This mucous
membrane is shed at each menstruation, and consists of columnar epithe-
lium, connective tissue and many tube-like uterine glands. After implant-
ation of the ovum, the endometrium is called the decidua because it is
shed following delivery. It is a rich source of prostaglandins.
The muscle fibres of the myometrium are smooth and involuntary,
swathing the fundus and body and encircling the isthmus (Fig. 1.11).
These fibres manifest unique properties in pregnancy and in labour. In
pregnancy they grow and stretch to accommodate the foetus. In labour
they systematically contract and relax, relaxing each time to a length just
less than they were before. This shortening is called retraction and it is the
means by which the uterine cavity becomes progressively smaller and
the foetus is expelled. The fibres are supported on a collagenous connect-
ive-tissue base. The body of the uterus lies against the superior surface of
the bladder and moves as the bladder fills and empties.
Congenital malformations of the uterus occur, resulting for example in
the uterus being in two separate halves to a greater or lesser extent (bicor-
nuate uterus). For some individuals this may become evident only in preg-
nancy or labour, whereas for others it may be considered to be the reason
for infertility. There has been a recent case reported in which a woman with
a uterus didelphys (in which bilateral müllerian ducts develop side by side
rather than fusing) delivered twins successfully (Nohara et al 2003). Twin
one was delivered by caesarean section at 25 weeks of pregnancy with a
16 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
VAGINA The vagina is about 7.5 cm long and passes upwards and backwards, par-
allel with the pelvic floor, towards the rectum from its opening on the
perineum. Most commonly it meets the longest axis of the uterus at about
90°. The vagina connects with the uterus via the cervix, which projects
into its vault. The vagina is a highly elastic channel capable of consider-
able distension. Within its wall is a layer of smooth muscle, the fibres of
which are placed both longitudinally and circularly, and the lining is
of stratified squamous epithelium. The vagina is positioned posteriorly to
the urethra and the base of the bladder, and anteriorly to the rectum. The
Anatomy 17
CIRCULATION AND The true pelvis is a highly vascular area. The arterial blood supply to the
NERVE SUPPLY female reproductive tract is via the left and right internal iliac arteries;
branches supply the ovaries, the uterine tubes, the uterus and vagina.
There is considerable overlap between these arteries so that where bleed-
ing occurs it may well be considerable and difficult to control. The uter-
ine arteries develop greatly in pregnancy to serve the enlarging uterus
and placenta. There is a highly developed lymphatic system with many
nodes within the pelvic cavity, apparently providing a good defence to
infection but unfortunately facilitating the spread of carcinoma. The
veins return blood via the internal iliac vessels and so to the inferior vena
cava. The uterine muscle is innervated by the autonomic nervous system
via the pelvic plexuses, and both parasympathetic (S2–S4) and sympa-
thetic (T10–L1) efferents are found. Sensory nerve endings are more
numerous in the cervix and the isthmus (which develops in pregnancy
into the lower uterine segment) than in the rest of the uterus, and pain
impulses such as those arising from labour are relayed via the hypogas-
tric plexus to enter the spinal cord through the posterior roots of T10–L1.
The cervix is sensitive to stretch whereas the isthmus is sensitive to both
pressure and stretch. Sensation from the perineum is conveyed via the
pudendal nerve to the spinal cord (S2–S4).
SUSPENSORY The female reproductive tract is loosely suspended across the midline of
LIGAMENTS the true pelvis, enfolded within the double layer of the slack, flimsy
broad ligament, which is attached either side to the lateral inner surface
of the pelvis. The ovaries are attached to the posterior layer of this liga-
ment, and to the posterior aspect of the uterus by a fibromuscular cord.
The uterine round ligaments are attached anteriorly to either side of the
fundus of the uterus; they are lax, and pass forward via the deep inguinal
ring and the inguinal canal to insert into the subcutaneous tissue of the
labia majora. The round ligaments help to keep the uterus anteverted and
anteflexed (see also p. 283).
18 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
THE KIDNEY The kidney is the size of the owner’s fist and of a shape so typical that
it is used as a descriptive term. The indentation on its medial aspect is
called the hilum, and here the ureter and renal vein leave and the renal
Anatomy 19
artery enters. The kidneys have a huge blood supply via two branches
directly from the aorta, and returning to the inferior vena cava. The kid-
neys are placed posteriorly in the loin associated with the first lumbar
vertebra; the left kidney is a little higher than the right because of the
wedge-shaped liver lying superiorly on the right side. The kidney con-
sists of a fibrous capsule, a cortex, medulla, and major and minor calyces
or collecting ducts, which channel urine into the pelvis of the kidney and
so to the ureter.
THE URETER Each ureter is about 25 cm long and is a hollow muscular canal about
the diameter of a small drinking straw; it is lined with transitional epithe-
lium, as is the whole urinary tract. Contraction in peristaltic waves of the
smooth muscle in the wall of the ureter assists the movement of urine
down to the bladder – even when a person is supine. As the ureter enters
the pelvis it lies in front of the sacroiliac joint, separated from it by the
bifurcation of the common iliac artery. At the level of the internal os, it is
1 cm from the cervix and passes through the transverse cervical liga-
ments. The ureter enters the thick muscular wall of the bladder obliquely
at each of the upper corners of the trigone of the bladder about 2 cm away
from the urethrovesical junction; this arrangement results in closure of
these two orifices and the prevention of reflux of urine when the detrusor
muscle of the bladder contracts. However, a high pressure in the bladder
may cause reflux and subsequent kidney damage.
THE BLADDER The bladder is a hollow sac of three layers of smooth muscle, corporately
called the detrusor muscle, whose fibres are arranged in a complex mesh-
work. When the detrusor muscle is in its filling phase, it is said to be com-
pliant and acts as a reservoir; when it contracts it becomes a pump. It is
lined with transitional epithelium and the outer surface is covered with
connective tissue composed of collagen and elastic fibres. The detrusor
muscle has outermost muscle fibres lying predominantly longitudinally,
an intermediate layer lying obliquely and circular, with an innermost
plexiform layer (Wall et al 1993); they are in an ideal arrangement to
reduce the lumen of the bladder in all directions when they contract in
unison. There is no specific polarity as there is with the uterus. The blad-
der is roughly boat shaped when empty, and lies directly behind the
pubic symphysis. It becomes oval and rounded as it fills and rises out of
the true pelvis and into the abdomen. The posterior part of the superior
surface is related to the anteflexed uterus. A little further posteriorly the
bladder is related to the cervix and vagina, and here a triangular, flat-
tened portion is called the trigone; the apex of the triangle points down-
ward and the base is uppermost. The trigone is acontractile, thicker than
the rest of the bladder, with an internal lining that is very smooth and
particularly richly innervated. The ureters enter at the two corners of the
base and the urethra leaves at the apex of the trigone. The bladder is
connected to the urethra by way of the bladder neck, and the trigone con-
tributes to its funnel shape. In this zone the detrusor muscle fibres are
20 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
0
sphincteric mechanism is
along the next 20–80%.
20
Pubic
(From DeLancey 1994a, with Vagina symphysis
permission.)
40
Sphincter
60
urethrae
80
100
Urethrovaginal sphincter
Compressor urethrae
sphincter muscle is made up of two striated muscle bands that arch over
the anterior aspect of the urethra. One band arises from the vaginal wall
on each side – the urethrovaginal sphincter; the other extends along the
inferior pubic ramus, above the perineal membrane – the compressor
urethrae (DeLancey 2002). These three portions of muscle work as a sin-
gle entity and are thought to be important in the maintenance of contin-
ence, particularly when the intra-abdominal pressure is raised (Fig.
1.13). Voluntary muscle contraction increases the urethral constriction
whenever there is any rise in intra-abdominal pressure; proximally it
constricts the lumen and distally it compresses the urethra from above
(DeLancey 2002). The sphincter is believed to be responsible for one-third
of resting urethral closure pressure (Rud et al 1980). Blaivas (2003) reports,
however, that there are a myriad of names suggested for the support
mechanism of the urethra; but at surgery he states he can only discrimi-
nate the pubourethral ligament.
The urethral smooth muscle is present in the upper four-fifths of the
urethra and is a continuation of the detrusor muscle but is different to it
on various accounts. It is composed of a more prominent inner longitu-
dinal layer, which may help to shorten and funnel the urethra, and an
outer thinner circular layer, which is thought to assist with reducing the
lumen (DeLancey 2002).
The blood supply to the urethra is carried in a highly vascular submu-
cosal layer. The source is via branches of the internal iliac arteries, and
drainage is via the venous plexuses in that region to the internal iliac
veins. The vascular plexus assists in forming the watertight closure of the
mucosal surface. It also appears to be hormonally sensitive, as does the
urethral mucosa.
It was long held that somatic efferent fibres via the pudendal nerves
supplied the striated urogenital sphincter, but it now seems possible that
22 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
it is supplied via the pelvic splanchnic nerves (S2–S4), travelling with the
fine, easily damaged parasympathetic fibres to the smooth muscle of
the urethra (Hilton 1989). However, there is still controversy as to whether
the actual motor supply to the sphincter is somatic or autonomic, or both.
Because the fibres are striated, a somatic nerve supply is most logical.
Whatever is the fact, it appears likely that, like the levator ani muscle,
there is electrical activity within the sphincter even in sleep. There is also
sympathetic innervation to the smooth muscle of the urethra.
The descending colon is about 25 cm long and passes down inside the left
lateral aspect of the trunk to enter the pelvis posterior to the anterior
superior iliac spine. At the pelvic inlet it is continuous with the sigmoid
colon, a 25 cm long loop of gut that passes medially and posteriorly to the
anterior aspect of the sacrum. From the level of the third sacral vertebra
it is called the rectum; for about 13 cm, it follows the curve of the sacrum
and coccyx posterior to the vagina. The rectum has a muscle wall com-
posed of a layer of longitudinal fibres outside a layer of circularly dis-
posed smooth muscle. There is a lining of mucous membrane which falls
into three very specific transverse folds, two on the left wall and one on
the right. On piercing the pelvic floor approximately 2.5 cm anterior to the
coccyx it continues as the anal canal to the external outlet. At the junc-
tion of the rectum and the anal canal, the puborectalis portion of the
levator ani muscle forms a sling, which pulls the junction anteriorly
to create the anorectal angle, otherwise known as the rectoanal flexure.
The puborectalis has no posterior attachment. The peritoneum reflects
across from the upper two-thirds of the rectum to the uterus, dropping
a little between the two structures to produce the pouch of Douglas.
The lining of the upper half of the anal canal is composed of colum-
nar epithelium, which lies in vertical folds called anal columns. By con-
trast, the lining of the lower half of the canal is of squamous epithelium,
which is continuous with the skin surrounding the anus. Just behind the
anus and below the coccyx is a mass of fibrous tissue called the anococ-
cygeal body.
The anal canal (Fig. 1.14) is about 4 cm long and joins the rectum with
the anus; it is kept firmly closed by the pull of the puborectalis portion
of the levator ani muscles and the internal and external anal sphincters.
The internal anal sphincter (IAS) is composed of an inner circular layer
of smooth muscle with an outer longitudinal muscle layer as a continu-
ation of the smooth muscle of the rectum. The IAS is thickened in com-
parison with that of the rectum and is an involuntary muscle under the
control of the autonomic hypogastric plexus. The function of the IAS is to
maintain resting pressure of the anal sphincter, which has a normal value
of 70 cm H2O using a microballoon system (other systems have the rest-
ing pressure between 60–160 cm H2O). Using the microballoon system a
pressure of less than 45 cm H2O is found with daily faecal leakage.
Anatomy 23
Sigmoid colon
Rectum
Rich innervation
of sensory
nerve fibres
Puborectalis
(cut for
cross-section view)
The external anal sphincter (EAS) has muscle fibres that surround the
IAS; it is under voluntary control and has been reported as being com-
prised of a series of three loops (Bogduk 1996):
The EAS is composed of both slow and fast fibres: the slow for tonic
contractions and the fast for phasic contractions. These are capable of
doubling the squeeze pressure (by a further 70 cm of H2O) when there is
a need for a powerful contraction to avoid the passing of wind or to delay
bowel emptying to a socially acceptable place. If there is an inability to
generate more than 50 cm H2O the person may be clinically presenting
with faecal urgency and soiling. (See also Ch. 12.)
The blood supply to both the rectum and the anal canal is via the rec-
tal vessels. The nerve supply to the rectum and the smooth muscle of the
upper half of the anal canal is via the inferior hypogastric plexuses, and
responds only to stretch. It was thought at one time that there were sens-
ory stretch receptors in the lining, and that these relayed the sensation
of fullness to consciousness. It is now known that the stretch receptors
within the levator ani muscle are stimulated by change in volume and
pressure of the distending rectum (Parks 1986). The nerve supply to the
lining of the lower half of the canal and the external anal sphincter is
from the pudendal nerve and the perineal branch of the fourth sacral
nerve. Thus this area responds to pain, temperature, touch and pressure.
24 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
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Anatomy 25
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and pelvic pain. Springer, London, p 161–165. Zacharin R F 1980 Pulsion enterocele: review of functional
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Further reading
Barnes J, Chamberlain G 1988 Lecture notes on gynaecology, Love S M 2000 Dr Love’s breast book. Perseus, Massachusetts.
6th edn. Blackwell, Oxford. Pemberton J H, Swash M, Henry M M (eds) 2002 The
Fry D 1999 Perinatal symphysis pubis dysfunction: a review pelvic floor: its function and disorders. W B Saunders,
of the literature. Journal of the Association of Chartered London.
Physiotherapists in Women’s Health 85:11–18. Schiff Boissonnault J, Kotarinos R K 1988 Diastasis recti.
Gosling J A, Harris P F, Humpherson J R et al 1985 Atlas of In: Wilder E (ed.) Obstetric and gynaecologic physical
human anatomy. Churchill Livingstone, Edinburgh. therapy. Churchill Livingstone, Edinburgh, p 63–82.
Govan A D T, Hodge C, Callander R 1989 Gynaecology Schussler B, Laycock J, Norton P et al (eds) 1994 Pelvic floor
illustrated, 4th edn. Churchill Livingstone, Edinburgh. re-education. Springer-Verlag, London.
Lee D 1999 The pelvic girdle, 2nd edn. Churchill Livingstone, Snell R S 1986 Clinical anatomy for medical students, 3rd edn.
Edinburgh. Little, Brown, Boston.
27
Chapter 2
Physiology of pregnancy
Jeanette Haslam
CHAPTER CONTENTS
Menstruation 27
Pregnancy and foetal development 29
The physical and physiological changes of
pregnancy 31
Complications of pregnancy 43
MENSTRUATION
Anterior pituitary
FSH LH
Menstrual cycle
Me
n
st
Progesterone level in blood
rua
Maturing follicles
tion
Endometrium
LH
Plasma
FSH
Oestrogens
Progesterone
secretions. Indeed there are women who, in ignorance, fear that they sig-
nify some pathology. Following menstruation, women usually experience
several ‘dry days’ when there is little or no obvious secretion within the
vagina. The first noticeable mucus is scant but opaque, white, thick and
sticky. After one or more days the mucus begins to thin, is still cloudy but
feels progressively more slippery. By about the 7th or 8th postmenstrual
day the mucus is watery, clear, more profuse and very slippery. Women
may have an impression of being wet. This state is associated with ovula-
tion and thus the peak of fertility. Over the remaining days, prior to the
next menstruation, the mucus quickly becomes thicker, opaque and more
sticky, and then there are several further dry days. This sequence gives the
woman the information she needs about her own fertility, and can even be
the basis for natural, non-invasive family planning, this being known as
the Billings ovulation method. In addition, sexual arousal increases secre-
tions to the vagina, and also from the Bartholin’s glands.
Following fertilisation the ovum begins to divide, and over the next 8
days the group of cells is nourished by secretions from the fallopian tube
as it is propelled along towards and into the uterine cavity. From possibly
the day of conception the outer layer (trophoblast) of this increasing
group of cells (morula) produces human chorionic gonadotrophin (HCG)
to prevent menstruation and involution of the corpus luteum in the
ovary. For 8 weeks the corpus luteum is the principal producer of the hor-
mones progesterone, several oestrogens and relaxin. If the morula is to
survive, implantation must occur in order to develop a more permanent
nutritional supply line and additional hormone production. The outer
cells become lined with a second layer, and together these two layers are
called the chorion.
The spherical ball of cells is now called a blastocyst; it is hollow, with
an inner mass of cells to one side which will develop into the embryo.
The chorion divides to produce a myriad little tongue-like processes or
villi all over the outer surface of the blastocyst. These burrow into the
uterine endometrium, or decidua as it is also known in pregnancy. It is
these chorionic villi that can be sampled between 8 and 10 weeks to
detect inherited disease (see p. 101). The villi actually penetrate the
decidual blood sinusoids, and maternal blood washes over them. The
blastocyst is thus embedded within the decidua; however, as it grows it
protrudes into the uterine cavity, stretching the covering surface of
decidua. The villi atrophy over this portion, but not where the blastocyst
remains in contact with the inner part of the decidua. The innermost site
develops into the placenta from about the 6th week.
The disc-shaped placenta grows through pregnancy, and at term
measures about 20 cm in diameter, is 3 cm thick and weighs about
500–700 g, approximately one-sixth of the baby’s weight. It maintains the
foetal circulation, which is entirely separate from that of the mother, and
30 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Alternatively, add 7 days to the date of the last menstrual flow and
then deduct 3 calendar months. This method of calculating the EDD is
known as Naegele’s rule. Pregnancy is divided for the purpose of descrip-
tion and discussion into three 3-month periods or trimesters: it culmi-
nates in labour and the delivery of the foetus and placenta, and is
followed by the puerperium, a period of 6–8 weeks during which time
the remaining changes of pregnancy revert.
For the first 8 weeks it is usual to call the developing baby an embryo;
thereafter to delivery it is called the foetus. The foetus grows within a
thin semitransparent sac (the amnion), is bathed in amniotic fluid and is
attached to the placenta by the umbilical cord. The fluid is secreted by the
placenta, amnion and cord. The foetus drinks it and excretes it as urine; it
is said to be replaced every 3 hours. It is of interest that where foetal kid-
neys are absent or the urethra is blocked there is less fluid than normal
(oligohydramnios), and where the foetus has atresia of the oesophagus
there may be increased fluid (polyhydramnios). The volume of fluid nor-
mally increases throughout pregnancy to its maximum of about a litre at
Physiology of pregnancy 31
The changes of pregnancy are chiefly the direct result of the interaction of
four factors: the hormonally mediated changes in collagen and involun-
tary muscle, the increased total blood volume with increased blood flow
to the uterus and the kidneys, the growth of the foetus resulting in con-
sequent enlargement and displacement of the uterus, and finally the
increase in body weight and adaptive changes in the centre of gravity
and posture. The demands that these changes must make upon a woman
should never be underestimated.
32 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
ENDOCRINE SYSTEM The changes of pregnancy are orchestrated by hormones and much con-
cerning their action and interaction has yet to be elucidated. However,
progesterone, oestrogens and relaxin seem to be the most important for the
physiotherapist. Increased joint laxity has been demonstrated in pregnancy
(Marnach et al 2003); however, in this study the changes in peripheral joint
laxity did not correlate well with maternal oestradiol, progesterone or
relaxin levels. It has, however, been suggested that relaxin might have a role
relating to continence in pregnancy (Kristiansson et al 2001).
Progesterone is produced first by the corpus luteum, then by the pla-
centa. The output of the corpus luteum reaches a maximum of about 30 mg
per 24 hours at about 10 weeks of pregnancy and thereafter declines. The
placenta begins an increasing production from about 10 weeks, which at
first supplements that from the corpus luteum and then completely takes
over the role. The amount produced rises steeply from about 75 mg per 24
hours at 20 weeks to 250–300 mg per 24 hours at 40 weeks. Three progesto-
gens are produced in the placenta but the chief one is progesterone.
Oestrogens are produced first by the corpus luteum; as with proges-
terone, this supply is gradually taken over by the placenta, reaching an
output of about 5 mg per 24 hours at 20 weeks and 50 mg per 24 hours
at 40 weeks. Several oestrogens are produced in the placenta; one of these
(oestriol) is produced in considerable quantities and excreted in the
maternal urine. The amount excreted in this way in 24 hours was for-
merly used as a measure of foetal well-being. In the developed world bio-
physical assessment, for example foetal growth by ultrasonography, has
replaced this biochemical test. There is evidence to show that the mater-
nal and foetal adrenal glands and the foetal liver also contribute towards
oestrogen synthesis in pregnancy (Fransden 1963). Relaxin is produced in
the theca and luteinised granulosa cells in the corpus luteum (Verralls
1993) and later in the decidua (Bigazzi et al 1980, Bryant Greenwood
1982, Yki-Jarvinen et al 1983, Zarrow & McClintock 1966). Research sug-
gests that it is produced as early as 2 weeks of gestation, is at its highest
levels in the first trimester and then drops by 20% to remain steady
(O’Byrne et al 1978, Weiss 1984).
Effects of relaxin 1. Gradual replacement of collagen in target tissues (e.g. pelvic joints,
joint capsules, cervix) with a remodelled modified form that has
greater extensibility and pliability. Collagen synthesis is greater than
collagen degradation and there is increased water content, so there is
an increase in volume.
2. Inhibition of myometrial activity during pregnancy up to 28 weeks
when women become aware of Braxton Hicks contractions.
3. May have a role in the remarkable ability of the uterus to distend and
in the production of the necessary additional supportive connective
tissue for the growing muscle fibres.
4. Towards the end of pregnancy, rising levels of relaxin effect softening
of the collagenous content of the cervix (Verralls 1993).
5. May have a role in mammary growth.
6. Affects relaxation of the pelvic floor muscles (Verralls 1993).
REPRODUCTIVE Amenorrhoea is one of the first signs of pregnancy for most women,
SYSTEM although it is not uncommon to experience a slight bleed, for 1–2 days,
at the time at which menstruation would be expected if conception had
not occurred. Within a few days of conception the cervix, if viewed with
a speculum, will be seen to have changed in colour from pink to a bluish
shade. From a firmly closed structure, which increases in depth early in
pregnancy, the cervix changes by a gradual but accelerating process, which
in the final weeks involves the softening, greater distensibility, effacement
and eventually dilation (collectively called ripening) of the cervix. It has
been described as changing from feeling firm like the cartilage of the nose,
to feeling soft like the lips. These changes can be felt on digital examination
and are produced by the endocrine-controlled restructuring of collagen
and other tissues. As pregnancy progresses a plug of thick mucus forms in
the cervical canal, sealing the uterus. The Bishop score is the accepted
method of calculating the degree of ripeness of the cervix before labour.
Nine points or more is considered favourable (see p. 54).
The growing uterus rises out of the pelvis to become an abdominal
organ at about 12 weeks’ gestation, increasingly displacing the intestines
and coming to be in direct contact with the abdominal wall as pregnancy
proceeds. The average fundal height related to gestation is shown in
34 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
36
40
30
24
18
12
The uterus increases in size dramatically, as does its blood supply (Fig.
2.5). The weight of the uterine tissue itself increases from about 50 g to
1000 g at term. The muscle fibres of the fundus and body are exceptional
in their ability to increase in length and thickness throughout pregnancy
to accommodate the growing foetus; it has even been suggested that new
fibres may develop. The collagenous tissue, on and by which the muscle
fibres are supported, increases in area and elasticity through pregnancy
under hormonal influence. It has been said that in the nulliparous
woman the uterus would hold about a quarter of a teaspoon of fluid,
whereas the gravid uterus at term would contain 10 pints. As pregnancy
progresses the isthmus develops to become the lower uterine segment,
and by term it accounts for approximately the lower 10 cm of the uterus
above the cervix. The musculature is not highly developed in this area
and towards term it becomes soft and stretchy, allowing the foetus to sink
lower in the uterus and into the true pelvis.
The muscle fibres of the uterus increase in activity, and coordinated
contraction of the uterus can be detected by the woman by about 20 weeks’
36 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
CARDIOVASCULAR The blood volume increases by 40% or more to cope with the increasing
SYSTEM requirements of the uterine wall with the placenta as well as servicing
the other demands placed on the body, for example weight gain – both
supplying the greater bulk and the increased power needed to move it.
There is a greater increase in plasma than in red cells; consequently the
haemoglobin level falls to about 80%. This effect is variously called ‘dilu-
tion anaemia’ or ‘physiological anaemia of pregnancy,’ and is one cause of
women experiencing tiredness and malaise from quite early in pregnancy.
Progesterone acts on the smooth muscle of blood vessel walls to pro-
duce slight hypotonia, and causes a small rise in body temperature;
therefore pregnant women generally have a good peripheral circulation
and do not feel the cold. The heart increases in size and accommodates
more blood, so the stroke volume rises and the cardiac output increases
by 30–50%; there is a progressive small increase in heart rate through
pregnancy. These changes begin to occur quite early, and it must be
Physiology of pregnancy 37
RESPIRATORY SYSTEM The increased circulating progesterone levels of pregnancy further sensi-
tise the respiratory centre in the medulla to carbon dioxide; this and the
increasing demand for oxygen act as mild stimulants to ventilation. The
resting respiratory rate goes up a little, from about 15 to about 18 breaths
per minute, and there is a lowering by some 2% of the maternal blood
carbon dioxide tension; consequently women notice breathlessness on
activity. Tidal volume increases gradually by up to 40%, and alveolar
ventilation also rises. The vital capacity seems to stay much as it was, so
it is the expiratory reserve that is reduced. By the third trimester in many
pregnant women, the enlarging uterus increasingly impedes the descent
38 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
overlying the linea alba. Striae or ‘stretch marks’ can develop over but-
tocks, abdomen and breasts and may become pigmented. These striae are
a consequence of rupture of the dermis; the overlying epidermis is
stretched and the resulting scar is therefore visible and permanent. Striae
are caused by the need for skin to stretch rapidly over the enlarging body
but may be aggravated by the hormonally mediated softening of collagen
and by unnecessary weight gain. Some individuals appear to be more
prone to striae than others so a genetic predisposition has been sug-
gested. Certainly the application of oils with or without massage is
unlikely to be effective in prevention or cure; however, they may ease the
sensation of tight and stretching skin.
There is an increase in blood flow to the skin, which increases the
activity of sebaceous and sweat glands, and so increases evaporation.
Pregnant women may be expected to drink more to compensate. Fat is
laid down, particularly in the second and third trimesters, on the thighs,
upper arms, abdomen and buttocks, and is said to be a store which is sub-
sequently called on in breastfeeding, provided a woman does not ‘eat for
two’ in the puerperium.
GASTROINTESTINAL Nausea and vomiting, thought now to be the response of some to HCG,
SYSTEM is not necessarily restricted to the early morning, nor does it always cease
by the 16th week. It can be aggravated by certain foods, even by their
odours, and by iron tablets, and if inappropriately managed in severe
cases (hyperemesis gravidarum) can lead to maternal dehydration, mal-
nutrition and weight loss. Gross et al (1989) showed a higher risk for
foetal growth retardation and possible foetal anomalies amongst suffer-
ers with weight loss. The gut musculature becomes slightly hypotonic
and the motility is decreased. The inevitable sequelae of this are prolon-
gation of gastric-emptying time and a slower passage of food. Delay in
the large bowel results in increased absorption of water and a consequent
predisposition to constipation because the faeces are dry and hard. The
reduced speed of oesophageal peristalsis, a hormonally mediated slack-
ness of the cardiac sphincter, displacement of the stomach and an increased
intra-abdominal pressure as pregnancy progresses, all favour the gastric
reflux or ‘heartburn’ of which so many women complain. There is soft-
ening and hyperaemia of the gums, and bleeding may occur from quite
minor trauma. Salivation may be increased.
It has been estimated that a pregnancy involves an energy expenditure
of about 1000 kJ (239 kcal) per day (Durnin 1989, Hytten & Leitch 1971);
however, since most women reduce or adapt their activity because of
fatigue or the restrictions of their increased size and weight, and also
because metabolism becomes more efficient (Van Raaij et al 1987), it is
rarely necessary in the UK to increase intake, but only to encourage a
well-balanced diet with plenty of fibre. The average weight gain is
between 10 and 12 kg (Hytten & Chamberlain 1980) and is distributed as
shown in Figure 2.6. Although obesity is associated with hypertension,
diabetes and the need for caesarean section, pregnancy is not the time to
commence a weight-reducing diet (Moore 1997).
40 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Breasts 0.5 kg
Foetus 3.3 kg
Placenta 0.6 kg
Amniotic fluid 0.8 kg
Increased uterus 0.9 kg
NERVOUS SYSTEM Mood lability, anxiety, insomnia, nightmares, food fads and aversions,
slight reductions in cognitive ability and amnesia are all well substanti-
ated and common accompaniments of pregnancy. Recent work has
shown a real decrease in brain size in pregnancy (Holdcroft 1997,
Oatridge et al 2002) How this and alterations in emotional, cognitive and
sensual function are brought about is not known, but they are presum-
ably hormonally mediated phenomena.
Water retention quite frequently causes unusual pressure on nerves,
particularly those passing through canals formed of inelastic material
like bone and fibrous tissue (e.g. the carpal tunnel), with resulting neuro-
praxia. This can be relieved by the use of lightweight splints (Wand 1990).
Occasionally pregnant women complain of symptoms indicating traction
on nerves, which can be due to increased weight, for example water
retention in the arm increasing its weight and producing depression of
the shoulder, and paraesthesia in the hand.
Physiology of pregnancy 41
URINARY SYSTEM The presence of HCG in the urine early in pregnancy forms the basis
of the pregnancy test; the level falls after 12 weeks of pregnancy.
Throughout pregnancy there is an increase in blood supply to the urinary
tract in order to cope with the additional demands of the foetus for waste
disposal. There is an increase in size and weight of the kidneys, and dila-
tion of the renal pelvis. The musculature of the ureters is slightly hypotonic
so that they are a little dilated, and also seem to elongate to circumvent
the enlarging uterus; the possible result of these factors may be vesi-
coureteral reflux (Mikhail & Anyaegbunam 1995) or kinking with pos-
sible pooling and stagnation of urine; this may predispose to urinary tract
infections. There is an increased urinary output, and small changes in
tubular resorption caused by the pregnancy may result in excretion of
significant amounts of sugar and protein. Diabetes may be first diag-
nosed in pregnancy because pregnancy is one of the factors that may pre-
cipitate its onset in women genetically predisposed to the condition. This
usually regresses after delivery (gestational diabetes).
As the pregnancy progresses the bladder changes position to become
an intra-abdominal organ, is pressed upon and even displaced by the
increasingly large and heavy uterus. Thus the urethrovesical angle may
be altered and the intra-abdominal pressure raised; the smooth muscle of
the urethra may become slightly hypotonic, and it seems possible that
supportive fascia and ligaments of the tract and pelvic floor may become
more lax and elastic (Landon et al 1990). What is certain is that many
women complain of frequency in early pregnancy, which has often
resolved by the time they come to the booking clinic. This may be due to
an early rise in urinary output (Francis 1960a) and to subsequent adjust-
ments to this. Later in pregnancy, particularly towards term, there may
be urge and stress incontinence. The latter is said to occur in 50% of prim-
igravida and the majority of multipara (Francis 1960b). This led Francis
(1960b) to suggest that it was pregnancy rather than parturition that
caused subsequent incontinence problems in women. However, it is now
well established that delivery can damage the urethral closure mech-
anism (Snooks et al 1984) and be a cause of pudendal nerve damage
(Smith et al 1989). The cause of changes in continence in pregnancy is
more likely to be multifactorial, as discussed above. Caesarean section
appears to be only partially protective (Wilson 2002).
MUSCULOSKELETAL The influences of pregnancy on the musculoskeletal system are the ones
SYSTEM that involve the physiotherapist most directly, first to attempt to prevent
disorders arising and then, where problems do arise, to treat them.
There is a generalised increase in joint laxity, and so in joint range,
which is hormonally mediated. Oestrogens, progesterone, endogenous
cortisols and particularly relaxin seem to be responsible for this. Research
(Calguneri et al 1982) has shown that there is a greater increase in joint
range, and therefore in the degree of laxity, in a second pregnancy than
the first, but that subsequent pregnancies produce no greater degree.
Generally joint laxity returns postpartum to near its prepregnancy state,
but this may take up to 6 months. Histological animal studies suggest
42 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
COMPLICATIONS OF PREGNANCY
BREECH POSITION Many foetuses lie in breech position at some time during pregnancy.
However, the majority have turned into a vertex presentation by the 34th
week of pregnancy. A breech lie is predisposed by: some uterine anom-
alies, oligohydramnios, placenta praevia, fibroids, a contracted pelvis,
some foetal anomalies, polyhydramnios and multiple pregnancy. The
condition is diagnosed by abdominal palpation but is sometimes missed.
Ultrasound examination should be considered if there is any doubt in the
examiner’s hands and has the added advantage of determining whether
the foetus is suitable for external cephalic version (ECV). There are pos-
sible problems with ECV: foetal distress, premature rupture of membranes,
premature separation of the placenta and preterm labour. The operator
must therefore be both skilled and able to manage any presenting
problems. Positioning for spontaneous cephalic version has also been
suggested (see Further Reading, p. 52). If version is unsuccessful or con-
traindicated, the condition and the possibility of caesarean section must
be discussed with the woman.
CARDIAC DISEASE Cardiac output increases by 30–50% during pregnancy. Therefore any
woman with an underlying cardiac condition must be closely monitored.
Obstetricians will then determine whether they have a low, moderate or
high risk condition and treat them accordingly. It is of prime importance
Physiology of pregnancy 45
that any pregnant woman with a cardiac condition has adequate rest,
avoids any infections and has antibiotic cover during labour (Symonds
1992). There is also a risk of cardiac decompensation, especially during
labour and in the 4 days following parturition. Those with a valve
replacement may require anticoagulant therapy.
DIABETES MELLITUS Pregnant women with diabetes mellitus need careful supervision, as even
well-controlled diabetes may become unstable in pregnancy. The total or
relative lack of insulin can result in dehydration, hyperglycaemia, ketosis,
polyuria and polydipsia. Ultimately, in someone untreated, the result can
be acidosis, coma and even death. In addition the risk of perinatal death
remains relatively high for the offspring of diabetic mothers; the incidence
of pre-eclampsia, of foetal abnormalities and of intrauterine death are also
higher. Type I diabetics are insulin dependent whereas type II may be con-
trolled by diet alone or oral hyperglycaemic agents. Those at increased
risk of diabetes are those with a family history of diabetes, a previous baby
weighing more than 4.5 kg, a previous unexplained perinatal death, poly-
hydramnios, obesity, a history of a baby with congenital abnormalities or
glycosuria on two occasions in the antenatal clinic (Bewley 1997). Babies
of diabetic mothers have a greater risk of being macrosomic, weighing
more than 4.00 kg. The maternal hyperglycaemia stimulates foetal insulin
production and this in turn favours protein and fat deposition in the
foetus. A macrosomic foetus is at greater risk of birth trauma especially
brachial plexus lesion due to shoulder dystocia (Bewley 1997). However,
some of the babies are very small owing to placental dysfunction. Diabetic
mothers are often admitted to hospital early (30 weeks) for careful sur-
veillance, and then for early induction for those who are most stable, or
for elective caesarean section at 37–38 weeks for those who are not.
ECTOPIC PREGNANCY The fertilised ovum occasionally implants outside the uterus, most com-
monly in the fallopian tube at the ampulla or the isthmus – the junction
of the tube with the uterus. The ovum burrows into the blood vessels of
the tubal musculature; there being no decidua, this can cause surround-
ing necrosis. 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. More recently the
development of immunoassays using monoclonal antibodies to -HCG
and high-resolution ultrasound scanners means that there can be a diag-
nosis of ectopic pregnancy before any significant haemorrhage occurs
(Bhatt & Taylor 1995). Treatment options can then be considered; these
may be surgical, medical or observation and monitoring.
FIBROIDS Fibroids of the uterus (see p. 278) are more common in older and in Afro-
Caribbean women. Acute abdominal pain may be caused by degenera-
tive changes resulting from altered blood supply or from pressure and
46 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
tension as the uterus hypertrophies and stretches. They may also obstruct
labour and lead to an abnormal lie of the foetus.
GENITAL HERPES Herpes simplex virus can cause facial sores (usually HSV-1) or genital
sores (usually HSV-2). Either type can affect a newborn baby. If the HSV
virus is present in the birth canal during delivery it can be transmitted to
the infant. Neonatal herpes is a rare but life-threatening disease in which
there can be damage to the infant’s skin, eyes, mouth, central nervous sys-
tem and internal organs and it can cause mental retardation or even death.
It is, however, quite rare in the UK, with an incidence of 1.65/100 000 live
births (Tookey & Peckham 1996). A genitourinary physician should be
involved with the care of the mother with acyclovir being the usual treat-
ment. Delivery by caesarean section is recommended for those mothers
with an active HSV-2 infection. Women’s health physiotherapists must be
aware of the risk of neonatal transmission from active HSV lesions.
INTRAUTERINE DEATH Even apparently light-hearted comments by pregnant women that foetal
movements have substantially reduced or appear to have ceased should
be taken seriously, for a foetus can become compromised and even die in
utero. A women’s health physiotherapist should arrange immediate
referral to a midwife or doctor, and steps should be taken to monitor the
foetal heart. Placental insufficiency and eclampsia can cause foetal death,
but often the cause is obscure.
HUMAN The HIV virus is a retrovirus affecting human lymphocytes and other
IMMUNODEFICIENCY cells of the central nervous system. There are different descriptors for
VIRUS (HIV) the level of HIV infection: asymptomatic, persistent generalised lymph-
adenopathy (PGL), AIDS-related complex (ARC), acquired immune
deficiency syndrome (AIDS) and neurological HIV. Initially the HIV
infection is asymptomatic with a variable incubation period. The transmis-
sion of the virus can be sexual, blood borne or maternal to foetus or infant.
In those women with HIV there is a greater risk of preterm labour and also
low birthweight babies. Foetal AIDS manifests itself as intrauterine growth
retardation (IUGR), microcephaly, a prominent forehead and blue sclerae
(Symonds 1992). The maternal transmission of HIV can be transplacental,
by ingestion or inoculation at birth or by breastfeeding (Murray 1997). In
treating an HIV positive woman it is essential to treat the woman as some-
one that is HIV positive rather than someone who is pregnant (Kotler
Physiology of pregnancy 47
INTRAUTERINE Foetal growth retardation may result from impaired placental function.
GROWTH Progressive hypoxia affects growth with eventually the foetal organs
RETARDATION beginning to fail, the placenta ageing, renal blood flow falling with a
decrease in amniotic fluid. Anoxia of the central nervous system results
in decreased movement, tone and foetal heart rate variability. The condi-
tion is poorly understood, but can be due to pre-eclamptic toxaemia,
hypertension, small placental separations, infarctions, failure of the pla-
centa to develop or premature reduction in its function. Foetal growth
may be accurately assessed by serial ultrasound scan measurement of the
biparietal diameter of the foetal skull and abdominal width. External car-
diotocograph of the foetus and Doppler studies may also be carried out.
MULTIPLE There is increased physical and emotional strain upon the mother with
PREGNANCIES multiple pregnancies, and as might be expected an increased likelihood
of the occurrence of the other complications of pregnancy. Obviously the
stretch on the structures of the abdominal wall will be greater than in a
singleton pregnancy. In addition, possibly due to the proportionately
larger content of the uterus at each stage in gestation, there is a predispos-
ition to pregnancy-induced hypertension (PIH) and premature labour.
PLACENTA PRAEVIA Normally the placenta implants and develops high up on the uterine
wall. However, occasionally implantation occurs lower down, close to or
over the cervix. Associated factors include multiparity, multiple preg-
nancy, older mothers, a scarred uterus, smoking and placental abnormal-
ity. There are four degrees:
• Type I – the major part of the placenta is in the upper uterine segment
but encroaches on the lower segment; vaginal delivery is possible.
• Type II – part of the placenta is in the lower uterine segment reaching
but not covering the internal os; vaginal delivery is possible, particu-
larly if the placenta is anterior.
• Type III – the placenta is to one side over the internal os when it is
closed, but not completely on dilatation; vaginal delivery should not
be allowed.
• Type IV – the placenta is sited centrally over the internal os; vaginal
delivery will not be allowed.
48 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
SICKLE CELL The ethnic origins of people with SCD are mainly Africa, the Caribbean,
DISEASE (SCD) eastern Mediterranean, the Middle East and Asia. Those with SCD have
sickle haemoglobin, such that when the haemoglobin gives up the oxy-
gen to the tissues it forms long rods inside the cell, making the cells rigid
and sickle shaped. This affects the viscocity of the blood causing local
stasis and transient vascular occlusion. Chorionic villus sampling (CVS)
at around the 9th or 10th week or amniocentesis between the 16th and
18th weeks of the pregnancy can determine whether the foetus is affected.
Hypertension has been found to be the most common complication for
pregnant women with SCD with one-fifth of the pregnancies producing
preterm deliveries and SFGA infants (Smith et al 1996). Therefore close
monitoring throughout pregnancy is essential. During labour, cardiac
function can be compromised because of chronic hypoxemia and
anaemia. Cord blood saved from a non-affected child can be banked for
use in the case of a further sibling suffering with the condition.
THE THALASSAEMIAS These genetic disorders are associated with a decrease in the production
(ALSO KNOWN AS of one or more of the globulin chains of haemoglobin. The two main types
COOLEY’S ANAEMIA) are alpha thalassaemia and beta thalassaemia and are more common in
populations from the Mediterranean countries, India and SE Asia. If all
four alpha-controlling genes are inherited, a baby will be stillborn, if three,
the baby is live but severely anaemic, if two then, hypochromic anaemia
is common, and if one, the alpha-controlling gene is deleted and the baby
is a clinically undetected carrier. Those women with the condition will
need repeated transfusions during their pregnancy. They are also at
greater risk of pregnancy-induced hypertension and urinary tract infec-
tions. Thalassaemia in the foetus can be determined by CVS early in preg-
nancy, or by sampling the foetal blood in the umbilical cord later in the
pregnancy.
UNSTABLE LIE, Towards term, if the longitudinal axis of the foetus is repeatedly chang-
TRANSVERSE LIE ing within the uterus, it is said to be unstable. This occurs almost exclu-
sively in grand multiparae, that is those with four or more viable past
50 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
References
Adewole I F, Franklin O, Matiluko A A 1993 Cervical Francis W 1960b The onset of stress incontinence. Journal of
ripening and induction of labour by breast stimulation. Obstetrics and Gynaecology of the British Empire
African Journal of Medical Science 22(4):81–85. 67:899–903.
Amon E 1992 Premature labour. In: Reece E, Hobbins J, Fransden V A 1963 The excretion of oestriol in normal
Mahoney M, Petrie R (eds) Medicine of the fetus and human pregnancy. Munksgaard, Copenhagen.
mother. J B Lippincott, Philadelphia, p 1398–1429. Goldberg I, Hod M, Katz I et al 1989 Severe preeclampsia
Artal R, O’Toole M 2003 Guidelines of the American College and transient HELLP syndrome. Journal of Obstetrics
of Obstetricians and Gynecologists for exercise during and Gynaecology 9:299–300.
pregnancy and the postpartum period. British Journal of Gross S, Librach C, Cecutti A 1989 Maternal weight loss
Sports Medicine 37:6–12. associated with hyperemesis gravidarum: a predictor of
Bewley C 1997 Medical conditions complicating pregnancy. fetal outcome. American Journal of Obstetrics and
In: Sweet B, Tiran D (eds) Mayes’ midwifery, 12th edn. Gynecology 160:906–909.
Baillière Tindall, London, p 548–568. Halliday H 1992 Prematurity. In: Calder A, Dunlop W (eds)
Bhatt A N, Taylor D J 1995 Advances in the treatment of ectopic High risk pregnancy. Butterworth Heinemann, Oxford,
pregnancy. In: Bonnar J (ed) Recent advances in obstetrics p 332–354.
and gynaecology, no. 19. Churchill Livingstone, London Hansen A, Jensen D V, Larsen E et al 1996 Relaxin is not
Bigazzi M, Nardi E, Bruni P et al 1980 Relaxin in human related to symptom-giving pelvic girdle relaxation in
decidua, Journal of Clinical Endocrinology and pregnant women. Acta Obstetrica et Gynecologica
Metabolism 51(4):939–941. Scandinavica 75(3):245–249.
Booth D, Chennelle M, Jones D et al 1980 Assessment of Hod M, Merlob P, Friedman S 1991 Gestational diabetes
abdominal muscle exercises in non-pregnant, pregnant mellitus – a survey of perinatal complications in the
and postpartum subjects using electromyography. 1980s. Diabetes 4(suppl):74–78.
American Journal of Physiology 26(5):177. Holdcroft A 1997 MRI brain changes. Modern Midwife
Brown M A, Whitworth J A 1999 Management of 7(8):5.
hypertension in pregnancy. Clinical and Experimental Hytten F E, Chamberlain G (eds) 1980 Clinical physiology in
Hypertension 21(5–6):907–916. obstetrics. Blackwell, Oxford.
Bryant Greenwood G D 1982 Relaxin as a new hormone. Hytten F E, Leitch I 1971 The physiology of human
Endocrine Review 3(1):62–90. pregnancy. Blackwell, Oxford.
Bullock J, Jull G, Bullock M 1987 The relationship of low Irons D W, Sriskandabalan P, Bullough C H 1994 A simple
back pain to postural changes during pregnancy. alternative to parenteral oxytoxics for the third stage of
Austrian Journal of Physiotherapy 33:10–17. labour. International Journal of Gynaecology and
Calguneri M, Bird H A, Wright V 1982 Changes in joint Obstetrics 46(1):15–18.
laxity occurring during pregnancy. Annals of Rheumatic Kadar N, Tapp A, Wong A 1990 The influence of nipple
Disease 41:126–128. stimulation at term on the duration of pregnancy. Journal
Crowley P 2002 Interventions for preventing or improving of Perinatology 10:164–166.
the outcome of delivery at or beyond term (Cochrane Kaufman B A, Warren M P, Dominguez J E et al 2002 Bone
Review). In: The Cochrane Library, Issue 4. Update density and amenorrhea in ballet dancers are related to a
Software, Oxford. decreased resting metabolic rate and lower leptin rates.
Douglas K A, Redman C W G 1994 Eclampsia in the United Journal of Clinical Endocrinology and Metabolism
Kingdom. British Medical Journal 309:1395–1400. 87(6):2777–2783.
Durnin J V 1989 Energy requirements of pregnancy. Lancet Kotler D P 2003 Human immunodeficiency virus and
ii:895–900. pregnancy. Gastroenterology Clinics of North America
Elliott J P, Flaherty J F 1984 The use of breast stimulation to 32(1):437–448.
prevent postdate pregnancy. American Journal of Kramer M S 2003 Aerobic exercise for women during
Obstetrics and Gynecology 149:628–632. pregnancy. In: The Cochrane Library, Issue 1. Update
Francis W 1960a Disturbance of bladder function in relation Software, Oxford.
to pregnancy. Journal of Obstetrics and Gynaecology of Kristiansson P, Samuelsson E, von Schoultz B et al 2001
the British Empire 67:353–366. Reproductive hormones and stress urinary incontinence
Physiology of pregnancy 51
Further reading
Artal R, Wiswell R, Drinkwater B C 1991 Exercise in Symonds E M 1992 Essential obstetrics and gynaecology,
pregnancy, 2nd edn. Williams & Wilkins, Baltimore. 2nd edn. Churchill Livingstone, London.
Sutton J, Scott P 1995 Understanding and teaching optimal Symonds E M, Macpherson M B A 1997 Diagnosis in color.
foetal positioning. Birth Concepts, Tauranga. Obstetrics and gynecology. Mosby-Wolfe, London.
Sweet B, Tiran D (eds) 1997 Mayes’ midwifery. A textbook
for midwives, 12th edn. Baillière Tindall, London.
Useful addresses
Action on Pre-eclampsia (APEC) Pre-Eclamptic Toxaemia Society
84–88 Pinner Rd, Harrow, Middlesex HA1 4HZ 33 Keswick Avenue, Hullbridge, Essex SS5 6JL
Website: www.apec.org.uk
Sickle Cell Society
Cooley’s Anemia Foundation 54 Station Road, London NW10 4UA
Website: www.thalassemia.org Tel 020 8961 7796
Website: www.sicklecellsociety.org
National Childbirth Trust (NCT)
Alexandra House, Oldham Terrace, Acton, London W3 6NH UK Thalassaemia Society
Website: www.nctpregnancyandbabycare.com 19 The Broadway, Southgate Circus, London N14 6PH
Website: www.ukts.org
Pre-Eclampsia Society
c/o Dawn James, Rhianfa, Carmel, Caernarfon, Gwynedd Thalassaemia International Federation
LL54 7RL Po Box 28807, Nicosia 2083, Cyprus
Website: www.dawnjames.clara.net Website: www.thalassaemia.org.cy
53
Chapter 3
CHAPTER CONTENTS
Introduction 53 Complications of labour 73
Physical and physiological changes 53 Interventions in labour 79
The process of normal labour 56 The puerperium 84
Management of normal labour 68
INTRODUCTION
PRELABOUR Enzymes released from 36 weeks’ gestation onwards affect the collagen
of the cervix to effect cervical softening prior to labour (Granstrom et al
1989). This effacement or taking up of the cervix occurs in the final 2 or 3
weeks of the pregnancy. The Bishop score (Table 3.1) calculates the degree
of ripeness of the cervix; a score of nine or more is considered favourable.
The position of the foetus at the start of labour is significant because it has
a crucial impact on the mechanics of labour. Usually (97% of the time) the
54 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
THE STAGES OF First stage of labour is said to be established when there are regular
LABOUR painful contractions with effective descent of the foetus and dilatation
of the cervix. A multiparous woman may have a dilated cervix of 3 cm
First stage without being in labour, whereas a primiparous woman may be
in established labour at a lesser cervical dilatation. The midwife is skilled
to assess each presenting woman to determine when the first stage of
labour is established. When the regular uterine muscle contractions are
established, they become progressively longer, stronger and closer
together. For most women these contractions are painful and many
require some form of analgesia. Within the uterus, the uterine contrac-
tions exert an intermittent upward pull on the lower segment of the
uterus and cervix, while at the same time applying downward pressure
on the foetus. This combination opens the cervix, pushing the foetus
against and through it (Fig. 3.1). It has been compared to pulling a polo-
neck sweater over the head. In addition the uterine cavity becomes pro-
gressively smaller. The first stage is almost always the longest stage. It is
said to be complete when the cervix has reached full dilatation – about
10 cm diameter depending on the size of the foetal head – to allow the
foetal head through to proceed down the vagina.
Second stage There is often a noticeable change in the tempo of contractions; they may
become more widely spaced and even a little shorter, while still remain-
ing intense. This continued action of the uterine muscle further reduces
the size of the uterus and expels the foetus from it into the vagina. This
process is accompanied in most women by a compelling urge to bear
down. The diaphragm and the abdominal muscles are brought into
Physical and physiological changes of labour and the puerperium 55
action to help push the foetus out. The pelvic floor distends under the
pressure, the puborectalis and pubococcygeus muscles are parted and
pushed aside and outward, and the soft tissues of the perineum extend to
form a canal, which gutters forwards from the coccyx. This canal pro-
trudes and is directed anteriorly. It takes time for the perineum to stretch
sufficiently to allow the foetus through, and performing an episiotomy
may accelerate its delivery. The second stage is normally much shorter
than the first, ending with the birth of the baby.
Third stage The third stage is the delivery of the placenta once it has detached from
the uterine wall. It is usually the shortest phase.
SIGNS THAT THE 1. Late in pregnancy the mucoid ‘show’ – often blood stained – is passed
START OF LABOUR per vaginam down the cervical canal; this may be considered a sign
MAY BE IMMINENT that labour is imminent. The purpose of this mucous plug during
pregnancy is to act as a barrier to upward-moving infection. Ripening
of the cervix and increased uterine muscle activity results in it being
released sooner or later. Except where there is any measurable loss of
fresh blood, women are advised to note the event but take no other
special action.
2. ‘Ruptured membranes’ or the ‘breaking of the waters’. This is a rupture of
the amniotic sac resulting in a sudden or gradual loss of amniotic fluid.
It may be difficult for a woman to discriminate between gradual, slight
amniotic fluid loss, and loss of urine due to stress or urge incontinence.
Where the foetus presents head first in labour, and the head is begin-
ning to fit snugly into the lower segment and cervix, a small bulging
portion of the sac filled with fluid may be in front of the head (the fore-
waters), and it is essentially cut off from the remainder (the hind-
waters). Thus when it is suspected that the membranes have ruptured,
the amount lost may be some guide to the position of the foetal head.
Where the head is high and not well applied to the cervix a larger
56 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
amount is lost than when the head is firmly applied. A gradual drip-
ping would suggest a small puncture in either the fore- or hindwaters.
Women are advised to report suspected loss of amniotic fluid, partic-
ularly if it is considerable, as it is possible for the umbilical cord to
prolapse downwards through the ruptured sac and already dilating
cervix, ahead of the presenting part where this is not well engaged. If
this is the case then subsequent uterine contractions will plunge the
foetus downwards and might compress the cord. Should this happen
the resulting vascular occlusion could compromise the foetus and
lead to distress or death. Any sign of umbilical cord prolapse requires
immediate medical care. It should be remembered that amniotic fluid
production will continue until delivery so that, even when large
amounts are lost, further dripping will occur.
3. Contractions. Braxton Hicks contractions increase in frequency and
strength as pregnancy progresses, to eventually become regular and
lasting 20–30 seconds at 20–30-minute intervals as a herald of the
uterine contractions of established labour. Labour is said to be estab-
lished when the uterine muscle contraction of the fundus and body
become increasingly apparent and settle into a regular, continuing
and increasingly intense and painful pattern.
These three signs are commonly presented in the literature and parent-
craft classes as heralds of labour. There is, however, wide individual vari-
ation, for example a ‘show’ and ‘ruptured membranes’ may occur well in
advance of or during labour, and intermittent sequences of strong,
painful contractions can be experienced without labour becoming estab-
lished (Braxton Hicks contractions). Therefore the only really reliable
signs that labour is established are regular, painful and continuing con-
tractions, and a progressively dilating cervix.
1. A rise in the oxytocin level. It has also been shown that there is an
increase in nocturnal myometrial activity from 24 weeks of pregnancy.
The plasma concentrations of oxytocin have been shown to have noc-
turnal peaks between 37 and 39 weeks (Moore et al 1994). The physi-
cal size and pressure of the growing foetus on the ripening cervix may
stimulate a neurogenic reflex which causes the posterior pituitary to
release more oxytocin. In addition, or alternatively, the maturing
foetus may produce increasing amounts of oxytocin, which cross the
placenta. Oxytocin is known to cause the uterine muscle to contract.
Physical and physiological changes of labour and the puerperium 57
2. Prostaglandin production. The uterine wall has the potential, like many
other tissues, to produce prostaglandins. These are fatty acids which
in 1930 were first found in semen and shown to cause smooth muscle
to contract. They have a short life because they are rapidly metabolised,
and therefore have local effects. It is known that oestrogens could trig-
ger the release of myometrial prostaglandins. It is also known that the
disruption of decidual cells, such as occurs when the amniotic sac is
artificially ruptured, would cause prostaglandin release. It has been
suggested that stretching of the uterine wall by the growing, kicking
foetus has a similar effect. The prostaglandins in semen may be the
explanation for the circumstantial evidence that intercourse appears to
stimulate the start of labour in some cases. However, Kavanagh et al
(2001) completed a systematic review of the literature for the Cochrane
database and concluded that the role of sexual intercourse for the
induction of labour is uncertain. However, it was also stated that it
would be difficult in any trials to standardise sexual intercourse as a
possible intervention for meaningful comparison with other methods
of induction.
3. Foetal adrenal hormones. Studies in animals (Currie et al 1973, Liggins
1974) have shown a rapid increase in the production of foetal cortisols
a few days before the onset of labour. These high concentrations act at
the placenta to reduce the secretion of progesterone and increase the
secretion of oestrogens. A marked rise in oestradiol is associated with
a prostaglandin being produced in the placenta. It is suggested by
some (Shearman 1986) that a similar set of changes must be operative
to enable the human foetus to control the onset of labour.
Late in pregnancy and continuing in early labour, the lower part of the
uterus – the isthmus – responds to the contraction of the muscle of the
fundus and body by stretching and thinning to form the lower uterine
segment. It is thought that uterine contractions are normally initiated
around the openings to the fallopian tubes, spread to the fundus and then
down the body of the uterus. Ideally there is a gradient pattern in these
contractions, with the fundus dominant and the lower uterine segment
less active; this is called normal uterine polarity.
The early signs, symptoms and circumstances are highly individual to
each labour but contractions usually settle into a regular pattern. Often,
initially, these are short in length (about 30 seconds) and some distance
apart (15–20 minutes), but progressively become longer, stronger and
closer together until they are about 1–1.5 minutes in length and occur
every 2–5 minutes. Occasionally women notice only the longer, stronger
contractions.
Further tension on the lower uterine segment causes the cervix to be
‘taken up’ or effaced, so eventually the cervical canal becomes part of the
containing uterine wall. It is then gradually opened or dilated. Thus ultim-
ately it is effacement and dilatation that releases the plug of mucus or
‘show’ if it has not occurred earlier. As labour progresses there is an
increase in oxytocin release by the posterior pituitary, which causes
58 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
• prior to sedation if the membranes rupture when the foetal head is not
well engaged
• if the woman wishes to push when there is nothing visible
• if there is undue delay in the second stage of labour
• to rupture the membranes if necessary.
Vaginal examination is kept to a minimum because of the risk of introduc-
ing infection and also it is a particularly uncomfortable investigation in
labour. There must always be an explanation for and description of the pro-
cedure in order for the women to give informed consent. Many units vagi-
nally examine women at 4 hourly intervals during labour for plotting on a
partogram. The descent can be measured by how much of the foetal head –
in fifths – is still palpable above the pelvic brim or is below the ischial
spines as palpated vaginally (see Fig. 2.4 on p. 34).
The second stage contractions vary from those in the first stage, in that
there is not only a uterine contraction creating force, but also a bearing
down caused by the contraction of the diaphragm and abdominal mus-
cles of the woman to aid expulsion. This stage can also be considered to
have two phases: the phase of descent in which the foetal head descends
down on to the perineum, and the perineal phase in which the perineum
stretches, adaptively remodels to form an extended passage and allows
the head through. It is now appreciated that a prolonged active second
stage may be dangerous for both child and mother, causing foetal distress
or maternal pelvic floor neuropathy. Therefore most labour suites have
their own criteria for deciding when assistance such as intravenous infu-
sion of oxytocic drugs, episiotomy, vacuum extraction or forceps should
be considered to accelerate delivery.
Following delivery, the uterus continues to contract, constricting the
placental vascular sinuses and causing the placenta to sheer away from
the wall and separate. The contraction and retraction of uterine muscle
has the effect of ligating the maternal blood vessels within the placental
attachment site and controlling the considerable risk of serious haemor-
rhage when the placenta eventually detaches. Further contractions and,
in most units, an intramuscular injection of ergometrine and oxytocin
given after delivery of the shoulders with continuous cord traction, nor-
mally result in the delivery of the placenta. It is known that nipple stimu-
lation, for example when an infant suckles, causes the posterior pituitary
to produce oxytocin. Some midwives utilise this fact by encouraging the
newly delivered infant to begin suckling in the third stage of labour to
enhance uterine contractions and speed the separation and delivery of
the placenta. Some even manually stimulate nipples in the first and sec-
ond stage where contractions seem to be failing.
THE PAIN OF LABOUR Pain has been defined as ‘an unpleasant sensory and emotional experi-
ence associated with actual or potential tissue damage, or described in
terms of such damage’ (Mersky 1979). Parturition pain is an experience
that is shared by women at every level of civilisation (Melzack et al 1981),
and it has been mentioned since the recording of history began. Although
cultural, socioeconomic, psychological and emotional aspects must have
60 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Causes of labour pain The main cause of pain during the first stage of labour is thought to be
directly associated with dilatation of the cervix and distension of the
lower uterine segment around the descending presenting foetal parts
(Fig. 3.1). The sensory nerve supply from these two areas of the uterus
is greater than that from the fundus or uterine body (see p. 17). Other
suggested causes of first stage labour pain include ischaemia of the
myometrium and cervix, pressure on sensory nerve endings in the uter-
ine body and fundus, inflammatory changes in the uterine muscles, and
reflex contraction of the cervix and lower uterine segment due to the ‘fear–
tension–pain’ cycle (Wall & Melzack 1984); however, these have not
been substantiated by research. Brown et al (1989) compared the pain
experienced at two stages of dilatation in the first stage of labour: 2–5 cm
and 10 cm. As cervical dilatation increased, there were significant
increases in self-reported and observed pain. Using words from the
McGill pain questionnaire, pain was characterised as ‘discomforting’
during early dilatation and as ‘distressing, horrible, excruciating’ as
labour progressed. Green (1993) states that anxiety regarding pain is a
strong predictor of negativity regarding labour and birth, together with
poor postnatal emotional well-being.
In common with pain from other viscera, first stage pain is referred to
the dermatomes supplied by the same spinal cord segments (T10–L1)
that receive input from the uterus and cervix (Fig. 3.3). As labour pro-
gresses and the intensity and frequency of the contractions increase, the
Physical and physiological changes of labour and the puerperium 61
pain zones enlarge and become more diffuse (Fig. 3.4). At the end of the
first stage of labour some women experience aching, burning and cramp-
ing discomfort in the thighs. This is due to stretching of, and pressure on,
pain-sensitive structures (uterine and pelvic ligaments and fascia, blad-
der, urethra and rectum) and pressure on the lumbar and sacral nerve
roots. Once the cervix is fully dilated the nature and distribution of pain
changes.
In the second stage and during delivery the pain is felt chiefly in the
soft tissues of the perineal region (S2–S4) as they stretch, distend and
even tear; in addition, pain may be experienced as the pelvic outlet is
pushed open by the foetus, affecting the symphysis pubis, sacroiliac and
sacrococcygeal joints. An effort has been made to describe the areas of
pain distribution as labour progresses (Bonica 1984), but a tremendous
variability should be expected. Some women will experience widespread
discomfort, and others will have more discrete painful areas.
The obstetric team must never underestimate the intensity of labour
pain. Using the McGill pain questionnaire, some scores as low as 10 (very
mild pain) were recorded by Melzack (Table 3.2), but at the top end of
the scale scores as high as 62 (extremely severe pain) were registered
(Melzack 1984). Primiparae tend to experience higher levels of pain than
multiparous women, and, although those women who have received
childbirth training record lower levels of pain than the untrained
(Melzack et al 1981), it is still greater during a first labour than
subsequently.
62 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
NORMAL LABOUR AND In 38% of cases, labour starts with the foetal head in the left occipito-
DELIVERY lateral (LOL) position; that is the foetus is facing the right maternal ilium.
A further 24% are in the right occipitolateral position. In either case the
The mechanics of long axis of the foetal head is on the long axis of the maternal pelvic inlet
labour (see p. 3). Initially the upper part of the head is the presenting portion;
however, as labour progresses the head flexes and descends so that the
upper and more posterior part of the head (the vertex) leads.
As the descent into the pelvis continues the foetal head rotates through
90° until the face is towards the sacrum and coccyx, and the occiput is
below the symphysis pubis. All the diameters in mid-cavity are similar
(see p. 3); this allows a corkscrew action with the body following, ending
with the long axis of the foetal head in the long axis of the maternal pelvic
outlet. In addition the foetus has to negotiate a ‘corner’ in its route as the
pelvic inlet is at right angles to the outlet.
Further descent produces extension of the foetal neck beneath the
symphysis pubis. Usually at delivery the baby’s head faces posteriorly;
the shoulders are still oblique but turning. As the shoulders descend,
their greatest width comes to lie anteroposteriorly in the long axis
of the outlet, and the baby’s head, which is by now delivered, turns to
face the mother’s right leg (restitution). The anterior shoulder slips under
the symphysis pubis first, and is usually quickly followed by the other
shoulder and the rest of the body.
The effect of labour on Both the mother and the foetus will experience modest stress even during
maternal and foetal a perfectly normal and straightforward labour, and levels of the cat-
physiology echolamines, adrenaline (epinephrine) and noradrenaline (norepineph-
rine) are raised, producing the familiar ‘fight or flight’ response. In both
mother and foetus this will result in the shunting of blood to vital organs
such as the heart and lungs, so making more oxygen available, and in
the mobilisation of energy stores. It must be appreciated, however, that
64 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
The foetus There is still a great deal that is not fully understood, but it is known that
the particular stress of the second stage and delivery on the foetus results
in a surge of catecholamines, predominantly noradrenaline (norepine-
phrine), which facilitates normal breathing, and helps the baby maintain
body heat and survive adversity – particularly low oxygen conditions – in
the first few hours of independent life. Compression of the foetal thorax in
both first and second stages squeezes out fluid that normally fills the
lungs, but absorption of the remaining lung liquid and the release of suf-
ficient surfactant appears to be dependent on an increase in plasma cat-
echolamines immediately at birth to prevent the neonate from drowning.
advocated that nothing should be taken orally during labour; this belief
continued for many decades. However, others believe that a lack of nutri-
tion in labour may lead to dehydration and ketosis with an increased
consequential need for intervention. Those who advocate feeding in
normal labour suggest the ingestion of frequent light meals that are low
in fat and roughage and easily absorbed; fluids should be allowed as
desired. This is generally considered reasonable provided that there is no
suggestion that there will be a need for general anaesthesia or that nar-
cotic analgesia has been given. Speak (2002) reviewed the available litera-
ture and concluded that guidelines dating from 1946 should not be used
to determine the management of women in labour; also that women
in labour should be given the choice. There is insufficient research evi-
dence to dictate a policy of no food or drink in labour; further research is
required.
The effect of labour on As the foetal head descends it follows the curve of the sacrum and coccyx
the pelvic floor and to reach the pelvic floor. It exerts pressure, which dilates the vagina,
perineum stretches the perineum, and separates and displaces the levator ani
muscles sideways and downwards. The bowel is compressed, and the ure-
thra is stretched as the bladder is pulled up above the symphysis pubis
by virtue of its attachment to the cervix and uterus. This makes more space
in the pelvis. The stretching, lengthening and consequent thinning of the
posterior portion of the pelvic floor and perineum, ahead of the foetus,
form the birth canal, and enable the vaginal opening to be turned and
directed more anteriorly. Physiotherapists should note that it is this
stretching, bowing and thinning of the pelvic floor, particularly when
aggravated by the use of instruments needed for assistance (e.g. forceps)
that is thought to be a cause of pudendal nerve damage. This has been
shown to be associated with faecal and urinary incontinence postpartum
(Allen et al 1990, Snooks et al 1984, Sorensen et al 1988, Sultan et al 1994a).
It can also cause vascular damage resulting in haematoma, or more general
bruising and oedema. Fascia may be overstretched and muscle fibres torn.
The stretching and thinning takes time in the second stage of labour
and may result in a tearing of the vaginal opening. Previously it was
believed that judgement should be used to determine, first, whether
foetal and maternal welfare are best served by waiting for the natural
stretching to occur or by accelerating the delivery process with an episi-
otomy and, secondly, whether an episiotomy is needed to avoid an
uncontrollable tear, perhaps involving the anal sphincter. However, there
is now evidence that using an episiotomy to prevent tears does not result
in less trauma, improve healing or decrease incontinence and dyspareu-
nia (Sleep et al 1984, Sleep & Grant 1987). Furthermore in a study of 697
66 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
low-risk randomised women, it was shown that perineal and pelvic floor
morbidity was greatest amongst women receiving median episiotomy
compared with those remaining intact or with spontaneous tears (Klein
et al 1994).
The duration of labour Each labour is individual, even in the same woman, and there are wide vari-
ations in duration, particularly between primigravidae and multigravidae.
Statistics seem to indicate that modern obstetric practices, particularly
induction, acceleration, sedation, ambulation and the greater use of cae-
sarean section, have resulted in labours on average being shorter now than
formerly. In many centres it is general policy to try to ensure that 24 hours
is the outside limit for a labour, it being considered more than enough for
all parties involved. A prolonged labour may cause maternal distress, with
a rise in temperature, pulse and blood pressure; dehydration, oliguria and
ketosis also develop, perhaps accompanied by vomiting (O’Brien 1997).
Other possibilities cited by the author are intrauterine infection, the risk of
ruptured uterus if there is an undetected cephalopelvic disproportion, and
of operative intervention, anaesthesia and postpartum haemorrhage. There
is also the possibility of intrauterine hypoxia of the infant with all the ensu-
ing problems that may occur as a result.
Nesheim (1988), in a sample of 9703 labours in Norway, found a
median duration of 8.2 hours for nulliparae and 5.3 hours for multiparae,
whereas Morrin (1997a) quoted in primigravidae 12–14 hours for the
first stage and 1 hour for the second stage, and in multigravidae 6–10
hours for the first stage and a second stage of up to 30 minutes. Nesheim
(1988) showed that induced labours were shorter than those with spon-
taneous onset, 1.9 hours shorter in nulliparae and 1.4 hours in multiparae,
and also that tall women had quicker labours than short women. Maternal
age did not seem to influence duration, but the weight of the baby, mater-
nal weight gain in pregnancy and the prepregnancy weight all correlated
positively with longer labours. The implications in health education are
clear: that women should be encouraged to achieve an optimum weight
for their height preconceptually and then control their weight gain dur-
ing pregnancy. Interestingly, Nesheim (1988) found that, whereas in nul-
liparae the occipitoposterior positions and failure of the head to flex
prolonged labour, breech presentations did not. In multiparae, none of
these presentations prolonged labour.
Positioning in labour Considerable research effort has been expended on determining whether
there is advantage, as logic would suggest, in the upright positions in
labour, for example sitting, standing or forward-leaning, and kneeling.
Caldeyro-Barcia (1979), Flynn et al (1978), Mendez Bauer et al (1975) and
Mitre (1974) seem to show a shorter first stage correlating with being
upright and ambulant, but McManus & Calder (1978) and Williams et al
(1980) could find no statistical difference whether a labouring woman
remained recumbent or was actively encouraged to be upright and move
around. It is agreed, however, that the labouring woman’s contractions are
stronger in the upright position (Flynn et al 1978, Read 1981). Positional
Physical and physiological changes of labour and the puerperium 67
The third stage usually lasts not more than 30 minutes. The mother is
normally so involved with the baby that, if all goes well, she is unaware
of the process. The woman intuitively adopts a resting posture with the
baby; many midwives prefer the supine position for the third stage
because the uterus is more easily observed and cord traction, if needed,
can be applied more effectively. It is said that there is also less danger in
this position of air reaching the blood sinuses in the placental site, which
could cause an air embolism.
Most maternity units now have written protocols regarding the manage-
ment of the labouring woman, with set criteria for intervention. These
predetermined consensus guidelines have the advantage of overcoming,
to some extent, the problems posed by several consultants serving one
unit, each with their own management preferences. Such protocols can
be of benefit also to midwives where the shift system and staff changes
can make continuity of care and communication difficult. However, it is
clear that management of the labouring woman does vary from place to
place as evidenced by the variation from one UK health region to another
of the caesarean section rate. Extremes of philosophy can be found, by
which one unit will routinely monitor women for a short period on
admission but intervene only where it is suspected that maternal or foetal
well-being are threatened, whereas another unit will apply a very active
management from the start, monitoring continuously and intervening
immediately if progress deviates from a set norm.
THE START OF LABOUR When a woman decides that labour may be starting she will alert her
carers, who will either go to her at home, or await her at a maternity unit.
In either case the midwife will be concerned to establish immediately that
both foetus and mother are well, and so will check the foetal heart rate and
the maternal temperature, pulse and blood pressure. The midwife will
then palpate the lie of the foetus and the presenting part, and palpate and
monitor the quality and frequency of any contractions. A vaginal examina-
tion determines the state of the cervix and confirms the level of the foetal
head. From all these data, in time, it will be possible to determine whether
labour is established. Urine will be tested for protein, glucose and ketones.
RECORDING THE In most consultant units the progress of labour is now recorded on a par-
PROGRESS OF LABOUR togram (Fig. 3.5), a combination of charts on which the pattern of uterine
contractions, the descent of the presenting part, cervical dilatation and
medication, together with measures of maternal well-being such as blood
pressure and pulse rate, are graphically recorded against time, and thus
are easily evaluated. There is a recognised norm, and this visualisation
highlights early evidence of labour failing to progress and allows consid-
eration of appropriate action.
Physical and physiological changes of labour and the puerperium 69
13. 00
14. 00
15. 00
16. 00
17. 00
11.00
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
OXYTOCIN
DROPS/MIN
5 5
CONTRACTIONS 4 4
3 3
PER 10 MIN 2 2
1 1
DRUGS
ENTANOX
AND
T.E.N.S
I.V.
FLUIDS
(inc Epidural)
200 200
190 190
180 180
170 170
BLOOD 160 160
PRESSURE 150 150
140 140
AND 130 130
PULSE 120 120
110 110
100 100
90 90
80 80
70 70
60 60
PROTEIN Nil Nil
URINE ACETONE Nil Nil
GLUCOSE Nil Nil
TEMPERATURE 364 362 364
Figure 3.5 A partogram. 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
70 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Medical and midwifery staff may monitor the foetal heart rate inter-
mittently using a Pinard stethoscope or a simple Sonic-aid. More continu-
ous surveillance requires a foetal heart monitor; this uses an ultrasound
transducer on the woman’s abdomen, and produces a printout, as well as
signalling the foetal heart rate via a flashing light or an audible bleep.
Alternatively the foetal heart rate may be recorded through an electrode
attached to the foetal scalp. The same machine, a cardiotocograph (CTG),
will also give a printout of uterine activity by means of a maternal toco-
graph. For this, either a very delicate pressure gauge is strapped exter-
nally to the woman’s abdomen, or a modified gauge may be passed
vaginally to monitor contractions more accurately internally. A recent
Cochrane report (Thacker et al 2003) concluded that the only clinically
significant benefit of continuous monitoring was the reduction of neo-
natal seizures. They also stated that the decision determining whether
continuous or intermittent auscultation be used during labour should
be made jointly between the clinician and the woman. Furthermore,
MacLennan (1999) states that the evidence regarding electronic monitor-
ing does not show that it prevents cerebral palsy.
FIRST STAGE OF Early in labour, unless there are special circumstances, women should be
LABOUR encouraged to continue with rest or gentle activities appropriate to the
time of day and consistent with the philosophy of conserving energy. It
is a disadvantage to go into labour tired. Management in the first stage
consists chiefly of regular monitoring of foetal and maternal well-being,
and relief of fear and pain by, in the first instance, ensuring that the
labouring woman has sympathetic and empathetic companionship.
Blood pressure is initially measured every 2–4 hours, then hourly as
labour advances (Morrin 1997a). Sosa et al (1980) reported a small study
using a supportive lay woman, a doula; this showed major perinatal
benefits for the supported group, including shorter labours. Women
should be encouraged to be as physically and mentally comfortable as
possible, moving or staying still as feels best, as discussed previously. So
for many women the first stage is passed with periods of walking
around, periods of sitting in chairs or beanbags, and periods of resting,
even dozing on a sofa or bed. Pleasant surroundings (Chapman et al
1986), music and a warm bath (Lenstrup et al 1987) or shower may be
invaluable. Changes of position are important (Roberts et al 1983) in
assisting progress. A woman should try to empty her bladder at 2 hourly
intervals (Morrin 1997a), as a full bladder may increase pain and delay
progress. The fluid input and output is recorded to assist in maintaining
a fluid balance. If a woman becomes ketotic or dehydrated then intra-
venous fluids and dextrose will be required. Ideally the decision regard-
ing additional pain relief is one made jointly by the mother and the
midwife. Cool flannels for sponging, sucking ice, and massage to the
back and abdomen are soothing to some. Women have for very many
years heeded the advice to have a warm bath in the first stage of labour
to assist with relaxation and hence pain relief. Some maternity units also
offer the option of a woman labouring and perhaps delivering her baby
Physical and physiological changes of labour and the puerperium 71
in a birthing pool; women having a home birth may also elect to hire a
birthing pool for their own use at home. The birthing pool is said to assist
relaxation, aid pain relief and enhance cervical dilatation. This is thought
to be due to the effects of buoyancy, reduction of anxiety and conserva-
tion of energy. However, concern has been expressed regarding the pass-
ing of infection to the mother and baby, water embolism and perineal
trauma (Morrin 1997b). It is therefore essential that strict protocols
should be adhered to regarding the suitability of the labouring mother
and the procedures to be followed (see pp. 95, 190).
SECOND STAGE OF The management of the second stage of labour consists of caring for the
LABOUR mother and foetus from the time of the full dilatation of the cervix until the
delivery of the baby. There are a variety of positions in which it is possible
for a woman to deliver her baby (see Fig. 6.4 on p. 180). The prime consid-
erations are the baby’s safety, the mother’s comfort and the position which
enables her to respond best to the bearing-down reflex. Difficulties can
arise if a midwife finds it impossible to monitor and control the delivery in
the position selected by the labouring woman. However, where the con-
ventional reclining posture has been chosen but the mother is not pushing
effectively or the urge to bear down is weak, she should be encouraged,
even temporarily, to change position, perhaps into some adaptation of
squatting if this is possible and safe. It has been suggested for some time
that lying on the back for prolonged periods in the second stage could
adversely affect the foetus by reducing placental perfusion; left-side lying
has been shown to reduce the problem. Johnstone et al (1987) showed that
even a tilt of 15° to the left, effected by using a firm pillow or towels under
the right hip, was effective in this regard. During the second stage of
labour, contractions become longer, stronger and more frequent to aid
expulsion. The pressure of the foetus, about 1 centimetre above the ischial
spines, stimulates nerve receptors in the pelvic floor increasing the urge to
bear down; this is known as Ferguson’s reflex (Morrin 1997b).
As the foetal head descends the perineum distends, the anus dilates
and the vagina opens progressively with contractions; however, some
regression may be seen between contractions. The midwife controls the
head at ‘crowning’ to allow the vaginal opening gently to complete the
extreme distension needed; the mother may be asked at this point to
refrain from pushing and to pant instead. The foetal head is encouraged
into extension under the pubic arch and the neck explored to locate the
cord. Once delivered, the baby’s head turns to face the maternal right leg.
The head is laterally flexed towards the anus to assist the delivery of the
right shoulder, then to the symphysis pubis to ease out the second shoul-
der; the body usually follows easily. The baby may need nasal and mouth
suction to clear the airways but is laid either between the mother’s legs or
on her abdomen. If active management of the third stage is adopted, an
injection of ergometrine and oxytocin is given into the mother’s thigh
once the shoulders are delivered, and the cord is clamped.
The accepted method of assessment and recording the baby’s condi-
tion is by the Apgar score (Table 3.3) at 1, 5 and 10 minutes after delivery.
72 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
THIRD STAGE OF The third stage is the time from after the delivery of the baby until there
LABOUR has been the expulsion of the placenta and membranes. There is difference
of opinion regarding clamping of the umbilical cord, cited in Morrin
(1997c). Inch (1985) believes that the cord should remain unclamped for
the unhindered compression of the placenta and retraction of muscle
fibres, whereas Prendiville & Elbourne (1989) state that early clamping of
the cord can reduce the length of third stage of labour. In a rhesus negative
woman there should never be a delay in cord clamping, otherwise there is
an increased risk of fetomaternal transfusion. Unless there is an individual
reason not to, common practice is to clamp the cord after it has stopped
pulsating. If the mother puts the baby to the breast, the release of oxytocin
will assist the physiological process of separation and delivery of the pla-
centa. Management, which may be passive or active, consists of ensuring
the complete separation and safe delivery of the placenta, and monitoring
and controlling haemorrhage where necessary.
Passive management (otherwise known as expectant or physiological
management) allows the natural physiological changes to take their course,
and excludes the use of oxytocic drugs. This usually takes 15–30 minutes.
Strong uterine contractions enable the midwife to feel the fundus of the
uterus. Initially it will usually be above the umbilicus, and feels bulky
owing to the presence of the placenta. Once the placenta has separated
completely, further contractions assist it into the lower uterine segment,
thus enabling the uterus to contract down progressively further, until the
placenta is expelled. The mother may be asked to assist with expulsive
effort. The midwife may prefer the mother to adopt a standing, kneeling
or squatting posture rather than lying back, to utilise both gravity and
intra-abdominal pressure in helping the process.
Active management requires an intramuscular injection of an oxytocic
drug after the shoulders are delivered. The midwife places one hand
above the symphysis, and when the uterus contracts, pressure is applied
on the fundus in an upward direction toward the umbilicus to prevent
Physical and physiological changes of labour and the puerperium 73
the uterus from being drawn down, while the other hand exerts steady
downward controlled traction on the cord. If the placenta is not delivered,
then controlled cord traction is tried again after 2–3 minutes during a
contraction. The sequence may have to be repeated. The chief objective
is to avoid inverting the uterus where complete separation has not yet
occurred. The mother is usually sitting back with her knees bent, to allow
the uterine pressure to be applied.
Active management of the third stage of labour has been recommended
by WHO (1994) in order to reduce the incidence of postpartum haemor-
rhage. However, in the UK this poses less of a problem, hence women
tend to be able to make an informed choice as to which method they pre-
fer. Once delivered, the placenta is weighed and examined for complete-
ness, and the total amount of blood loss is estimated.
COMPLICATIONS OF LABOUR
FAILURE TO PROGRESS The phrase ‘failure to progress’ is used to indicate that labour has
stopped proceeding from phase to phase as expected, and the presenting
part is not descending and rotating any further as time passes. There are
a variety of possible causes; for example, contractions may be insuffi-
ciently strong or long, the pelvis may be too small for the size of the foe-
tus (cephalopelvic disproportion) or the cervix may fail to dilate. The
experienced midwife will quickly recognise a deviation from normal on
the partogram, and most centres now have their own set criteria for
appropriate active intervention.
FOETAL DISTRESS Uterine contractions are a normal stress to the foetus, compressing it and
producing a temporary reduction in the oxygenated blood supply through
the placental site. A healthy term foetus with a normal CTG has a normal
baseline foetal heart rate of 110–150 beats per minute with a normal base-
line variability of 10–25 b.p.m. Accelerations are transient increases in
foetal heart rate of 15 b.p.m. or more lasting 15 seconds or more. Two accel-
erations recorded in a 20-minute period are termed ‘reactive’ and indicate
optimal foetal health. Decelerations are transient reductions in the foetal
heart rate from the baseline by more than 15 b.p.m. and lasting more than
15 seconds; these indicate foetal distress (Varma et al 2000). At best the
foetal heart rate is unaffected by the contractions, or there is only a slight
deceleration coincident with the peak of contractions (early decelerations)
and the rate then picks up. In the absence of other adverse signs, a drop
of not more than 40 b.p.m. is often acceptable, but foetal hypoxia must be
suspected if:
Foetal hypoxia is the most common cause of foetal distress and may be
due to pressure on the cord, premature separation of the placenta, hyper-
tonia of the uterine muscle or hypertonia of maternal blood vessels. The
passing of foetal meconium per vaginam may also be a serious sign, indi-
cating the possibility that foetal hypoxia has induced anal sphincter
muscle hypotonia. Hypoxia can be confirmed by foetal scalp blood sampling
and testing the blood pH value. Normally foetal blood is more acid (pH
7.25–35) than maternal blood (pH 7.44), but in the presence of hypoxia the
pH value falls, a pH of less than 7.20 being an indicator of foetal distress.
MATERNAL DISTRESS Previously labour was classed as prolonged when exceeding 24 hours;
however, it is now believed that the acceptable limit is 12 hours (O’Brien
1997). This has reduced the number of women suffering from exhaustion.
In a normal labour there is rarely any cause for real anxiety about the
mother’s physical condition; however, a constant watch is kept. A dis-
tressed woman in labour shows signs of both mental and physical exhaus-
tion; there is an increase in pulse rate, temperature and blood pressure
with the development of oliguria, ketosis and dehydration. Therefore the
mother’s urine is regularly checked for protein and ketones.
The emotional distress which some women experience is associated
with fear, pain and apparent lack of progress. Good antenatal prepar-
ation, together with continuity of care in labour, sensitive support and
companionship, adequate appropriate pain relief, skilled attention to
comfort and regular realistic progress reports and reassurance, go a long
way towards preventing the labouring woman experiencing excessive
emotional distress.
MALPRESENTATION When the presenting part is other than the vertex, for example the but-
tocks, arms or face, it is categorised as a malpresentation. The most
common of these, the breech, is discussed here; suggestions for further
reading are given at the end of the chapter.
BREECH The presenting part of the foetus is the buttocks, i.e. the ‘breeches’ end.
PRESENTATION Approximately 3% of foetuses present buttocks first at term. In the mid-
dle trimester it is much more common, owing apparently to there being
more room to move at this stage, but the majority eventually turn to
become cephalic presentations. A breech presentation is potentially dan-
gerous because of the severe intermittent pressure on the after-coming
head from the dominant part of the uterus. In addition the foetal head,
which is the largest part, will not have been moulded to the bony birth
canal so there could be the risk of cephalopelvic disproportion. There is
also some anxiety that the cervix might close on the foetal neck and
obstruct the passage of the head; forceps may therefore be used to protect
and guide the after-coming head. It is now believed that the major cause
of intracranial haemorrhage in a breech delivery is anoxia (Sweet 1997).
Other dangers of breech delivery include fractures, dislocations, brachial
Physical and physiological changes of labour and the puerperium 75
1. fully flexed – both legs are flexed and drawn up on the abdomen, most
common in multigravidae
2. extended – legs are flexed at the hips but extended at the knees, and the
feet are in contact with the baby’s shoulders, most common in primi-
gravidae
3. footling – one or both feet present first (below the buttocks) with the
hips and knees extended.
MALPOSITION When the vertex is less than optimally placed there is said to be malposi-
tion. The most common malposition is the occipitoposterior; for other
possibilities see Further Reading, p. 91.
Occipitoposterior When the foetal head enters the pelvis or turns midcavity, so that the
position occiput is toward the maternal sacrum rather than the maternal symphy-
sis pubis, it is said to be in the occipitoposterior position (OP). Commonly
the occiput will be toward the right side of the sacrum (ROP), and less
often to the left (LOP). The head will eventually rotate in a majority of
cases to present at the pelvic outlet in the OA position as previously
described. OP labours tend to be longer as there may be slower descent of
the foetal head and hence slower dilatation of the cervix. If there is failure
76 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
of the head to flex sufficiently, the longer diameter of the foetal head is
presented; therefore cervical dilatation may have to be greater and the
perineum is more greatly distended. An episiotomy is more than likely to
be required. Severe backache is a frequent problem, probably because of
the pressure of the occiput on the sacrum, and epidural anaesthesia may
be appropriate. If rotation of the foetus becomes obstructed it is called a
‘transverse arrest’, and most probably an emergency caesarean section
becomes necessary.
Prolapse or For the cord to prolapse into the vagina or to appear at the vulva, the
presentation of amniotic sac must have ruptured (see p. 55), and the presenting part is
the cord likely to be high or ill fitting for some reason (e.g. malpresentation, mul-
tiparity). Subsequent pressure on the cord from the head during contrac-
tions, traction, or simply the colder environment, outside the amniotic
sac may cause the foetal blood supply to be obstructed, so early delivery
is imperative. It is possible for the cord to rest alongside and even ahead
of the main presenting part within an intact amniotic sac. This is a serious
state which can cause foetal distress, and which requires constant vigi-
lance to diagnose. Medical help must be immediately summoned at the
first observation of any umbilical cord prolapse. An American review of
65 cases identified from 26 545 deliveries determined that cord prolapse
continues to be associated with poor perinatal outcomes despite emer-
gency delivery (Prabulos & Philipson 1998). Furthermore, a Turkish
study has shown that abnormal foetal presentation and multiparity are
associated with an increased risk of umbilical cord prolapse (Uyger et al
2002). It has also been reported that umbilical cord prolapse is a possible
complication of external cephalic version in patients with rupture of
membranes and oligohydramnios (Berghella 2001).
KNOTS OF THE A true knot of the umbilical cord is caused by the movement of the foetus
UMBILICAL CORD knotting the cord prior to birth. A false knot may be due to the cord blood
vessels being longer than the cord or other irregularities and node for-
mation (Morrin 1997c). In a large study population of 69 139 singleton
deliveries (Hershkovitz et al 2001), true knots of the cord resulted in sig-
nificantly higher foetal distress with a higher proportion of meconium-
stained amniotic fluid. Furthermore there was an increased likelihood of
caesarean delivery and a fourfold higher rate of antepartum foetal death
among these foetuses (Hershkovitz et al 2001). The obstetric factors sig-
nificantly correlated with true knots were gestational diabetes, hydram-
nios, patients undergoing genetic amniocentesis and male foetuses. Any
patient attending for physiotherapy who mentions that there is a dimin-
ution of foetal activity should be checked by a midwife or doctor.
INCOORDINATE The ideal pattern of uterine polarity (see p. 57) does not always occur.
UTERINE ACTIVITY Disordered uterine action, which is painful yet unproductive, occurs
most commonly (96%) in primigravid labours, with hypertonia of the
Physical and physiological changes of labour and the puerperium 77
HAEMORRHAGE Because of the hugely enhanced blood supply to the uterus, which has
developed through pregnancy, haemorrhage at any stage of labour is
extremely serious and emergency steps to expedite delivery must be
taken, possibly by caesarean section. Where haemorrhage is uncontrol-
lable, a hysterectomy may be necessary; mercifully this is very rare.
CONTRACTED PELVIS There are some women who have a normally shaped but small gynae-
AND CEPHALOPELVIC coid pelvis; small hands and feet correlate with this. Women with an
DISPROPORTION android pelvis have pelvic walls that converge so that the outlet is nar-
row and the ischial spines may be very prominent (see p. 3). In women
with a flat pelvis the inlet is narrow and difficult for the foetal head to
pass through; there are yet others whose pelvis has been affected by
trauma or disease. When one of the diameters of the true pelvis (see
p. 3) is 1 cm less than the ideal gynaecoid pelvis, it is called a ‘contracted
pelvis’. In addition, some babies are large in proportion to their mothers.
A woman’s pelvis is not routinely assessed in pregnancy. Ultrasound
assessment is used to determine foetal size in comparison with the
woman’s size. Where apparently the foetal head is physically unable to
go through there is said to be cephalopelvic disproportion (CPD). A deci-
sion is usually made toward the end of a pregnancy, where there is a
potential problem, either to deliver by elective caesarean section or to
allow a ‘trial of labour’ with or without early induction. However, despite
reasonable antenatal care, CPD can arise spontaneously in labour and is
a reason for failure to progress.
A ‘trial of labour’ usually indicates that CPD is suspected, but it is
hoped that moulding of the foetal head during labour and the maximum
flexibility of the maternal pelvis at that stage may allow a normal vaginal
delivery. Very careful monitoring of the descent of the head will soon
indicate delay, and caesarean section can be carried out where necessary.
Induction at earlier than 40 weeks’ gestation will mean the baby is
smaller (see Table 2.1, p. 31).
PLACENTAL ABRUPTION Occasionally partial or complete separation of the placenta occurs before
the birth of the baby. Blood may be retained at the site or drain out
through the vagina. Where it is retained it may seep into the myo-
metrium, causing marked damage (Coulevaire uterus). Any tendency for
placental separation is a critical situation requiring immediate delivery of
the baby by the most expeditious means.
78 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
MULTIPLE BIRTHS Twin pregnancy is the most common to come to delivery; in more than
80% of cases the first baby will present by the vertex, and there is an
almost equal chance of the second baby being vertex or breech. There is
an increased risk of premature labour owing to the bulk of the pregnancy,
possibly because uterine muscle has a finite limit of stretch at which
labour contractions start and the cervix begins to open.
Where there are more than two babies it is usual for them to be delivered
preterm by elective caesarean section.
PERINEAL TRAUMA Labial lacerations are a common occurrence in the childbirth process.
However, evidence-based management of minor tears has yet to emerge
Labial lacerations from the scientific literature (Arkin & Chern-Hughes 2002). They may
bleed profusely and be painful but are generally superficial. Usually they
are not sutured but kept dry and clean with analgesia as appropriate.
Haematoma Stretching of the vagina and labia at delivery may result in rupture of
veins. The resulting haematoma can be quite large, cause great pain, and
may require aspiration. Vaginal haematoma can be a consequence of
delivery in which there is shoulder dystocia.
Perineal tears Perineal tears may occur spontaneously at delivery, or tearing may
extend an episiotomy. It has been shown that perineal massage in the last
5–6 weeks of pregnancy is an effective method to increase the likelihood
of an intact perineum for women undergoing a first vaginal delivery, but
not for women with a previous vaginal delivery (Labrecque et al 1999).
An English study (Shipman et al 1997) also showed benefits from ante-
natal perineal massage. They found that the best effect was in the age
group of 30 years and above. It has also been concluded that perineal
massage during the second stage of labour does not decrease the likeli-
hood of an intact perineum or reduce the risk of pain, dysparenia or urin-
ary and faecal problems (Stamp et al 2001).
Perineal tears are classified according to the structures involved and
are almost exclusive to the posterior perineum:
First and second degree tears will be repaired following infiltration with
lidocaine (lignocaine) 1% unless there is an epidural block in progress. A
midwife or doctor may perform the repair. Third and fourth degree tears
may require a general anaesthetic and will be performed by an obstetrician
Physical and physiological changes of labour and the puerperium 79
RETAINED PLACENTA The placenta may have separated normally from the uterine wall but still
AND PLACENTA need assistance to leave the uterus. Allowing the baby to suckle to stimu-
ACCRETA late oxytocin production and uterine contraction, or rubbing the
abdomen to stimulate contractions and firmly pressing upward on the
fundus while applying gentle traction on the cord, is often sufficient (see
p. 73) for it to be delivered.
Where separation appears to be incomplete, or is not occurring at all,
there is an increase in the possibility of haemorrhage or shock. The man-
ual removal of the placenta takes place under epidural, spinal or general
anaesthesiae depending on the individual circumstances. In rare
instances the placental chorionic villi have invaded the myometrium
(placenta accreta) to such an extent that separation is very difficult and
may cause life-threatening haemorrhage; in this case a hysterectomy may
be the only safe course to take.
INTERVENTIONS IN LABOUR
TO INITIATE LABOUR If for some reason induction of labour is being considered and the normal
IN THE FIRST STAGE ripening of the cervix has not yet occurred, then prostaglandin pessaries
or gel applied to the cervix may produce the required effect. Sometimes
Prostaglandins this is sufficient in itself to encourage the uterus to begin contracting, and
labour to commence. Prostaglandin E2 is thought to be superior to other
forms and is the most commonly used. Oral administration of Prosta-
glandins need multiple doses over a longer time and can be associated
with maternal gastrointestinal side-effects.
Forceps delivery Assistance with forceps may be necessary in the second stage:
Median
Medio-lateral
Vacuum extraction or The indications for vacuum extraction are similar to those for forceps and
ventouse delivery are the common method of choice for an assisted delivery. A suction cup
of an appropriate size is introduced into the vagina and applied to the
foetal scalp posteriorly. Suction is used to draw the scalp up into the cup.
Careful traction can then be given during uterine contractions. The suc-
cess of the ventouse delivery can be dependent on the expertise of the
operator. At delivery the baby will have a raised, red imprint of the cup
on its head (chignon), which will persist for some days. This method of
giving assistance has taken longer to gain acceptance in the UK than in
other parts of the world (Chalmers & Chalmers 1989), but has continued
to increase in popularity (Johanson et al 1993).
There has been considerable discussion as to whether vacuum extraction
has a lesser morbidity of the maternal anal sphincter than does forceps
delivery. Work by Sultan et al (1994b) showed vacuum extraction to be
associated with fewer third degree tears than forceps delivery. However,
although MacArthur et al (1997) found that instrumental delivery was
associated with the development of faecal incontinence, there was no
significant difference between forceps and vacuum extraction.
CAESAREAN SECTION Delivery of the infant through incisions in the abdominal and uterine
wall may be classified as ‘elective’, indicating that this mode of delivery
has been chosen for specific reasons ahead of labour, or ‘emergency’,
where it is decided on safety grounds to terminate labour. It may be car-
ried out under either epidural (see p. 196) or general anaesthetic, at any
stage of labour.
Reasons for an elective caesarean section are:
• placenta praevia
• multiple births of more than two babies
• malpresentation (breech presentations may or may not be caesarean
deliveries depending on the complications presenting)
• peri- and postmortem delivery if appropriate
• active genital herpes
• previous vaginal reconstructive surgery
• previous incontinence surgery
• pelvic tumours
• severe intrauterine growth retardation
• foetal macrosomia
• some foetal abnormalities
• ‘precious babies’, history of infertility, etc.
• maternal request.
Reasons for an emergency caesarean section are:
• antepartum haemorrhage
• foetal or maternal distress
• failed trial of forceps
• prolapse of the umbilical cord
• failure to progress.
Many caesarean deliveries are done under spinal or epidural anaesthesia;
the mother is then able to see and hold her baby immediately after
delivery. Often emergency caesarean deliveries have to be done under
general anaesthesia as speed is of the essence; general anaesthesia takes
less time to take effect than epidural or spinal anaesthesia. There are two
types of caesarean section. One is the classical section, consisting of a lon-
gitudinal incision in the upper uterine segment, via a paramedian inci-
sion. It is used for very premature babies where no lower segment has
been formed. The other type is the lower segment section; this is the more
common today and is favoured by women for its good cosmetic result. A
Pfannenstiel (bikini line) incision, with separation of the recti, and a
transverse incision into the lower uterine segment are used. These heal
well, and do not usually preclude repeated caesarean section for future
pregnancies or subsequent normal vaginal deliveries.
Caesarean section now has low risk of morbidity and mortality in
comparison with former years (Jibodu & Arulkumaran 2000). Many
women perceive benefit from a caesarean section, but the issues are com-
plicated and far reaching. Decisions regarding the mode of delivery may
ultimately be based after full discussion on preference rather than statis-
tics (Jibodu & Arulkumaran 2000). Edwards & Davies (2001) enquired of
344 women attending a routine antenatal clinic as to which mode of
delivery they would prefer in an uncomplicated pregnancy. Of the
women surveyed, 14.5% elected for caesarean section. The main reasons
given were the avoidance of a prolonged labour, maternal trauma and
foetal well-being. The researchers concluded that it is hard to refuse a
well-informed woman an elective caesarean section on request even if
this results in an additional rise in the caesarean section rate.
Physical and physiological changes of labour and the puerperium 83
Procedure for lower An incision is made through the skin and subcutaneous tissue in the nat-
segment section ural fold just above the pubic hair. Transverse incisions are made in the
anterior part of the rectus sheath on each side, the linea alba is divided,
and these are blended into one transverse incision which can be stretched
manually (the posterior portion of the rectus sheath is deficient at this
level). The rectus sheaths are mobilised to expose the rectus muscles,
which are then retracted laterally to gain access to the abdominal cavity.
The peritoneum is exposed and is opened with a transverse incision.
The bladder is located and retracted away from the lower uterine seg-
ment, which is excised transversely and the wound further extended by
manual stretching and tearing. This minimises bleeding and avoids the
risk of instrumental damage to the foetal head. The head is eased out
first, either manually or with Wrigley’s forceps, and then the body. The
cord is clamped and the baby held head down, while suction is used to
clear mucus and liquor from the upper respiratory tract.
Active management of the third stage includes intravenous ergometrine
given to effect placental separation; when this has occurred, the placenta
can be gently withdrawn. The incision in the uterus is then closed with two
layers of sutures, followed by closure of the peritoneum. The two recti are
approximated and held together by three or four lightly tied sutures. The
sheaths of the recti and the skin are then closed. A drain may be inserted.
THE PUERPERIUM
The puerperium is the final phase in the childbearing continuum, and is the
period of 6–8 weeks following delivery in which the woman’s genital tract
returns to a non-pregnant state. The process by which this occurs is called
‘involution’, and it commences as soon as the placenta is expelled. Once the
placenta separates from the uterus, placental hormone production ceases,
causing a dramatic decline in maternal blood levels of oestrogens and prog-
esterone, and consequently in the physiological effects of these on maternal
respiration, cardiovascular system, digestion and metabolism (see p. 31).
THE UTERUS By the end of labour the uterus has considerably reduced in size, and this
reduction continues by three processes. First, uterine contractions continue
after delivery, becoming intermittent. Suckling by the baby at the breast
stimulates the posterior pituitary to release more oxytocin, which causes
further bursts of uterine contraction. Even the sight, sound or smell of the
baby can have this effect, which causes labour-type pain to be felt in the
lower abdomen; it may also be referred to the lumbar region. More mul-
tiparous women experience this than primiparae, in a ratio of 2 : 1 (Murray &
Holdcroft 1989); it is described as throbbing, cramping or aching. For some
women the pain is considerable – moderate to severe as scored on the
McGill pain questionnaire – and is referred to as ‘after pains’.
Secondly, there is an actual reduction in uterine tissue: retraction of the
uterine muscle has the effect of controlling haemorrhage, and also grad-
ually reduces the blood supply to the muscle tissue to a point where the
additional muscle and supportive collagen required for pregnancy can
no longer be maintained. Consequently a degrading process (autolysis) is
Physical and physiological changes of labour and the puerperium 85
set in motion, whereby the excess material is liquefied and absorbed into
the bloodstream to be excreted via the kidneys.
Thirdly, for 2 to 3 weeks a parturient woman experiences a diminishing
discharge called the lochia, similar to a heavy period, which consists of
blood and necrotic decidua. The lochia is alkaline and organisms flourish in
it more readily than in the normal vaginal secretions, which are acid, so
there is an increased risk of infection. Much of the endometrium is regener-
ated in a fortnight; only the placental site takes longer. In the first few hours
after delivery the cervix remains flaccid and open, but then gradually closes.
The parous cervix has a permanently different appearance to a nulliparous
one, the opening at the external os being a slit rather than a tiny circle.
One sign that the uterus is involuting (i.e. returning to a non-pregnant
state), will be found in the gradual drop in the fundal height, which can be
palpated. On the first postpartum day it is usually just above the umbil-
icus, by 6 days it is midway between the umbilicus and the symphysis,
and by 10 days has disappeared down behind the symphysis. However,
the parous uterus is always a little bigger than it was when nulliparous.
THE VAGINA AND In the first few hours women often experience numbness of the perineum
PERINEUM whether or not local anaesthesia was used. At first the vagina is very lax
and women may notice air held within it, being released when they move,
sit down or take a bath. In addition trauma such as labial tears, episiotomy,
oedema and haematoma causes pain and takes time to heal. There may
be pain inhibition of PFM contractions; actual trauma to the nerve supply
to the pelvic floor musculature may manifest itself in difficulty in con-
tracting the PFM and in bowing of the pelvic floor on straining.
There is a noticeable increase in the amount of urine passed in the first
few days as the body releases the excess fluid retained in pregnancy. It has
high nitrogen content owing to the autolytic process in the uterus; women
often complain of frequency. Continence is sometimes disturbed in the
puerperium and women experience variously: urgency, pain on micturi-
tion, stress incontinence, retention of urine and occasionally faecal inconti-
nence. Trauma to the urethra, to supportive ligaments in the pelvis and to
the muscle in the area and its nerve supply account for this. It is of great
importance that those women having epidural anaesthesia understand that
they must attempt to micturate as soon as leg sensation has returned and
they are mobile. Bladder sensation can take up to 8 hours to return after the
last top-up (Cutner 1997). If micturition is delayed for this time, the bladder
will have become overly distended with the possibility of long-standing or
even permanent damage. Vigilance is necessary to ensure good bladder
care especially for those at risk. For this reason it is advocated that those
women having an epidural for delivery should have a catheter inserted to
remain in position for 12 hours after the last top-up (Cutner 1997).
LACTATION The level of prolactin produced by the anterior pituitary rises steadily
throughout pregnancy, but its effect on the milk-producing cells of the breast
is inhibited by the placental hormones (particularly oestrogen). As the
86 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
placental hormones decline, a point is reached – usually about the 3rd or 4th
postpartum day – when prolactin is free to act and milk production begins.
Up until that time the suckling child will obtain colostrum. Milk is produced
by glandular cells and stored in the alveoli of the 15–20 lobes of each breast.
Suckling, and eventually, by a conditioned reflex, even the sight, sound or
smell of the baby, stimulates the posterior pituitary to release oxytocin,
which, in addition to its effects on uterine muscle (see p. 84), causes myoep-
ithelial cells around the alveoli to contract. This contraction propels the milk
with variable force into the lactiferous sinuses ready for removal by the
baby, and is called the ‘let-down’ or milk ejection reflex. Some women feel
sharp pains and experience actual spurting out of the milk, whereas others
sense only tingling and find the milk just dripping from their nipples.
It is important for the physiotherapist to understand the physical
process by which the baby gains the milk. This is well described in
the booklet Successful Breastfeeding produced by the Royal College of
Midwives (RCM 2002). In addition to the ‘let-down’ reflex, milk is trans-
ferred from the breast by the baby taking the whole nipple and some of
the areola well into the mouth so that it lies over the length of the tongue.
The baby then squeezes the milk-filled sinuses behind the nipple by com-
pression of the lower jaw and tongue against the upper jaw and hard
palate (see pp. 13 and 208).
Human breast milk is unique, and, although an infant does apparently
thrive on other available milks, there is no question but that ‘breast is
best’ for babies, with very rare exceptions. It is the recommendation of
the RCM (2002) that babies should be exclusively breast-fed until they are
at least 4 months (and preferably 6 months) old. Regrettably, although
64% of women in the UK choose to breastfeed (OPCS 1985), only 26% are
still fully breastfeeding at 4 months. Fisher (1989) documents the subtle
and critical differences that make colostrum and then human breast milk
so infinitely superior to anything else for babies. Research continues to
show that breast milk has value other than nutritional benefit (Coppa et al
1990, Goldman 1993). Breast milk not only contains the right nutrients in
the correct proportions for all aspects of human development, it also con-
tains enzymes to help digest them appropriately, and important anti-
infective agents such as macrophages, neutrophils, IgA and lysozyme, as
well as antiallergic factors, to protect the growing child.
Very few women are physically unable to breastfeed if they really want
to, and very few babies are best fed by anything other than their mother’s
milk. The establishment of breastfeeding is therefore one of the most
important matters in the early puerperium, and a person prepared to give
the unhurried, skilled, consistent help to women to achieve this ranks
very highly in value to both mother and baby. The length of each feed
should not be restricted because it has been shown (RCM 2002) that the
calorific content of the later or hindmilk is higher than the foremilk.
MANAGEMENT IN THE It is usual to encourage women to rest quietly for the first 2–6 hours, even
PUERPERIUM after the most straightforward labour, to allow clotting over the placental
site to occur and to give the body time to adapt to the substantial changes
Physical and physiological changes of labour and the puerperium 87
Venous thrombosis, Superficial and deep venous thrombosis are not common conditions
pulmonary embolism despite the potential risks of trauma, stasis and infection and heightened
activity of the body’s coagulation system in the puerperium. However,
pulmonary embolism continues to be a cause of maternal death. The
88 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Gravitational oedema Many women have experienced gravitational oedema up to delivery and
this must be encouraged to disperse postpartum. A few women develop
oedema of the feet and ankles for the first time after delivery; this is not
easily explained except in terms of vascular damage.
Puerperal infection Puerperal infection usually refers to infections of the genital tract; but
pyrexia may be due to infection anywhere in the body (e.g. chest or urin-
ary tract). Endometritis, salpingitis, pelvic cellulitis (parametritis) and
even peritonitis are all possible. Such conditions were the scourge of
childbearing until this century and, although they are rarely seen now in
developed countries, physiotherapists, particularly those working in the
Developing World, should be aware of them. Treatment is by administra-
tion of the appropriate antibiotic.
Vesicovaginal fistula Although vesicovaginal fistula is rarely seen in the UK, it has become
apparent that in less developed countries, women delivering without
proper assistance may sustain serious tearing of the perineum and even
high vaginal tears which are then not sutured. Prolonged second stage or
sheer obstruction can result in ischaemia and necrosis, causing tissue
breakdown and a vesicovaginal or urethrovaginal fistula. The result is
that from delivery onwards a substantial number of women suffer from
incontinence of urine and faeces; they are disabled and ostracised, and
are often too poor to pay the high fees required by doctors to effect a
repair (Tahzib 1989).
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93
Chapter 4
CHAPTER CONTENTS
Introduction 93 Antenatal classes 104
Antenatal care options 95 Diet and weight gain in pregnancy 119
Routine antenatal care 97 Planning and leading labour and parentcraft
Antenatal screening 100 classes 126
Preconceptual care 102
INTRODUCTION
with fewer than two in Europe), the risk of maternal mortality during preg-
nancy may be as high as 1 in 15 in a developing country. Additionally, con-
traction of some diseases such as tuberculosis, malaria and human
immunodeficiency virus (HIV) may be aggravated by pregnancy and poor
nutrition, and lack of access to clean water may increase complications.
Discrimination against women in society and the home, and levels of
abuse and violence (Murray 1999), can also affect mortality rates.
For every maternal death there are at least a further 30 women (approxi-
mately 15 million per year) damaged through childbirth so as to never
regain their full health. Furthermore, it is important to consider that for
every woman who dies or who is damaged by pregnancy or childbirth,
a family is greatly affected too. One of the worst consequences of childbirth
is vesicovaginal fistula (see p. 88), which is often caused by prolonged,
obstructed labour. This results in continuous leakage of urine and some-
times faeces. Women suffering from this horrific condition, which is particu-
larly endemic in the sub-Saharan region of Africa (Tahzib 1989), often
become rejected social outcasts. Tragically the restorative surgery which
could transform their lives is largely unavailable except in specialist centres.
Women’s health physiotherapists working in affluent Western coun-
tries where women are increasingly demanding a better quality of birth
must never forget their less fortunate sisters for whom simply surviving
pregnancy and giving birth to a healthy baby who grows into adulthood
may be all that matters. The ‘Safe Motherhood Initiative’ is a global effort
begun in 1987 aiming to reduce these maternal mortality and morbidity
rates using the following objectives: to ensure women’s access to health
services, and raise awareness of them; to provide family planning ser-
vices and increase the numbers and training for health-care providers,
thereby promoting women’s rights to whether and when to have children
(www.rcm.org.uk).
The current UK maternal mortality rate is given as 11.4 per 100 000
deaths. This is a combination of both direct deaths (medical conditions
exacerbated by pregnancy) and indirect deaths (deaths from conditions
that directly arise from pregnancy). The latter category outweighs that of
deaths from direct causes and includes a high number of suicides (Lewis
2001). Higher-risk groups are women from lower socioeconomic classes,
very young girls, specific ethnic groups and those from the travelling
community.
The aims of modern antenatal care are:
WATER BIRTHS The use of water for labour or birth is an increasingly popular choice of
delivery for women (RCM 2000a, see also p. 190). Currently, an estimated
50% of maternity units offer this facility, with between 15 and 60% of the
women delivering at those units using the service (RCM 2000a). How-
ever, a survey in England and Wales between April 1994 and March 1996
identified only 0.6% of births occurring in water, of which 9% were home
births (Tookey & Gilbert 1999). The facilities for water birth (see AIMS
in Useful Addresses, p. 138) are limited within the NHS but pools can be
hired for use at home or in hospital. Potential benefits of immersion in
warm water include relaxation, pain relief and less perineal trauma, with
adverse consequences including infection, water inhalation by the baby
and decreased mobility. Nikodem (2003), when reviewing the above ben-
efits and risks for water birth, concluded there was not enough evidence
to evaluate the use of immersion in water. More research is needed in this
area, as suggested by Alderdice et al (1995), but they concluded from
their survey that there was no evidence not to continue with water
immersion as an option. To support this, although Schorn et al (1993)
found no improvement regarding progression of labour using water
immersion, no evidence was found of increased maternal, neonatal or
infectious morbidity. (For more information see Further Reading, p. 138.)
HOME BIRTH If a woman decides that she would like to have her baby at home, in the
UK she does not need to have the permission of her general practitioner
(GP) or an obstetrician. However, there is a statutory obligation on the
part of the local Supervisor of Midwives to provide midwifery care ante-
natally, during labour and delivery, and postnatally.
The UK home birth rate is about 2% but has large geographical vari-
ations from 1 to 20% (Macfarlane et al 2000). Home birth should be under-
stood as mainstream maternity care and offered as a realistic and positive
option. This can be promoted by selecting low-risk women and providing
adequate infrastructure and support (Springer & Weel 1996). Hospital
birth is still perceived as a safer option than home delivery even though
there is no evidence that this so (RCM 2002).
96 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
GP/MIDWIFERY GPs who have undertaken appropriate training may offer a service with
SHARED CARE midwives based at the local surgery. Delivery may be at home or in hospital.
MIDWIFERY-LED UNITS These are stand-alone units which have a midwifery-managed model of
care. These have been implemented into the maternity services to pro-
vide a service which fulfills the individuals’ needs. A study carried out in
Glasgow completed a randomised controlled trial (RCT) of 1299 women
comparing midwifery-led care with the more traditional shared care (i.e.
doctor and midwife), in terms of clinical efficacy and patient satisfaction
(Turnbull et al 1996). The results showed a similar level of intervention,
or lower, for the midwifery-led unit. There were less episiotomies and
reduced induction of labour with the midwifery-led model, and only
32.8% needed to transfer from this care to involve an obstetrician in
labour. Women using both services expressed satisfaction with care, but
the midwifery-led model scored significantly higher in all aspects from
the antenatal to the postnatal period. Other studies comparing the two
models of care have also found no major differences between the two in
terms of outcome for the women and babies (Campbell et al 1999). The
current opinion is that these units are clinically effective for healthy
women and are to be advocated, but integrated with existing services.
CONSULTANT CARE Women identified as high risk during pregnancy, that is with a risk of
thrombosis, thromboembolism, gestational diabetes, or hypertensive dis-
ease, or with a poor obstetric history, will probably be based under the
care of the consultant obstetrician having hospital-based visits on a more
frequent basis. Their care may be shared with their GP or midwives.
CONSULTANT These larger units are usually based in district or regional centres,
OBSTETRIC UNITS although a few still exist as independent entities. They should all have
access to up-to-date diagnostic procedures, and be able to call upon staff
The antenatal period 97
PRIVATE OBSTETRIC A woman may decide to use the private sector for all her antenatal care
CARE/INDEPENDENT and delivery, using private hospitals and having much more input by
MIDWIVES their obstetrician. Alternatively, she may opt to have all her care under an
independent midwife, delivering at home or in a private unit. Presently,
due to the increasing litigation culture that is being adopted, insurance
companies are reluctant to insure this group, or are charging huge insur-
ance premiums which are financially difficult to meet. Many independent
midwives therefore currently work without the protection of insurance,
which has potential risks for both themselves and their clients.
BOOKING VISIT Usually, women are reviewed by a midwife, unless medical risks are iden-
tified and involvement by the obstetrician is necessary. To ensure every
woman has an antenatal care plan tailored to her individual needs, details
of the woman’s social, family, medical, psychological and past obstetric
history are taken. This also assesses her health and attempts to uncover
any factor that may adversely affect childbearing.
All mothers should have their body mass index (BMI) calculated at the
time of booking. A BMI of more than 30 indicates obesity, a risk factor for
thromboembolism, gestatational diabetes and pre-eclampsia (PET – see
p. 48). If the BMI is low, this may indicate an eating disorder resulting in
the woman being undernourished. There may also be emotional implica-
tions regarding the expected weight gain of pregnancy.
This first visit provides an ideal opportunity to provide advice and edu-
cation regarding general lifestyle, for example diet, exercise, alcohol and
smoking. All pregnant women should also be given advice about the cor-
rect use of car seatbelts as soon as possible (see p. 107). Routine blood tests
will be taken and antenatal screening options discussed.
Violence against women encompasses physical, psychological, sexual
and emotional abuse. It can often start (30%) or escalate during pregnancy
(Lewis 2001, Mezey 1997, RCM 1999). It is associated with both maternal
and foetal death, severe morbidity, miscarriage, depression, suicide as well
98 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
SUBSEQUENT VISITS The pattern of visits has been reviewed in recent years to ascertain whether
the frequency, which is based largely on tradition, could be replaced by a
more evidence-based model of care. Currently the National Institute for
Clinical Excellence (NICE) is reviewing guidelines for antenatal care to be
published in October 2003. The schedule of care will vary in each Trust and
allow for flexibility with each woman, but after the first attendance it is
usual for the next visit to follow the ‘anomaly scan’ at 20 weeks. Monthly
visits from 24–26 weeks, fortnightly visits from 32–34 weeks to 40 weeks
and weekly visits until delivery are usual. Any anxieties or problems the
woman may have should be discussed at these visits. In addition the fol-
lowing are always recorded: blood pressure, urine, presence of oedema,
fundal height and ‘lie’ of the foetus, foetal movements and foetal heart rate.
Blood pressure Although there is an increase in blood volume and cardiac output during
pregnancy, this is not normally accompanied by a rise in blood pressure; in
fact there may even be a slight drop during the middle trimester, which is
probably due to the hormonally mediated dilatation of blood vessels. Blood
pressure is taken at each antenatal visit, and it is important to record a base-
line blood pressure early in pregnancy as a rise can be the first sign of a
potentially serious complication such as pregnancy-induced hypertension.
Urine Urinalysis is carried out at each visit for protein content; colour and
odour are also noted. Increased proteinurea may indicate pregnancy-
induced hypertension or the possibility of infection, or both. The latter
may be diagnosed by laboratory testing of an MSU (mid-stream speci-
men of urine).
Oedema The hands and lower limbs are checked for the presence of oedema, and
for other indications of fluid retention, which may be another sign of
pregnancy-induced hypertension and PET (e.g. paraesthesia, see p. 48).
Fundal height and the The level of the fundus of the uterus is noted and compared with the ges-
‘lie’ of the foetus tational stage (see p. 34). Intrauterine growth restriction (IUGR) may be
suspected if the fundal height is lower than expected. Multiple pregnancy
The antenatal period 99
Foetal movements Although foetal movements are usually noticed by the mother, at some
time between 16 and 22 weeks’ gestation, the foetus has in fact been mov-
ing from 8 weeks. Until the uterus has risen out of the pelvis and is actu-
ally in good contact with the anterior abdominal wall, the woman is
unaware of movements because the uterus is insensitive to touch. In a
second or subsequent pregnancy she will probably notice her baby mov-
ing earlier, possibly because she recognises the sensation. As pregnancy
advances, foetal movements may be used as a measure of the baby’s
well-being. All women should realise that a decrease or cessation of nor-
mal movement for any length of time might have serious implications.
The women’s health physiotherapist must be constantly alert to this pos-
sibility and pick up even the mildest expression of maternal anxiety. It
takes only a few moments of the midwife or doctor’s time to listen for the
foetal heart, or it can be monitored using a CTG. ‘Kick’ charts are an eas-
ily used monitoring device. If a foetus moves less than 10 times in an
average day, the pregnancy is likely to be assessed more carefully.
Foetal heart rate Although foetal movements reported by the mother can be a good indi-
cation of the baby’s well-being, most midwives and doctors will also
record the foetal heart rate. Although the foetal heart can be seen to be
functioning as early as 8–10 weeks using ultrasound scanning, it is not
usually possible to hear the heart beat before 16 weeks using a Sonic-aid
monitor. The normal rate will vary between 110 and 150 b.p.m. A Pinard
stethoscope, largely replaced by the electronic Sonic-aid monitor, will
pick up the heart rate from about 20 weeks. Fathers may like to put an ear
against their partner’s abdominal wall in order to hear this exciting
sound. Alternatively the cardboard tube from a toilet roll can substitute
for a stethoscope!
Other tests Blood tests are used to detect haemoglobin levels, the presence of sexu-
ally transmitted infection, blood group, blood sugars, rubella antibodies
Blood tests and haemoglobinopathies.
Haemoglobin levels A decrease is normal during pregnancy because of the increased blood
plasma volume (see p. 36). Women showing signs of anaemia may be pre-
scribed iron supplements in either tablet or liquid form as well as being
advised about dietary input to help address the problem.
Sexually transmitted All pregnant women should be given information on HIV and its trans-
infection mission from mother to child. HIV testing should be recommended as
part of routine antenatal care (RCM 1998). Transmission of HIV from
100 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Blood group The woman’s blood grouping will be determined, as will her Rhesus
status. If a Rhesus negative status is identified, prophylactic anti-D injec-
tions would be given at 28 and 34 weeks’ gestation. (NICE 2002) Anti-D
is administered in order to prevent the mother from developing anti-
bodies to the Rhesus factor during pregnancy. These antibodies, although
rare, may cause significant foetal anaemia.
Haemoglobinopathies Tests for the haemoglobinopathies (e.g. sickle cell disease and thalassaemia),
may be carried out when one of the parents is of non-Northern-European
descent (see p. 49).
ANTENATAL SCREENING
A woman during her pregnancy today now expects to have some form of
antenatal screening for foetal abnormality but there remains a wide vari-
ation in options and practices used.
Down’s syndrome occurs in approximately 1 : 800 births; the risk
increases with maternal age. Down’s syndrome is the most common chro-
mosomal problem found at birth (a disorder where the affected person
has an extra copy of chromosome 21). Routine screening aims to detect
this and other foetal abnormalities, either by maternal serum screening or
by nuchal translucency (NT) measurement (see ultrasound screening).
MATERNAL SERUM As well as measuring the alpha fetoprotein (AFP) level, screening may
SCREENING also record additional hormone levels. Depending on how many markers
are used, this is termed the double, triple or quadruple test. These levels
are combined with maternal age to provide a risk estimate of the foetus
having Down’s syndrome. Currently, the UK National Screening
Committee (NSC) suggests that the cut-off level for an increased risk
should be around 1: 250 at term, and by using ultrasound scans to accur-
ately date the pregnancy, the test should yield a detection rate of about
60% for a 5% false positive rate (NSC 2002). It is usually performed
between 15 and 18 weeks of pregnancy, and if women have a screen posi-
tive result (i.e. above the cut-off value) then they will be referred for fur-
ther invasive diagnostic procedures such as chorionic villus sampling
(CVS) or amniocentesis.
High levels of AFP may also indicate neural tube defects (NTDs) such
as spina bifida or anencephaly, but multiple pregnancies will also pro-
duce high levels.
The antenatal period 101
ULTRASOUND This valuable diagnostic technique has become increasingly more sophis-
SCANNING ticated and, since the 1990s, has been developed to measure the nuchal
translucency, an area of subcutaneous fluid at the nape of the foetal neck.
Increased thickness may indicate Down’s syndrome as well as other
chromosomal and structural abnormalities (Hyett et al 1999, Snijders et al
1998). The optimal time to perform this test is between 11 and 14 weeks
of pregnancy and it is combined with maternal age to give a risk estimate
which, if high, will lead to the offer of CVS procedure or amniocentesis.
In 2001, a survey in England found that 72% of women were offered
serum screening only, 15% NT screening and 13% a combination of both,
with 87% of women who were offered screening having an ultrasound
scan to date pregnancies accurately prior to the tests (NSC 2002).
Although the NSC recommends that all pregnant women should be
offered second trimester serum screening, it is aware of the need to stand-
ardise interpretation of results throughout the country, thereby improv-
ing accuracy of detection rates. In turn, offering invasive diagnostic
procedures only to women who really need them reduces unnecessary
anxiety and cost levels to the service.
In the UK most pregnant women will have at least one anomaly scan
at around 20 weeks’ gestation, and this is used for detection of certain
abnormalities (e.g. spina bifida, anencephaly and cardiac abnormalities).
Where pregnancies are complicated by problems such as pregnancy-
induced hypertension (PIH), IUGR and antepartum haemorrhage, or
where there is more than one foetus, a series of scans may be carried out.
CHORIONIC VILLUS Chorionic villus sampling is a technique which is carried out transab-
SAMPLING dominally. Fragments of placental chorionic villi are removed under
ultrasound guidance and inspected for genetic foetal abnormalities such
as Down’s syndrome. Although the benefit of this technique is that it can
be performed early in pregnancy (between 11 and 13 weeks’ gestation), it
carries a risk of about 1% miscarriage in experienced hands.
Because of the speed with which the medical profession has adopted pro-
cedures such as ultrasound investigations during pregnancy, it has
become increasingly routine. More research regarding its effects and clin-
ical effectiveness is needed including the psychological and social conse-
quences (Bricker 2001).
Although most parents enjoy the reassurance and connection of seeing
their baby during a scan, respect for a woman’s wishes must be given if she
declines screening. Further provision regarding explanation of all ante-
natal screening and potential outcomes need to be addressed, with support
in place for negative outcomes. Furthermore, if a woman is not prepared to
consider the termination of her pregnancy, there is no point in suggesting
CVS, amniocentesis or any other test that may show abnormalities.
PRECONCEPTUAL CARE
Although many babies are still conceived accidentally, more and more
hopeful parents-to-be and their medical advisers are becoming aware
of the benefits of dealing with health problems and attaining optimal
physical and mental well-being prior to pregnancy. Both partners may
decide to prepare for conception by giving thought to their diet, alcohol
consumption, smoking habits, exercise routines, occupation and drug
(medicinal or social) intake. Today, one in seven couples (Chambers 1999)
will experience difficulties with conceiving and will need specialist help,
but may, by addressing all of the above, improve their chances of success.
Every organ system within the mother’s body will alter and adjust
according to the demands made upon it by the growing foetus (see p. 31).
Therefore, the woman who begins pregnancy feeling fit and comfortable
is more likely to be able to cope with the physical and emotional changes
during the subsequent 9 months. Östgaard et al (1994) found that women
who were exercising weekly prepregnancy had reduced back pain dur-
ing pregnancy. Women who have been taking the contraceptive pill are
usually advised to discontinue its use 3 months before the hoped-for
pregnancy.
Where such conditions as spina bifida and anencephaly have previ-
ously occurred, folic acid will be recommended (see p. 120). Genetic coun-
selling should be available to parents with a family history of hereditary
disease. Renal disorders, as well as identified risk factors for maternal
morbidity and mortality (e.g. cardiac disorders, diabetes and hyperten-
sion) should be treated and stabilised before conception. Essential drug
regimens and their possible teratogenic effects should be considered.
Many of today’s women, including those with disabilities, are aware
of their responsibility in asserting control over their own health and
bodies, and are very open to preconception advice. However, women
in lower socioeconomic groups may understandably be primarily con-
cerned with finance, accommodation and food, and might give precon-
ceptual planning, exercise and antenatal classes little priority. Even so,
it is still possible for the women’s health physiotherapist whilst on the
The antenatal period 103
postnatal wards to teach the principles of good ‘body care’ between preg-
nancies (see p. 210). The women’s health physiotherapist should be the
member of the postnatal team who, with enthusiasm and knowledge, can
create good body awareness during the childbearing years, which will
benefit mothers and their families throughout life.
Some women attempt to become superfit overnight preconceptually by
means of overvigorous activity such as aerobics, jogging or weight training.
Taken to its extremes, this could lead to amenorrhoea. Such overzealous
enthusiasm can be channeled into safer activities by the women’s health
physiotherapist; swimming, Pilates, yoga, cycling and walking, for exam-
ple, are less likely to cause injuries. Assessment and treatment of back prob-
lems before the physiological ligamentous changes begin, and imprinting
the concept of good back care, could prove invaluable in the months of
pregnancy and later. The women’s health physiotherapist can give advice
regarding urinary disorders (e.g. stress incontinence, urgency or frequency)
and begin pelvic floor and abdominal muscle education or re-education
using exercise and possibly biofeedback. All women, but particularly those
who are attending infertility clinics, will benefit from stress-reducing tech-
niques, including relaxation and positive thinking. Women with physical
impairment or pathologies such as multiple sclerosis, rheumatoid arthritis
or the effects of a cerebrovascular accident would benefit from the spe-
cialised skills and support of the women’s health physiotherapist to
empower them for the marathon of pregnancy and motherhood.
INFERTILITY/ Ninety per cent of couples having unprotected sex will conceive within a
SUBFERTILITY year, 50% of them in the first 3 months (Chambers 1999). The causes of
infertility can be divided into male or female factors, or a combination of
the two, with a third of couples no factor is identified. Treatment options
are varied, but within the NHS investigations and availability can be
limited and necessitate a frustrating wait for couples in an already stress-
ful situation.
The causes of infertility are varied, as are the treatment options.
Hormonal treatment may be advocated for a woman failing to ovulate as
with polycystic ovaries (PCO). Clomifene is commonly used, either alone
or with gonadotrophins; however, there is an increased risk of multiple
pregnancies and ovarian hyperstimulation syndrome (OHSS).
If a woman has tubal disease, then in vitro fertilisation (IVF) is one of the
first options, with success affected by duration of infertility, woman’s age
and previous pregnancies. Multiple pregnancies are more likely. There are
many other assisted-conception techniques including intracytoplasmic
sperm injection (ICSI), where the egg is again fertilised before being trans-
ferred to the uterus (as in IVF), but where one sperm is injected directly
into the cytoplasm of the egg. This may be used where the sperm count is
low. For more details of assisted conception see Chambers 1999.
Pregnancy, especially for primiparous women, can be a combination of
incredible excitement at the prospect of being a mother combined with
anxieties regarding the health of their baby, carrying them to full term
and the labour itself. If a couple has been through assisted conception to
104 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
achieve this pregnancy, they will probably have all of the above emo-
tions, plus not surprisingly, increased worries regarding a positive out-
come. Whether the women’s health physiotherapist is treating the
mother for a musculoskeletal condition or the couple as part of an ante-
natal class, appropriate sensitivity to their needs has to be demonstrated.
EARLY PREGNANCY The entire female organism adapts to preserve and nourish the fetus
growing within the uterus and with the anabolic metabolism comes a
mental tranquillity and somnolent beauty.
(Llewellyn-Jones, 1969)
ANTENATAL CLASSES
‘EARLY BIRD’ CLASSES Some centres are offering sessions directly after the initial booking visit
when interest and motivation are often at its highest. Although it is
appreciated that some women may miscarry, the support that such a
group offers outweighs the disadvantages. Women are encouraged to
bring their partners or some other person of their choice. The classes will
probably be shared by physiotherapists with midwives, dieticians, health
visitors, dentists and, possibly, doctors. The antenatal screening options
offered within the particular Trust may also be discussed. Prioritisation
106 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Pregnancy back care Postural, hormonal and weight changes, ergonomic education involving
sitting and working positions, bending, lifting and household activities
should all be considered (Figs 4.1–4.5) Ideally, no woman should go
home without an individual posture check, instruction in using seatbelts
in pregnancy (Fig. 4.6), and information regarding access to further help
if she is experiencing back pain or other physical discomfort (see p. 142).
Symphysis pubis Although the true incidence of this pregnancy-related condition has not
dysfunction (SPD) yet been identified, it is a common occurrence usually beginning in the
antenatal period. Many women may experience the signs and symptoms
of SPD but are unaware of its management; indeed not all health profes-
sionals are familiar with it. It is therefore important to flag this up during
the antenatal class to enable the woman to seek further help during both
pregnancy and labour (see p. 153). National guidelines for this condition
Pelvic floor and A brief explanation of the role of the pelvic floor using a model of a pelvis
pelvic-tilting exercises should be given by the women’s health physiotherapist teaching pelvic
floor muscle (PFM) contractions. Mason et al (2001) showed that women
who had learnt and practised PFM contractions during pregnancy experi-
enced less urinary incontinence postpartum than those who had not
learnt the skill antenatally. A study comparing PFM ability with a nulli-
parous group and a group of women at 10 months postpartum with no
incontinence symptoms demonstrated the former had increased muscle
power and endurance, again indicating the importance of exercising
this muscle during the postpartum period (Marshall et al 2002). Where
the group is large, pelvic tilting can be demonstrated while sitting on the
edge of a chair (Fig. 4.7). The group should understand that this exercise
can be helpful for maintaining abdominal muscle strength (particularly
the transversus abdominis muscle), correcting posture and easing back-
ache, and that it can be done in a standing position (Fig. 4.8) as well as
crook lying, side lying and prone kneeling (Fig. 4.9).
Exercises for An explanation should be given as to how pregnancy can affect leg circula-
circulation and cramp tion, and women who travel long distances and have sedentary jobs should
especially be encouraged to carry out frequent foot and ankle exercises.
(4.7) (4.8)
Figures 4.7–4.8 Pelvic tilting.
Ankle dorsiflexion and plantar flexion, and foot circling carried out for 30
seconds regularly, should be suggested; 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 should also be shown. Additional suggestions for 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.
Fatigue Many women who are pregnant for the first time (and their partners) are
completely overwhelmed by the intense tiredness that they experience in
the first trimester. Sometimes this is so severe that they feel totally unable
to function when evening comes. This fatigue is sometimes aggravated
by ‘evening sickness’. The assurance that for most of them this will pass,
and advice on coping strategies and relaxation techniques are reassuring
and helpful.
The effects of stress on An attempt should be made to elicit the causes and the effects of stress
body and mind from the group itself. The Mitchell method of physiological relaxation
(see Further Reading, p. 138) is ideally suited for teaching informally and
can be reinforced by a handout. Other stress-coping strategies, such as
music, a warm bath or shower, a walk or exercise, dancing and massage,
should be discussed (see p. 167).
Emotional reactions The session will not be complete without some discussion of the amazing
range of possible psychological and emotional responses to the recently
confirmed pregnancy experienced by both partners.
Advice on lifestyle Work and how long to continue it, adaptations and alterations in lifestyle
if necessary, sport and exercise should all be discussed. Plenty of oppor-
tunity should be given for questions and discussion.
At the end of these ‘early bird’ sessions, the supply of supporting
leaflets reinforcing the main points and providing contact details of the
women’s health physiotherapist is desirable. The ACPWH leaflet Fit for
Pregnancy covers many of the above topics (see Further Reading, p. 138).
STRESS AND The changing roles of women in the early twenty-first century, combined
RELAXATION with a materialistic and more mobile society and its search for wealth and
possessions, as well as the loss of close family support, impose pressure
on all and especially on young women and their partners embarking on
parenthood. Women today are often delaying motherhood while they
pursue their careers; the mean age of first time mothers in 2000 was 27,
with the average age of all mothers being 29, part of a continuing upward
trend (Botting 2001). In England and Wales the survey showed in
1997–1999 only 38% of women were under the age of 25 when they had
their first baby, compared with 49% between 1988 and 1990. While
110 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Physiological effects The body’s response to threat, whether physical or mental, real or imag-
of stress ined is essentially that of ‘fight or flight’. The physical manifestations
include increased heart rate, raised blood pressure, rapid respiration or
breath holding. Blood is drained from areas of low priority, such as the
gastrointestinal tract and the skin, and diverted to skeletal muscle. The
mouth dries, the pupils dilate, the liver releases its glycogen store, blood
coagulation time decreases and the spleen discharges additional red
blood cells into the circulation. Sometimes the bladder and bowel may be
affected, causing frequency and diarrhoea. There are certain similarities
in joint and muscle response whatever the causative stress. A common
theme runs through the positions adopted which combine to produce a
posture of tension.
These include hunched shoulders, flexed elbows and adducted arms,
clenched or clutching hands, and flexed head, trunk, hips, knees and
ankles. The face contorts to express the relevant emotion. In anger, the
brow is furrowed, the chin juts forward; in grief, pain or fear, it is drawn
in and down to the chest. The jaw is frequently clenched together.
The antenatal period 111
Teaching This method utilises knowledge of the typical stress/tension posture and
neuromuscular control the reciprocal relaxation of muscle – whereby one group relaxes as the
opposing group contracts. Thus, stress-induced tension in the muscles
The Mitchell method of that work to create the typical posture may be released by voluntary con-
physiological relaxation traction of the opposing muscle groups. Proprioceptive receptors in
joints and muscle tendons record the resulting position of ease, and this
is relayed to and registered in the cerebrum. Laura Mitchell, who devel-
oped this beautifully simple and elegant technique (Mitchell 1987),
devised a series of very specific orders which are given to the areas of the
body affected by stress: for example, for hunched shoulders – ‘Pull your
shoulders towards your feet. Stop. Feel your shoulders are further away
from your ears – your neck may feel longer.’ Because of the simplicity
and the physiological basis of this method it is suitable for all levels of
intellect. Physiotherapists would be wise to use the exact instructions
prescribed, which have been developed after many years of trial and
error. A leaflet form of this method is available from the ACPWH (see
Further Reading, p. 138).
112 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Contrast method The contrast method stems from the work of Edmund Jacobson and
involves alternately contracting and relaxing muscle groups progressively
round the body to develop recognition of the difference between tension
and relaxation (Jacobson 1938). Although this technique has been taught
extensively for many years, some people find that it increases a feeling of
tension, which makes it of doubtful benefit for those feeling tense and tired.
Visualisation and imagery This method encourages a person to think in pictures as opposed to
words, using all of the senses (Payne 1998). Imagining a pleasant and
warm environment of their own choice, such as a favorite country walk
or sunny day at the beach, can be used to induce a feeling of calm and
enhance the relaxation methods described.
Touch and massage All physiotherapists will naturally appreciate the physiological poten-
tials of massage in inducing relaxation and relieving pain. Simple touch
can communicate a sense of companionship, caring and sharing, particu-
larly when received from a loving partner. Soothing stroking, effleurage
or kneading to appropriate areas may be used with good effect when
properly taught.
(b)
(a)
(c) (d)
The antenatal period 113
proficient she should be able to adapt the concepts to less supported pos-
tures, even standing. However, the women’s health physiotherapist must
be aware that as pregnancy progresses prolonged periods of supine lying
are to be avoided owing to supine hypotensive syndrome (see p. 37).
Right side lying is a favourable alternative.
Through the course of antenatal classes, it is hoped that women and
their partners will become increasingly able to identify the effects of
stress in those around them, and more particularly in themselves. This
recognition is an essential part in the development of ‘body awareness’,
and enables women to know when to use the appropriate stress-reducing
techniques to induce a relaxation response. It should be emphasised that
this approach is not limited to pregnancy and labour, but should become
a lifelong philosophy and skill. It must also be emphasised that a formal
relaxation technique is not the only way to manage stress. Yoga, move-
ment, music, aromatherapy, warm baths and countless other alternative
coping strategies all have a place. People should be guided and encour-
aged to seek their own individual solutions.
EXERCISE AND It has long been suggested that women whose lives were filled with hard
PREGNANCY active work and who were consequently physically fit tended to have
easier labours than those with a more sedentary lifestyle. (Exodus 1 : 19;
Vaughan 1951). Until the twentieth century, however, most women were
grateful simply to survive the multiple hazards of pregnancy, labour and
the puerperium; a healthy baby was an additional bonus! With the envir-
onmental and medical advances that have led to safer childbirth and a
substantial drop in the maternal and foetal mortality rates has come an
enormous change in expectations of parturient women. Some, particu-
larly middle-class professionals, approach childbirth as they would a
job or an examination – they study, prepare and train for it. Others, con-
scious of being relatively ‘unfit’ (in the athletic sense of the word), feel
that they ought to improve their strength, flexibility, stamina and endurance
in preparation for pregnancy and childbirth – or actually during the
months after their pregnancy has been confirmed. All these women prob-
ably hope that exercise will give them an easier pregnancy and a shorter
labour, and enable them to cope more efficiently with the exhausting
early days of new motherhood.
It is not possible to set strict guidelines for women wanting to exercise
during pregnancy as there are too many variables, such as individual fit-
ness levels, the intensity and type of exercise and the individual factors
affecting each pregnancy. With exercise and activity now being encour-
aged as part of a healthy lifestyle, more women are likely to be exercising
before and during pregnancy. This increase in the number of women
wishing to be active during pregnancy means the women’s health physio-
therapist will be involved in educating and encouraging exercise in many
different situations. These range from leading antenatal exercise groups,
advising women who are habitual exercisers and are wishing to continue
with exercise, pregnant women who wish to become more active but do
not regularly exercise, and about the use of suitable home exercise videos.
114 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
3. There will be a small increase in the number of calories per day needed
during pregnancy and this is mostly significant in the last trimester; if
a woman is exercising this will also increase the amount needed.
Hypoglycaemia may arise with maternal exercising, which could
lead to foetal hypoglycaemia.The pregnant woman has a reduced
fasting blood sugar compared with the non-pregnant woman,
and also metabolises carbohydrates faster. Hypoglycaemia is more
likely to happen during a resting and fasting state, so the pregnant,
exercising woman has to ensure her calorific intake is adequate when
exercising.
Foetal risks 1. Foetal distress could occur during vigorous and prolonged exercise
because of the selective redistribution of blood flow away from the
splanchnic organs, including the shunting away of the uteroplacental
blood flow towards the working muscles by up to 50%. In the normal
healthy woman and during mild and moderate exercise this will only
rarely be a problem. The effects of vigorous activity by the pregnant
woman on the foetal heart rate have shown an increase of 5–15 beats
per minute. The exercise intensity of up to 70% of maternal aerobic
power for short time periods does not affect foetal heart rate.
2. Foetal growth and development – studies have shown maternal exer-
cise to increase, decrease and have no effect on birthweight. Magann
et al (2002) studied the significance of exercise on maternal and foetal
outcome on low-risk healthy pregnant women. They were divided
into four groups ranging from no exercise to heavy exercise (exercising
voluntarily at more than 28 weeks and continuing until 28 weeks ges-
tation or throughout their pregnancy). The women who exercised to a
moderate to heavy level delivered babies who were 86 g on average
smaller than the group of non-exercisers. No adverse consequences
were identified in the lower-birthweight babies.
3. Foetal malformations, arising from the teratogenic effects of a raised
maternal core temperature during the first trimester, are possible (see
thermoregulation).
4. Preterm labour, with or without delivery, is a concern, especially in the
last trimester; the concern is that exercise may trigger uterine contrac-
tions. When Hatch et al (1998) conducted a study investigating mater-
nal exercise and time of delivery, no association was found between
low to moderate exercise and gestational length. Alderman et al (1998)
found, using a sample of 291 women, that moderate to vigorous phys-
ical activity for 2 hours per week or more in any month was associated
with a reduced risk of a large birthweight baby for gestational age, and
there was no significant effect or risk for small infant size. Artal &
Sherman (1999) support this view. Indeed, a study comparing aerobic
exercise in the first two trimesters of pregnancy and type of delivery
found that sedentary women were more likely to deliver by caesarean
116 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Contraindications Currently there are three main bodies which offer recommended guide-
lines and contraindications for exercise in pregnancy; the American
College of Obstetrics and Gynecology (ACOG 1994b, 1995), American
College of Sports Medicine (ACSM 1991) and the Society of Obstetrics
and Gynaecology of Canada (SOGC 1995). There is some disagreement as
regards interpretation of current research to optimise safety of mother
and foetus but Table 4.2 gives some guidance (see also the ACASC pos-
ition paper in Further Reading, p. 138).
Women in these categories tend to be aware of their limitations; there
is no reason, however, why routine antenatal exercises for leg circulation,
pelvic floor muscles and gentle movements to maintain good posture
and back comfort (e.g. pelvic tilting) should not be taught and practised
regularly (see Early Bird Class p. 105). Activities that may be contraindi-
cated include competitive and contact sports, and activities such as horse
riding, skiing, waterskiing and scuba diving carry far greater risks when
a woman is pregnant.
Guidelines for women • Jerky, bouncing, ballistic movements and activities should be avoided.
exercising during • Regular mild to moderate exercise sessions, at least three times a week,
pregnancy are safer than intermittent bursts of activity.
Swimming and water Swimming is possibly the perfect pregnancy exercise. Even non-swimmers
exercise in pregnancy can benefit from a programme of exercise and relaxation in a pool. The
buoyancy of the water supports the mother’s increasing body weight,
enabling her to continue with the excellent toning and strengthening
activity which increases her physical fitness and endurance, as well as
promoting her sense of well-being. In addition, exercise in water offers
several physiological advantages to the pregnant woman (Katz 1996).
As well as being a form of exercise, a study involving a group of women
from 18 weeks’ gestation to the 1st week postpartum, randomised to either
water gymnastics once a week or to a control group, found a significant
reduction in intensity of back or low back pain in the first group as well as
a decreased number of women on sick leave due to back pain (Kihlstrand
et al 1999). The regular swimmer should be encouraged to continue with
her normal routine, adapting her strokes and the distance of her swims to
her advancing pregnancy; as with all other sports, she should be warned to
‘listen to her body’ and slow down accordingly. A woman with SPD needs
to avoid breaststroke as the hip abduction can exacerbate the condition;
front crawl can be suggested as an alternative. Care should be taken with
either stroke not to exaggerate the lumbar lordosis, which can happen if a
woman is not submerging her head under water.
Women should ‘warm up’ prior to their main swim, and ‘cool down’ fol-
lowing it. A session of relaxation aided by the buoyancy of the water can be
most therapeutic, particularly in the final trimester. For non-swimmers a
programme of suitable exercises can be suggested, including activities for
the legs, arms and trunk, as well as ‘water walking’ and relaxation. Many
swimming pools and leisure centres now provide special sessions for
The antenatal period 119
Pilates Pilates is currently enjoying vast popularity, but was initially developed
by its master Joseph Pilates back in the mid twentieth century. The Pilates
method encompasses an holistic approach to exercise, developing body
awareness and general fitness, which starts from a central core of stabil-
ity concentrating on abdominal and pelvic floor muscles. Hence, this
gentle form of exercise can be employed by the pregnant and postnatal
exercising woman to help maintain and retrain these muscles in both
stages, as well as focusing on posture and coordination. However, it is
important to ensure that women are directed to classes led by instructors
who have had the appropriate training.
That ‘we are what we eat’ is undoubtedly true, but the assertion that
pregnant women need to ‘eat for two’ in terms of quantity is now quite
out of date. During pregnancy, the body works more efficiently, saving
energy by adjustments in physical activity and adapting its metabolic
rate. The average woman needs only an extra 300 calories per day in the
second and in the third trimester when the baby is growing at its fastest
rate. What is important is the nutritional intake in the first trimester, as
this is when the formation of the foetus is occurring and major influences
will be the uterus, placental structure and the mother.
A normal weight gain of 11–15 kg (25–35 lb) is expected, but will vary
according to prepregnancy weight, height, age, and whether the woman
has had a baby previously. The approximate distribution can be seen from
Figure 2.6 (see p. 40). If a woman’s BMI is high, she will be encouraged
to aim for a weight gain towards the lower end of the scale; the opposite
will apply to those with low BMI. Maternal weight gain or loss is also
a poor indicator of foetal well-being – another reason why routine weigh-
ing of women has stopped. Women should eat according to appetite,
120 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
adopt the habits of a healthy diet, and be advised that pregnancy is not
the time to start dieting. Current evidence suggests that a single birth
results in a 2–3 kg increase in average body weight (Gunderson & Abrams
1999), with postpartum weight retention more likely with a higher gesta-
tional weight gain, especially if the weight is gained earlier in the preg-
nancy (Muscati et al 1996, To & Cheung 1998).
Breastfeeding is often advocated to help lose weight retained postpar-
tum. A study comparing the effect on mothers’ weight of breastfeeding or
bottle feeding from birth to 18 months postpartum did find a significant
positive association with breastfeeding (Janney et al 1997). Similar find-
ings were found by Dewey et al (1993), the weight loss being significantly
higher in breastfeeding mothers at 12 months postpartum (by 2 kg) com-
pared with mothers using formula feeding. The accumulative effect of
breastfeeding was emphasised, that is, to gain the benefit of the weight
loss postpartum, women needed to breastfeed for at least 6 months.
If a healthy diet is adopted preconceptually and maintained through-
out pregnancy, this should give a good balance of the nutrients needed to
maintain the mother’s health during pregnancy, as well as helping her
baby grow and develop normally. The five basic food elements are pro-
teins, fats, carbohydrates, fruit and vegetables and dairy products.
Folic acid This helps in the prevention of neural tube defects such as spina bifida
(Garcia-Morales et al 1996). It is found in vegetables (cauliflower, frozen
peas, tomatoes), oranges, breakfast cereals and yeast extract. It is recom-
mended that a daily supplement of folic acid (0.4 mg/day) is taken by all
women both preconceptually and in the first trimester of pregnancy.
The following vitamins and minerals can all be acquired in the appropri-
ate amounts with diet and without additional supplements:
Calcium This is needed for bone, teeth and gum formation. It is found in dairy
products, sardines and dried fruit. The foetus takes the quantities
required by absorbing it from the mother’s stores; it is important there-
fore to maintain intake. Vitamin D helps with absorption of calcium.
Omega-3 fatty acids These are important for development of the baby’s brain and neural
(e.g. fish oils) development. They are found in mackerel, salmon, sardines and other
oily fish, as well as flaxseed.
Dietary fibre This is to help prevent the constipation common in pregnancy. It is found
in fruit, vegetables, nuts and pulses, wholemeal bread and cereals. It is
important to be taken in combination with high water intake.
FOODS TO AVOID Women’s immunity is lowered during pregnancy, so they are more open
to infection. It is thus worthwhile advising on the foods that should be
avoided despite the relatively small risk they pose in terms of infection
and potential damage to the unborn baby.
Listeria This bacterium is rare, occurring only in 1/20 000 pregnancies (University
of Sheffield 1999). It can cause flu-like symptoms in mothers, miscarriage
in early pregnancy, premature labour and stillbirth. It has been associated
with certain foods, and the following guidance is recommended:
Salmonella This is a common cause of food poisoning, causing sickness and diar-
rhoea in the mother. It rarely harms the baby during pregnancy, but it is
best to avoid a severe infection. As it is associated with raw eggs and
poultry, women should be recommended to:
• Wear gloves when emptying a cat tray or gardening. Wash hands after
handling cats/kittens.
• Pregnant women should not help with lambing or milk ewes recently
delivered, as sheep may carry toxoplasmosis, Listeria or Chlamydia.
Liver Excessive amounts of vitamin A in the retinol form have been associated
with congenital malformations, therefore the advice should be:
Dark fish Dark fish (e.g. swordfish, shark, tuna or marlin) contain high levels of
mercury, which can affect the development of the foetal nervous system;
therefore it should not be eaten frequently. It is currently recommended
to limit consumption to two portions per week.
Peanuts The number of children with allergies, including peanut allergy, has been
increasing over the years and the reason for this is unclear. However, it is
thought that they may develop during pregnancy. As peanut allergy can
be life threatening the current recommendation is that if a woman or her
partner has a known peanut allergy, or suffers from asthma, eczema, hay
fever or other food allergies, she should avoid peanuts both during preg-
nancy and whilst breastfeeding.
Caffeine This does not need to be avoided during pregnancy, but it is suggested to
limit it to 300 mg/day. It is found in tea, coffee, cola drinks and chocolate.
High levels of caffeine consumption have been associated with low-
birthweight babies and miscarriage (Rasch 2003). However, other studies
have found no association with IUGR, low birthweight or preterm deliv-
ery with moderate caffeine consumption (Bracken et al 2003, Clausson
et al 2002, Grosso et al 2001). Women who drink large amounts of coffee
(more than eight cups/day) double the risk of stillbirth compared with
non-caffeine-drinkers (Wisborg et al 2003).
From the above list, it is easy to see why some women worry about what
they should and should not be eating or drinking to avoid harming their
baby, so perspective must be maintained that the above infections are
relatively unlikely. If common sense and basic food hygiene are main-
tained all should be well. The women’s health physiotherapist must keep
abreast of current guidelines and, if unsure, be able to direct women to
the appropriate professional or information resource.
SMOKING IN There is strong evidence to show that maternal smoking, and possibly
PREGNANCY AND maternal passive smoking, is harmful to the foetus, and that it can affect
LATER the pregnancy and the subsequent development and health of children
after they are born. It is accepted that there is a direct link between mater-
nal smoking and low birthweight, as well as an association with exposure
to environmental tobacco smoke (Windham et al 2000). Smoking is also
associated with foetal hypoxia, IUGR, placental abruption, premature
rupture of membranes, miscarriage, premature delivery (Wisborg
et al 1996) and low Apgar scores. It has been demonstrated ultrasonically
(Pinette et al 1989) that there is an acceleration of placental maturation and
therefore of premature senescence and calcification leading to poor func-
tion in smokers. Wisborg et al (2001), using a cohort of 25 102 singleton
children, found an increased risk of stillbirth associated with mothers who
smoked and an infant mortality of almost double the risk, compared with
a child of a non-smoking mother. Yet, if women stopped by 16 weeks’ ges-
tation, their risks became comparable with non-smokers throughout the
pregnancy. The problems do not cease with the birth of the baby.
Postnatally, the consequences of smoking during pregnancy continue
with smoker’s children having three times the risk of sudden infant
death syndrome (SIDS) than those of non-smokers, the risk increasing
with the number of cigarettes smoked (Wisborg et al 2000). When chil-
dren are brought up in families where smoking continues, long-term
after-effects have been reported including increased childhood mortality,
postnatal growth retardation and chronic respiratory illnesses.
124 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Stopping smoking is one of the most effective steps a woman can take
to improve her baby’s health and that of her own. In the last UK survey,
35% of women smoked before or during their pregnancy, but the figure
reduced to 20% for women continuing throughout the pregnancy (DOH
2002). Although this figure does not indicate what proportion of women
stopped smoking independently, professional advice and support can
achieve significant cessation rates. As the risks of maternal and paternal
smoking continue into the baby’s infancy and childhood, the women’s
health physiotherapist should be able to direct motivated women to the
relevant groups, and resources to help stop the habit.
MEDICATION IN Since the thalidomide disaster in the 1960s, when an antiemetic drug
PREGNANCY given in early pregnancy to women suffering from nausea and vomiting
was found to be the cause of severe limb and organ deformities in their
babies, it has become obvious that the placenta does not act as a barrier to
harmful chemicals. Research showing no adverse effect on animals does
allow the assumption that this will be the same on humans. It is import-
ant for women who find that they are pregnant, and those likely to
become pregnant, to understand that some drugs can damage the develop-
ing foetus. The most sensitive time for embryonic damage is in the first
trimester; women and their partners need to realise that it is not only
doctor-prescribed medicines that can damage babies, but also over-the-
counter treatments.
The mother’s health must be the primary consideration, but where a
woman becomes ill in pregnancy, or has a pre-existing condition that
obliges her to take medication, doctors will always try to use drugs with
the least known risk, changing original prescriptions to substances known
to be safer. Drugs with major teratogenic effects are rare, but retinoic acid
(used to treat severe acne), some cytotoxic drugs and radiochemicals can
cause grave damage. Pregnant women whose foetuses have been exposed
to these substances are offered terminations. Tetracycline taken in preg-
nancy is known to cause subsequent discoloration of children’s teeth, and
many other drugs in common usage can cause damage of various sorts and
degrees depending on the stage in the pregnancy that they were taken.
Physiotherapists presently do not prescribe as part of their clinical practice
but, if seeking further information on drugs which are potentially harmful
to the foetus, should refer to the current British National Formulary (BNF).
A patient should always be referred back to her GP or obstetrician for fur-
ther clarity. It is important for women to realise that they have a responsi-
bility in this context too; they should always remind their doctor, dentist or
pharmacist that they are pregnant whenever medication is prescribed or
when they buy ‘over-the-counter’ remedies of any kind.
Although it is probably safest to avoid unnecessary medication during
pregnancy, it is estimated that over one-third of women take self-pre-
scribed ‘over-the-counter’ medication during pregnancy (Jordan 2002).
Paracetamol is the commonest painkiller for use both during pregnancy
and breastfeeding (Byron 1995), for example for headaches or colds, and
is commonly prescribed without ill effect.
The antenatal period 125
ADDICTIVE DRUGS IN Although many centres have pockets of drug users, addiction in the UK is
PREGNANCY not as great as it is in other parts of the world. Many regular drug abusers
will have other health problems and probably poor social conditions too;
sadly, they are often identified as a group likely to be poor attenders
regarding antenatal care so that the foetus is at risk from several sources.
Congenital abnormalities have been reported following the use of the
narcotics, cocaine, lysergic acid diethylamide (LSD) and the ampheta-
mines (including ‘Ecstasy’). Placental insufficiency, IUGR and perinatal
mortality are all increased where women use heroin and its derivatives.
A major problem is the effect of narcotic drug withdrawal on the foetus
and neonate, which can prove fatal if not very carefully managed both
during pregnancy and the immediate postpartum period. However, the
prognosis for the infant of the drug-addicted mother is good if the
mother cooperates with antenatal care and drug control (Bolton 1987).
CLASS When planning new antenatal courses it is imperative for the team to
ARRANGEMENTS explore the perceived needs of the prospective clientele; these vary from
area to area and can fluctuate within a community. Whether urban or
rural, populations develop and change, and the ethnic and socioeconomic
composition can be dramatically altered. The women’s health physiother-
apist needs to be flexible in her approach, adapting the classes according
to the needs of the group: are the groups aimed at primiparous or multi-
parous women; are they couples or women only; and what provision has
been made for non-English-speaking parents or those with disabilities?
A study completed by the NCT asking parents to identify what they
thought the content of the classes should be, found that questionnaires
completed before their classes, after them and following delivery, were
all consistent in requesting more coverage regarding the changes in their
lives and relationships with the arrival of a new baby (Nolan 1997) as
well as the practicalities of a new baby.
The advantages of an ‘early bird’ class are generally recognised, and
are discussed on page 105. Commonly the main antenatal course consists
of four to six sessions, and usually begins around 32 weeks’ gestation.
The number of classes offered and which professionals facilitate them
will vary widely according to the resources and preferences of individual
trusts. Parent education sadly remains low on the priority list of some
units, partly owing to resource implications and professional reluctance
to take classes during unsociable hours. This can result in shortened
courses, with the result of fewer classes being offered leading to exclu-
sion of certain topics.
Some women, although entitled to take time to attend antenatal classes,
often find it hard to commit during the working day and as mentioned pre-
viously are continuing to work until close to term. Managers within Trusts
The antenatal period 127
Environment Antenatal classes are frequently held in very unsuitable places such as
‘nooks and crannies’, basements and windowless ‘cupboards’. Ideally
128 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
A 6-WEEK COURSE Class and class facilitators meet each other. Although all the people attend-
ing have one obvious thing in common, they are essentially a group of
Week 1: introductions strangers to each other. ‘Ice breakers’ are invaluable in decreasing awk-
wardness and inhibition to then allow the group to gel and interact. This
may be time consuming but pays dividends for the course in the long
term, as anyone who has ever been faced with a situation where eliciting
group participation is an uphill struggle will verify!
The first session is an ideal opportunity to tackle immediate problems
and worries, for example any specific queries re back pain, SPD and gen-
eral aches and pains, and other priority concerns. Encourage class attend-
ers to take responsibility for their own learning and identify topics they
want to cover during the course, so it remains very parent centred. From
this a plan for each session is devised providing well-structured classes
incorporating the parents’ agenda, which boosts their self-esteem by
valuing their opinions. A balance is needed between preparation for
labour and for parenthood, with time allotted for postnatal emotional
issues.
If there is time include:
A class reunion This encourages the formation of friends and a support network. Include
discussion with a recently delivered mother and father, accompanied by
their baby, their experience of labour and early postnatal problems and
discomforts, and how to cope with them.
A visit to the delivery suite may be incorporated into one of the classes or
offered on a separate occasion, but is a useful way to dispel fears and pre-
conceptions parents may have regarding this place so much talked about
but never actually experienced.
Some services offering daytime classes arrange a partner’s evening
session to include fathers unable to attend during the working day.
Regrettably, in some centres, financial restraints result in classes being
available mainly to primigravidae and only exceptionally to multigravi-
dae. Ideally, any pregnant woman who wants to attend antenatal classes
should be free to do so, no matter how many babies she has had. Where
courses are available to multigravidae, they are often a condensed or
‘refresher’ version, but there are great advantages in mixing women of dif-
fering parity.The special needs of multigravidae (which can be met in any
class) include talking through previous labour experiences, updating their
knowledge of labour management, considering the impending changes in
the family, and how to make time for the baby as well as the existing chil-
dren. Relaxation becomes more important as parity increases. In some
respects a multigravid woman will be more self-confident, but age and
experience bring other anxieties – she may well feel that her luck is running
out: Will this baby be normal? What could go wrong in this labour? Many
of these feelings, problems and their solutions can be fully shared in a
group of mixed parity; women can be very supportive of each other.
Although these guidelines may appear rather formal, it must be
remembered that the sensitive women’s health physiotherapist will be
constantly alert to the day-to-day needs of the individuals in the class,
and will be prepared to divert from the original course plan whenever
necessary. At the same time the facilitator must be able to guide and con-
trol discussion. Although group discussion can change attitudes, and must
be encouraged, women and their partners do come to antenatal classes to
gain information and may resent the conversation being monopolised by
a few vociferous participants. Antenatal educators must not fall into the
trap of solely preparing their parents for the ‘grand finale’ of pregnancy –
labour. They must always remember that labour, particularly for the
primigravida, is in fact the transition to a totally new lifestyle which will
gradually evolve, and time and consideration needs to be given to easing
the adjustment.
The findings of studies investigating effectiveness of antenatal parent
education classes vary. Hetherington (1990) found prepared couples
were more likely to receive little or no pain medication, whilst Nichols
(1995) found no differences when comparing attenders with non-attenders
in terms of childbirth satisfaction, parenting sense of competence, and
ease of transition into parenthood. However, it was suggested that fur-
ther evaluation of course content is needed; rather than looking at birth
outcomes as a measurement of successful parent education, studies
The antenatal period 131
THE TRANSITION TO Why consider life after birth? Parenthood is the only job people are
PARENTHOOD expected to do 24 hours a day, 7 days a week, 52 weeks a year. Yet, while
in today’s world most new appliances or things come with a manual,
babies do not come with one to identify their specific wants and charac-
ter. There are many, many baby ‘experts’ out there, books to read, and
websites to browse. However, it is now being recognised that more help
is needed to instil confidence in today’s parents regarding their individ-
ual baby’s development and care.
The confirmation of a pregnancy is greeted by a wide range of emotions
from women and their partners: joy and satisfaction if the pregnancy is a
planned and wanted one; ambivalence, which can turn to acceptance and
pleasure, even if it was unplanned; despair and rejection when the preg-
nancy is unwanted. Even women and men who have struggled with infer-
tility over the years, undergoing all sorts of physically and psychologically
demanding treatments, may as the wildly hoped-for pregnancy progresses
develop physical and emotional problems. A percentage of women will not
enjoy being pregnant, for a number of reasons, and this is to be acknow-
ledged by any health professional involved with their care. Pitt (1978),
132 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Fathers Although it is the woman’s body that conceives, carries and gives birth to
the baby, and is equipped by nature to provide everything in the way of
nourishment the infant requires in the first few months of life, parent-
hood is usually a shared experience. Fathers too go through a sequence of
changes as they leave independence or the ‘cosy twosome’, or face a new
addition to an established family. While many men are delighted at the
prospect of becoming a father, this is combined with fears and anxieties
about how they will cope with the new demands that will be made on
them. Within one generation there have been notable changes to the
father’s role, with men now much more actively involved with childrea-
ring, rather than the traditional role of being the sole financial provider.
Research has shown many benefits for involved fathers including: first-
borns who have good relationships with their fathers, being much more
accepting of a new sibling, and women with involved partners being less
likely to suffer with postnatal depression (Martyn 2001).
In a few societies ritual couvade is practised by men. Special dress, con-
finement, restriction of activities, avoidance of polluting substances and
mock labour are all said to signify magical protection of the mother and
The antenatal period 133
infant, symbolic expression of the bond between father and child and the
acceptance of fatherhood. As has been seen, many men in our society
today also complain of a variety of physical and emotional health prob-
lems during their partners’ pregnancies and in the early postpartum
period as well. It has been suggested that this is an expression of the
father’s subjective involvement in the pregnancy (Munroe & Munroe,
1971) and also an expression of profound caring for their partner and
unborn child (Clinton, 1985). Also, ante- and postnatal depression is by
no means restricted to women.
The women’s health physiotherapist must also understand the anx-
ieties expectant fathers may have: ‘Will I be able to cope with her distress
in labour?’; ‘Will this enlarged, moody female ever again become the
slim, happy, active girl I used to know?’; ‘Will sex ever be the same again?’
Common concerns may also include the responsibilities that come with
parenting, worrying about being a good father, financial concerns pro-
viding for his family if his partner is not working, and adjusting to shar-
ing her with the baby. These are some of the doubts and fears men have
and they are often unable to express. Men have few role models and posi-
tive images of fatherhood to draw upon; attending classes which encour-
age discussion with other expectant fathers may help reduce worries,
and a skilled facilitator can give them a realistic and practical insight into
beginning to adjust to their role as father.
ANTENATAL CARE OF Grantly Dick Read when writing about breastfeeding in his book
THE BREASTS AND Childbirth Without Fear (1954) said: ‘The newborn baby has only three
PREPARATION FOR demands: warmth in the arms of its mother, food from her breast and
BREASTFEEDING security in the knowledge of her presence. Breastfeeding satisfies all
three.’ Chloe Fisher, a senior community midwife (now retired) in
Oxford, has described breastfeeding as ‘a wonderful, programmed
human interaction which gives the mother intense satisfaction, and her
baby all it requires to sustain life for many months’ (Inch 1987). Perhaps
the best preparation for successful and happy breastfeeding comes long
before pregnancy – during childhood in fact (RCM 2000b). Children who
are brought up in a culture where babies are breastfed quite uncon-
sciously, and by many role models, mothers, sisters or friends, will grow
up aware that this physiologically normal method of nourishing the new-
born can be natural, easy and pleasurable for both mother and baby
(Toothill 1995). Having seen mothers breastfeeding, young women will
have confidence in their own bodies being able to provide milk, and their
babies knowing how to take it.
Despite the many benefits to both mother and baby regarding breast-
feeding (Wilson et al 1998), the UK continues to have one of the lowest
breastfeeding rates within Europe. The last British infant-feeding survey
in 2000 showed that 69% of babies were initially breastfed, with a drop to
42% by 6 weeks and 28% at 4 months (DOH 2001). While this showed a
small increase in the number of women who commenced breastfeeding,
by 6 months the rate had dropped to 21% (the same level as for 1995),
even though the WHO recommends that babies should be exclusively
134 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
ROLE OF THE As mentioned previously, the topic of breast or artificial feeding is one of
WOMEN’S HEALTH the main priorities to cover within parentcraft education by the midwife.
PHYSIOTHERAPIST The women’s health physiotherapist can provide valuable additional
advice and ergonomic education regarding best feeding positions to
ensure proper support of the sore perineum and spine (see p. 217).
The antenatal period 135
Because the shape of the breast when the nipple is offered is all import-
ant, women must appreciate that it will be more difficult for their baby
to be positioned correctly if they are leaning back, as their breasts will be
flatter than if leaning forward, in which the breast assumes a more
pointed shape making it easier for their baby to ‘latch on’. Side lying, as
well as leaning forward initially when sitting, can achieve the desired
effect, with the former also being comfortable for backache. Whilst the
promotion of breastfeeding for both mother and baby is to be recom-
mended, it is necessary to remember that some women will choose not
to do so or discontinue at an early stage. There are many reasons for this,
for example a previous bad experience, lack of confidence regarding
adequate milk supply, or a partner’s negative attitude. If the woman is
aware of all the benefits and support networks are in place to facilitate
breastfeeding, respect for the individual’s choice antenatally must be
shown and incorporated into her antenatal care plan; however, there
must be flexibility to allow for a change of mind.
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138 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Further reading
ACPWH (Association of Chartered Physiotherapists in Research Series (Report no 16), available from Camberton
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guidelines. ACPWH, c/o CSP, London. Katz J 1983 Swimming through your pregnancy. Doubleday,
ACPWH (Association of Chartered Physiotherapists in London.
Women’s Health) Guidelines – Symphysis pubis Katz J 1995 Water fitness during your pregnancy. Human
dysfunction. Professional Affairs, London. Kinetics.
ACPWH (Association of Chartered Physiotherapists in Kitzinger S 2000 Rediscovering birth. Pocket Star, Boston.
Women’s Health) leaflets: The Mitchell method of simple Lawrence Beech B 1996 Water birth unplugged. Books for
relaxation; Fit for pregnancy; Fit for birth; Fit for Midwives Press, Cheshire.
motherhood. Ralph Allen Press, Bath. Milton P 2000 Management of infertility for the MRCOG and
Artal R, Wiswell R A, Drinkwater B L 1991 Exercise in beyond. RCOG Press, London.
pregnancy, 2nd edn. Williams & Wilkins, Baltimore MD. Nolan M 1998 Antenatal education – a dynamic approach.
Baum G 1998 Aquarobics. WB Saunders, New York. Ballière Tindall, London.
Brayshaw E 2003 Exercises for pregnancy and childbirth: Place of Birth and Alcohol and Pregnancy. Informed Choice
a guide for educators. Books for Midwives Press, Initiative leaflets for professionals produced as a result of
Oxford. a collaboration between MIDIRS and the NHS Centre for
Burgess A 1997 Fatherhood reclaimed. Vermilion, London. Reviews and Dissemination. They can be obtained from
Callander C, Millward N, Lissenburgh S et al 1996 Maternity MIDIRS, 9 Elmdale Road, Clifton, Bristol BS* 1SL or
rights and benefits in Britain 1996. DSS Research Series email – [email protected]. www.midirs.org.uk.
(Report no 67), available from the Stationary Office. RCM (Royal College of Midwives) 2002 Successful
Figes K 2000 Life after birth. Penguin, Harmondsworth. breastfeeding, 3rd edn Churchill Livingstone, Edinburgh.
Forth J, Lissenburgh S, Callander C et al 1996 Family- Schott J, Priest J 2002 Leading antenatal classes: a practical
friendly working arrangements in Britain 1996. DfEE guide. Butterworth-Heinemann, Oxford.
Online Sources
www.acasc.org ASASC (American Chiropractic www.midirs.org National Electronic Library for Health
Association Sports Council) Position statement: exercise MIDIRS informed choice leaflets for professionals:
and athletic participation during pregnancy by Place of birth
D’Arcy Forbes. Alcohol and pregnancy.
www.dartmouth.education/~obgyn/mfm/index.html www.rcm.org.uk/data/international/data/safe.htm.
www.dwp.gov.uk 1997 Press notice July. www.shef.ac.uk/pregnancy_nutrition.
Useful Addresses
Association of Breastfeeding Mothers ISSUE (The National Fertility Association)
PO Box 207, Bridgewater, Somerset TA6 7YT 114 Litchfield Street, Walsall WS1 1SZ
Email [email protected] Website: www.issue.co.uk
Association for Improvement in the Maternity Services (AIMS) Foresight – proponents of preconceptual care.
5 Ann’s Court, Grove Road, Surbiton, Surrey KT6 4BE 26 The Paddock, Godalming, Surrey GU7 1XD
Website: www.aims.org.uk Website: www.forsight-preconception.org.uk
Association of Chartered Physiotherapists in
Maternity Alliance
Women’s Health
3rd Floor, 2–6 Northburgh Street, London EC1V 0AY
c/o Chartered Society of Physiotherapy
Website: www.maternityalliance.org.uk
14 Bedford Row, London WC1R 4ED
Website: www.womensphysio.com Multiple Births Foundation
Down’s Syndrome Association Queen Charlotte’s and Chelsea Hospital, Goldhawk Road,
155 Mitcham Road, London SW17 9PG London W6 0XG
Website: www.downs-syndrome.org.uk Website: www.mbf.org.uk
Useful websites
www.midirs.org.uk
www.shielakitzinger.com
www.Babycentre.co.uk
141
Chapter 5
CHAPTER CONTENTS
Introduction 141 Nerve compression syndromes 155
Back and pelvic girdle pain 142 Circulatory disorders 157
Some common syndromes and their treatment 149 Other problems 159
INTRODUCTION
Pregnancy is often the first time in a woman’s life that she will experience
so many different ‘feelings’, both physically and psychologically. The
vast majority of primigravidae will experience ‘aches and pains’ during
pregnancy. For some, these will be many, varied and maybe disruptive
to function. For some, their first experience of the hospital environ-
ment, and personnel, comes during pregnancy or the birth. Perhaps it is
because of these factors, and because pregnancy and birth are ‘unknown’
experiences, that the so-called ‘minor ailments’ of pregnancy can assume
major importance to the woman herself.
The majority of these discomforts can be directly related to the physical
changes that take place during pregnancy, and their resultant biomechan-
ical effects upon functional movement. The growing uterus, and its con-
tents, can give rise to experiences of ‘pulling, pressing and pushing’
discomfort or pain. Some women describe ‘sharp stabbing pains’, or
‘dropping-out’ feelings. The understanding of the physical and biome-
chanical changes taking place is an essential part of the ‘coping strategy’.
Frequently, a clear explanation, and consequent understanding, of the
reasoning behind the symptoms will in the majority of cases be sufficient
to enable the mother-to-be to ‘manage’ and cope with them. Unfortunately,
pregnant women with discomfort, for example backache, are still fre-
quently told: ‘What do you expect, you are pregnant, you can’t expect relief
until the baby is born.’ Once a physiotherapeutic diagnosis has been made
142 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
More than one-third of women experience back and pelvic pain at some
stage during pregnancy (Young & Jewell 2002), yet there is a danger
amongst health professionals of considering these symptoms as inevitable
and unimportant. The intensity and duration of the pain can fluctuate
throughout the pregnancy and often from one pregnancy to the next in the
same woman. There is also great variation in severity between individuals:
one person may complain of minor, transient, stiffness or discomfort, while
another may be totally disabled. Östgaard & Andersson (1991), in a retro-
spective review, showed that back pain occurs twice as often in women
who had back pain before becoming pregnant, and occurs more in women
who have been pregnant before. These women also tend to have symp-
toms for longer. Research indicates that, in about 50% of those pregnant
women experiencing pain, it is of sufficient intensity and duration to affect
their lifestyle in some way, and for one-third of these individuals the pain
is severe (Berg et al 1988, Fast 1999, Mantle et al 1977, 1981, Nwuga 1982).
The first episode of pain in a pregnancy may occur at any stage, but for
the majority it is between the 4th and 7th months (Bullock et al 1987, Fast
1999, Mantle et al 1977, 1981). In general, back pain seems to be felt at a
lower level by a woman when she is pregnant than when she is not preg-
nant (Mantle et al 1981). Mantle et al (1977) and Fast (1999) found the
majority of sufferers have low back pain; for about half of these it radi-
ated into the buttocks and thighs, and occasionally down the legs as
sciatica. The mechanical stresses from the gravid uterus, and the com-
pensatory lordosis (Laros 1991), would support this theory. For many
women the back pain is made worse by standing, sitting, forward bend-
ing, lifting – particularly when combined with twisting (Berg et al 1988) –
and walking. Some complain, in addition or solely, of pain over or in the
symphysis pubis; for a few the thoracic region is affected, rather than the
lower back and pelvis. Coccydynia can also be a problem antenatally,
although it is uncommon and is often linked with a previous injury.
The general population are subject to back pain and therefore it should
not be automatically assumed that a pregnant woman’s backache, or leg
pain, is as a direct result of her pregnancy; nor need pregnancy be an
adverse or prolonging factor to recovery from back problems. It is also
worth noting that back pain before pregnancy does not necessarily lead to
back pain during pregnancy. Some women actually experience less back
pain than usual whilst pregnant. However, it is generally accepted that
there are a number of factors that could account for the significantly higher
incidence of back pain in pregnant women compared with that in their
non-pregnant peers: fatigue, increased mobility of joints (Calguneri et al
Relieving the discomforts of pregnancy 143
PREVENTION OF One of the main aims of the women’s health physiotherapist antenatally
BACK PAIN is to prevent back pain. For some women back pain may well be
inevitable. In this case the aim will be to prevent an increase or exacerba-
tion of symptoms and to educate the woman to ‘manage’ her symptoms.
A study by Östgaard et al (1994) found that pain was reduced by indi-
vidual education early in pregnancy. The suggestion was that perceived
pain was less as a result of understanding and knowledge of how to man-
age the condition. The principles of back care are the same for the preg-
nant woman as they would be for the non-pregnant, although the
application of those principles may have to be adapted. It is good sense
to encourage a woman to be aware of her own body, and to seek to under-
stand and ‘contain’ any back pain she is experiencing before undertaking
a pregnancy, even though there is no clear correlation between back pain
before and during pregnancy.
Antenatal classes should include education in body awareness and
back care, with regular reinforcement and feedback. It is essential that the
health professional leads by example as a method of reinforcement. The
antenatal class is an ideal avenue to providing cost-effective opportun-
ities that, in the long term, will influence the wider community in this,
and many other, health promotional aspects.
The adaptation of Lying can be very uncomfortable during pregnancy. Comfortable resting
back-care principles in and sleeping positions are essential. Additional support may be necessary
pregnancy in the form of pillows, or extra mattress support, in order to gain not only
a position of comfort but one that will facilitate quality ‘positioning’ to
Lying prevent symptoms. The altered body mechanics as a result of pregnancy
144 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Rolling Rolling can be performed more efficiently, and with less risk to the
sacroiliac and symphysis pubis joints, by maintaining adduction at the
hips and flexion at the knees. All human movement is performed more
efficiently if it is facilitated as follows:
• turning the head in the direction of ‘travel’ will facilitate the upper
trunk to ‘roll’
• folding the arms across the chest with the top arm leading in the direc-
tion of ‘travel’ will facilitate the midtrunk to ‘roll’
• slightly flexing the outside knee and laying it on the inside leg (closest
to ‘travel’) will facilitate the lower trunk to ‘roll’.
The body weight has now ‘shifted’ closer to the direction of travel. A ‘lead’
from the arm, and flexed knee will result in an effective, safe and efficient
(ESE) ‘roll’.
There is potential risk involved in getting out of bed. Many women,
during pregnancy, micturate during the night. It is essential that injury
does not occur whilst getting out of bed. The ESE technique is to roll on
to the side, push down against the bed or ‘grab’ the bed sheets with the
‘lead’ arm, and push up sideways at the same time as swinging the legs
over the edge of the bed. This process should be reversed when going
from sitting to lying.
Sitting Sitting can be just as uncomfortable during pregnancy. The aim of the
chair is to be of support to the user with the following criteria:
fingers-width from the popliteal fossa, and horizontal (i.e. hips at 90°,
knees at 90°)
• feet fully supported and flat on the supporting surface
• spine fully supported enabling natural spinal curvature – a small pil-
low in the ‘lumbar hollow’ may be necessary
• enabling the functional activity, e.g. writing, word processing, watching
television.
These criteria are even more important during pregnancy, with every-
thing in moderation. Women should be encouraged not to sit for too long,
Relieving the discomforts of pregnancy 145
Standing and walking It is essential to maintain a good standing and walking posture at all
times, not just during pregnancy. Standing posture can be maintained by
the following:
For example, when vacuuming the floor, the vacuum cleaner should
be as close to the operator as possible (avoiding a ‘top-heavy’ bend),
the action of pushing kept in the same plane (to avoid twisting), knee
extension used when pushing the vacuum cleaner (to utilise the ‘power’
muscles), and the spine not held rigid but allowing it to move ‘with’ the
movement.
The mechanical effects of functional activity upon spinal structure
may under normal circumstances, initiate symptoms. During pregnancy
the risk is exacerbated.
Once pregnancy advances, and abdominal girth increases, it may be
necessary to adapt functional activities. It will become essential to main-
tain the strength of the quadriceps as this is the muscle group that will
enable the woman to be able to continue to get down to, and up from, the
floor, chair, etc. When getting something from floor level the woman
146 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
• avoid squatting unless fitness and stamina ‘prevail’. This is not a stable
position unless the feet are flat on the floor and the weight is within the
base of support. The knee extensors are much less efficient in raising
the body up against gravity, when the knees are flexed beyond 90°
• go down on one knee so that both knees are at 90°, feet on the floor with
as large a surface area as possible, knees in line with hip joints …
• to kneel (with both knees) if staying down there, e.g. cleaning the bath
• go back to one knee when ready to raise up
• put the hand to knee/stool/bath and push through at the same time
as …
• push through the floor, equally with both legs, to extend the knees.
not to examine the sacroiliac joint ‘until the lumbar spine, hip and lower
limb examinations, including neurological tests, have been completed …
one should resist the tendency to find what one would like to find’
(Grieve 1981). A thorough assessment by the women’s health physiother-
apist, with appropriate time allowed by their manager for this, may alle-
viate the worrying statistics as well as result in a more accurate diagnosis.
Subjective examination Patient positioning is even more important with this client group; the
woman needs to be comfortable and well supported.
Routine questioning should be used constantly, linking responses to the
‘problems’ of pregnancy and listening for anything that might suggest
necessitating referral (e.g. oedema, headaches may be indicative of pre-
eclampsia). Throughout the process it is worth remembering that the ‘sta-
tus’ of the woman – maybe anxious (more about the baby than themselves),
stressed, tired – may heighten pain perception. Reassurance is essential.
Mandatory questions concerning the perineum and micturition should
be asked. Are there any changes in perineal sensation or micturition
habits? It is necessary here to discriminate between significant symptoms
and the frequency and stress incontinence experienced by many preg-
nant women, also the pain, hyperalgia or numbness of the perineum,
which may be associated with piles, haemorrhoids and venous throm-
bosis of the vulva, often resulting from constipation in pregnancy or from
the direct downward weight of the foetus. Back pain may accompany
urinary tract infections.
The onset of symptoms is particularly significant during pregnancy, as is
the history of this and any previous episodes. Hormonally mediated colla-
gen changes commence early, whereas important abdominal enlargement
and weight gain are later manifestations. It is important to remember that
severe backache may also be a sign of impending labour. The woman’s
own assessment of the cause is always worthy of note. Padua et al (2002)
reported on a multicentre study of 76 women with back pain in the third
trimester, and found that an evaluation of the patients’ perspective of their
symptoms made it possible to identify predictive factors for the occurrence
of back pain. Of particular interest is a similar episode in a previous preg-
nancy, for there are some women who recognise conception by a recom-
mencement of ‘the backache’. Research has shown that there is a greater
degree of joint laxity in second pregnancies than in first (Calguneri et al
1982), and Mantle et al (1977) and Nwuga (1982) noted the incidence and
severity of back pain increased with parity. Fast (1999) found more disabil-
ity caused by backache in women with prior pregnancies, and suggested
changes in posture or weakness of trunk muscles as explanations. Berg
et al (1988) found that low back pain in a previous pregnancy increased the
likelihood of sacroiliac dysfunction in the present pregnancy.
148 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
The general health, occupation and lifestyle of the woman must be esti-
mated. The philosophy of equality of the sexes, the employment climate
whereby the woman may be the sole breadwinner of a partnership, the
dispersal geographically of families and the belief – correct in itself – that
pregnancy is a normal physiological process, can all lead to pregnant
women expecting and being expected to do too much. Individual limita-
tions must be recognised and conceded. Dramatic improvements in back
pain in pregnancy have been achieved simply by discontinuing employ-
ment. In contrast, there is increasing evidence that physically fit women
have fewer aches and pains in pregnancy than their unfit sisters (Hall &
Kaufman 1987).
Objective examination Positioning of the woman for stability and comfort is essential. Standing
may need the support of a wall or plinth, prone lying may be possible
with pillows, supine lying may require lateral tilting to avoid supine
hypotensive syndrome and those with pelvic pain may find the action of
getting on or off the plinth painful. Tests in lying should be completed
speedily. Side lying is generally well tolerated.
Anatomical and biomechanical changes should be taken into account;
for example joint mobility will be increased, trunk mobility will be
reduced and joint range may be reduced if oedematous.
Routine observation should be performed in support standing with the
woman appropriately undressed. Findings can then be compared with
those observed as the patient moves, and with the patient in other pos-
itions as the examination proceeds. Asymmetry must be interpreted with
caution as virtually all patients have bony anomalies of some sort. Waist
contours and shoulder levels can also be misleading if the foetus is lying
asymmetrically.
A functional assessment is essential. Changes produced by movement
should be observed; ranges of movement, stiffness, pain, lengths/levels/
contours, sensation, power and reflexes. Palpation of all appropriate
areas will give the assessor more information. In a clinical specialty so
prone to litigation, it is essential then to record assessment findings. Time
to fulfil this requirement ‘completely’ should be included within the
treatment time.
It is inappropriate to ‘detail’ hands-on techniques in this text. If the
reader does not feel confident in this area it is essential to spend time with
‘musculoskeletal’ colleagues, and share knowledge and skills to the bene-
fit of the client.
Findings then need to be interpreted to enable a treatment regimen to
be decided upon and then implemented. It is essential that the patient is
included in this process so that her perceived problems are addressed.
Communication should also take place with the professional who is tak-
ing the ‘lead’ on the care of the woman: the obstetrician, GP or midwife.
Safety is of paramount importance and all aspects of the pregnancy must
be included in the assessment before treatment is decided upon.
Once a course of action has been decided upon it should be remem-
bered that the pregnancy will not diminish and may even heighten the
normally powerful placebo effect of any treatment given by a thoroughly
Relieving the discomforts of pregnancy 149
LOW BACK PAIN It is worth remembering that there are many causes of back pain and that
the pregnant woman is not immune to the ‘ills’ her peers are prone to.
However, pregnant women are more ‘at risk’ as a result of physiological
(e.g. joint laxity), anatomical (e.g. increased lumbar curve) psychological
(e.g. inability to concentrate) and mechanical (e.g. altered centre of mass)
changes taking place during pregnancy.
Treatment It is essential that the woman be fully informed about her ‘condition’, and
that support networks are in place to enable her to ‘manage’ it. There
is no evidence to suggest that advice to stay active is harmful (Hilde
et al 2002), but there is evidence to suggest that prolonged bed rest is. It
would therefore be wise to advise the woman to remain active within her
pain range. The expert with regard to human function is the physiothera-
pist. The women’s health physiotherapist will be able to use her ‘core’
skills, along with her obstetric knowledge, to the benefit of the woman; this
is an essential role in enabling the woman to ‘manage’ her symptoms – how
to sit, to lie, to move with minimum effort, maximum effect and least pain.
If the symptoms are less acute, a reduction in overall activity is still
advisable, but with a similar approach to ‘managing’ symptoms, and
maintaining ‘back care’ and posture. Physiotherapeutic ‘input’ is essen-
tial in advising the woman on an appropriate course of action, and
administering pain relief to enable function – gentle heat and massage
have been used to effect, and maybe the use of transcutaneous electrical
nerve stimulation (TENS) is indicated if the pain continues (see p. 185).
NB The physiotherapist is reminded to take careful note of current research
with regard to the use of TENS in pregnancy. At the time of going to press there
is no evidence that it might be harmful to the foetus, but there is also no evidence
that it is harmless. The physiotherapist should make a professional judgment as
to its use in light of a detailed assessment. If the decision is taken to use TENS,
and the mother consents to its use, then the completion of a consent form is
advisable.
150 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
SACROILIAC JOINT Pregnancy could have many possible effects on the sacroiliac joint; for
DYSFUNCTION example joint laxity may allow repetitive new movement at one, or both,
joints causing pain, if combined with sufficient activity. The newly per-
mitted movement could result in the uneven surfaces becoming ‘fixed’,
therefore rendering the joint immobile and having a mechanical effect
upon the other joint. Both anterior and posterior torsion, or rotation of
the ilium on the sacrum, have been described, but there is disagreement
as to which is the more common (Don Tigny 1985). It seems likely, how-
ever, that the complex and highly individual configuration of the sacro-
iliac joint allows for any number of possible directions of movement. The
increased weight during pregnancy thrusts the sacrum downwards
between the ilia in all upright postures, and in walking, each sacroiliac
joint alternately transmits the total loading. Is there a potential for the
joint to fail as a result of joint laxity? Certainly sclerosis of the sacroiliac
joints (e.g. osteitis condensans ilii) is seen on X-ray after childbirth.
Schemmer et al (1995), using plain film, arteriography and computed
tomography (CT), found a statistically significant association of osteitis
condensans ilii with parity. This usually disappears in a few months,
but indicates transient stress. A support belt may provide comfort for
some women.
Changes in orientation or degrees of movement at a sacroiliac joint may
affect the symphysis pubis, and also the spine. It has also been shown
that pain from the lumbar spine, and occasionally from the hip, may be
referred to the sacroiliac region, and there is no doubt that disorders of
the lumbar spine and sacroiliac joints can coexist. Thus pain experienced
over a sacroiliac joint is not synonymous with disorder of that joint; other
possibilities must be explored and other confirming or refuting signs
sought. Accurate and thorough assessment is essential if treatment is to
be successful.
SCIATICA When a pregnant woman complains of sciatica, her obstetrician may pos-
sibly suggest it is the baby sitting on a nerve. However, this, unless the
woman is near term, seems unlikely. Sciatica may accompany backache
and sacroiliac joint dysfunction; it will rarely occur alone. The L4 and L5
component of the sciatic nerve, due to its course, would become involved
in any dysfunction or inflammatory reaction at this site. An increased
lumbar lordosis resulting in lying and standing would also change the lie
of these roots. Increased loading may result in the spinal foramina being
reduced in size with consequent root compression. Disc lesions are not
unknown, and is it impossible for abdominal adhesions (e.g. following
infection or surgery) to be another causative factor?
Treatment Management of the symptoms is by far the best approach, with reduced
activity levels, within pain-free range. Advice from the physiotherapist
on positioning, back care, posture correction, activities of daily living and
pain relief can be taken ‘as read’.
Relieving the discomforts of pregnancy 153
SYMPHYSIS PUBIS The width of the symphysis pubis has been shown to increase asympto-
DYSFUNCTION (SPD) matically in pregnancy from about 4.8 mm to 7–9 mm (Abramson et al
1934). A study of pelvic girdle relaxation in pregnancy found that 31.7%
of pregnant women reported the symphysis as a site of pain (MacLennan
et al 1997). The pain is described as a ‘burning’ or ‘bruised’ feeling in and
around the joint, which may also radiate suprapubically and to the
medial aspect of the thigh(s). Pain varies in severity and may be of grad-
ual onset or incidious. It may be linked to a specific activity or a traumatic
incident. It is provoked by weightbearing, especially unilateral, and hip
abduction. Difficult activities will include:
Treatment It is essential that the woman, and if possible her partner, are made fully
aware of the condition. The difficulties caused by SPD in relation to ‘nor-
mal’ activities can be alarming and a full understanding will help with
‘coping strategies’.
Rest and reduction of non-essential ‘chores’ is vital, as is keeping the
legs adducted and avoiding single leg standing (Fry et al 1997).
Pelvic support may reduce pain levels, for example a Tubigrip ‘roll-
on’, trochanteric belt, SPD belt or maternity support underwear, by help-
ing to stabilise the pelvic mechanics.
In severe cases functional aids may be required (e.g. walking aids, a
‘helping hand’, a slide board or turntable).
Gentle isometric contraction of hip adductors, in sitting – small cush-
ion between the knees (whilst maintaining pelvic stability), may relieve
adductor tension. Supervised exercise in water is a positive approach,
though care should be taken when getting in or out of the pool, and
breaststroke must be avoided.
THORACIC SPINE PAIN Some women during pregnancy complain of pain over the thoracic
spine. The rib cage expands during pregnancy as a result of the growing
foetus. This may well have a mechanical effect upon the costovertebral
joints resulting in pain. There may be symptoms radiating to the upper
limb as a result. Muscular symptoms may be the result of the increasing
size and weight of the breasts.
This may also be linked with pain along the anterior margin of the
lower ribs (i.e. costal margin pain (rib ache), and intercostal neuralgia).
The ‘flaring’ can increase the diameter of the chest by as much as
10–15 cm. ‘Intercostal neuralgia’ is a term sometimes used to describe the
intermittent pain, usually unilateral, which can radiate around the chest
and may be referred to the lateral abdominal wall.
women under this age. It has been suggested (Smith et al 1985) that there
may be a transient failure of the usual changes in calciotrophic hormones
which prepare the maternal skeleton for the stress of childbirth. Dunne
et al (1993) also suggest that there is an underlying genetic abnormality,
perhaps collagen linked, that may contribute. Brayshaw (2002) followed
up the subjects in Dunne’s (1993) study. The symptoms experienced by
these women were as follows:
CARPAL TUNNEL Carpal tunnel syndrome, the most common of the nerve compression syn-
SYNDROME dromes, is clinically recognised as impairment of sensory and sometimes
motor nerve function in the hand, caused by compression of the median
nerve as it passes through the narrow carpal tunnel under the flexor
156 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Positions which put the wrist joint into a position of stress should be
avoided (e.g. prone kneeling) – taking weight through the wrist and arm
could be adapted to taking weight through the knuckles or forearm.
Although the syndrome usually resolves spontaneously following delivery
(Heckman & Sassard in 1994 found that 95% had complete relief 2 weeks
post partum), decompression surgery may occasionally be necessary.
BRACHIAL PLEXUS Some women complain of pain and paraesthesia in the shoulder and
PAIN arm. Fluid retention and postural changes are thought to cause this, but a
familial factor has been noted which could be associated with some
anomaly such as a cervical rib.
light touch and pin-prick – can vary from mild to severe. This condition
may occur as early as 25 weeks’ gestation.
Treatment • TENS: Fisher & Hanna (1987) placed electrodes along the course of the
nerve and found it to be highly successful, non-invasive, non-neurolytic
and to carry no foetal risk.
The physiotherapist is reminded to take careful note of current research with
regard to use of interventional modalities.
POSTERIOR TIBIAL Ankle oedema can compress the posterior tibial nerve as it passes behind
NERVE COMPRESSION the medial malleolus. This will lead to paraesthesia of the sole of the foot
and the plantar aspect of the toes.
CIRCULATORY DISORDERS
VARICOSE VEINS IN The hormonally induced hypotonia of the walls of the veins and raised
THE LEGS intra-abdominal pressure, an increase in blood volume, together with the
presence of incompetent valves, lead to unsightly and often uncomfort-
able varicosities.
• Avoid standing or sitting for long periods, with the legs dependent, or
the knees crossed.
• Frequent and vigorous ankle dorsiflexion and plantar flexion may be
performed (for at least 30 seconds) though it is doubtful as to whether
it really has an effect.
• Brisk walking is far more advantageous in promoting efficient venous
return.
• Elevate feet when sitting or lying.
• Support tights, or elastic support stockings, may be worn and should
be put on in bed before getting up in the morning.
VULVAL VARICOSE The causes of these are identical to varicose veins in the legs, but fortu-
VEINS nately they are less common in the vulval region. They are incredibly
painful and restricting.
158 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
HAEMORRHOIDS Together with the venal hypotonia, here there is a relative relaxation of the
intestinal smooth muscle, resulting in a slowing of faecal material through
the gut, consequent increased fluid absorption and harder stools, often
leading to constipation. Straining to move the bowels can cause balloon-
ing of the veins in and around the anus; these are called haemorrhoids or
piles. The increase in uterine weight and resultant pressure on the bowel
and the pelvic veins may also be contributing factors. Haemorrhoids are a
frequently unmentioned source of discomfort.
MUSCLE CRAMP Different theories as to the cause have been suggested – calcium defi-
ciency, ischaemia and nerve root pressure among them. Towards term,
increased fluid retention together with reduced activity, particularly in
the evenings, may be an additional factor. Many women suffer from
cramp during pregnancy. The most common site is the calf, the cramp fre-
quently being triggered by the stretching in bed and plantarflexing at the
ankle. This painful problem can also occur in the feet and thighs.
THROMBOSIS AND Thrombosis is not common in pregnancy, but is significant because of the
THROMBOEMBOLISM possibility of thromboembolism. The raised level of fibrinogen together
with a slowing of venous blood flow, particularly in the legs, as pregnancy
progresses, predisposes to this condition. Pulmonary embolism, rare but
potentially fatal, may be the result.
OTHER PROBLEMS
CHONDROMALACIA Because of the increased ligamentous laxity, slightly wider pelvis and
PATELLAE femoral torsion, chondromalacia of the patella can occasionally be a
problem. The woman will complain of aching at the front of her knee,
which is exacerbated by prolonged sitting or by knee flexion or extension
activities. Although symptoms may disappear after the baby is born, it is
possible that the increase of knee flexion, with the necessity to squat or
kneel when picking up toddlers, can lead to a recurrence of this trouble-
some condition months later.
RESTLESS LEG The restless leg syndrome is an unpleasant ‘creeping’ sensation, deep in
SYNDROME the lower legs, causing an irresistible desire to move the leg in order to
relieve the sensation; a leg may even involuntarily twitch or jump. The
aetiology is uncertain, but it is strongly associated with pregnancy. Of 500
women interviewed at an antenatal clinic, 97 (19%) were diagnosed as
having this syndrome (Goodman et al 1988), so it is important for the
physiotherapist to be aware of it. The symptoms seem to be associated
with fatigue, anxiety or stress.
• bed rest
• a period of reduced activity, e.g. giving up work.
160 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
The vast majority of women will be symptom-free soon after the birth of
their baby. Reassurance and understanding, coupled with advice to rest
more, will help to alleviate their worries.
UTERINE LIGAMENT The ‘remodelling’ undergone by the skeletal ligaments and collagenous
PAIN connective tissue is thought to affect the uterine suspensory ligaments.
They are also under considerable stretch from the rapidly growing uterus.
The sudden, sharp stabs of lower abdominal pain or the constant dull aches,
often unilateral, in the iliac fossa are not only distressing, but can make the
woman wonder if she is in labour. It is often helpful to explain that
the uterus is ‘tethered’ to the pelvis like a tent, or a hot-air balloon, and that
the worrying ‘cramps’ are not significant and are not damaging the baby.
• warmth or cold
• massaging or stroking, over the site of the pain.
PAIN FROM Abdominal or pelvic pain in the pregnant woman may be a result of ten-
ABDOMINAL sion on, or subsequent stretching of, abdominal adhesions from previous
ADHESIONS surgical interventions. The symptoms may also be linked to pelvic inflam-
matory disease. Stress related to problems of conception (fertility sur-
gery), which may have led to a lowering of the pain threshold when the
long-awaited pregnancy is finally achieved, may be a contributory factor.
FIBROIDS These benign tumours tend to hypertrophy during pregnancy, when they
can give rise to pain as a result of red degeneration. Sometimes they are
actually visible and palpable through the abdominal wall. Following the
birth of the baby, and as part of the process of involution, a decrease in
size can be expected.
FATIGUE The tiredness so often experienced in the first trimester is usually less
noticeable in the second, but becomes increasingly severe towards ‘term’
as weight increases and mobility becomes more of a problem.
• acceptance by the woman, her partner and her employer that there
will need to be a reduction of ‘normal’ daily activity
• daily, lunch-time rest is essential
• weekends should be used wisely; the temptation to complete, at any
cost, tasks such as redecoration before the birth of the baby should be
resisted.
INSOMNIA AND Many women experience a disturbance in their ‘sleep pattern’ as their
NIGHTMARES pregnancies progress. Discomfort, visits to the toilet, cramp, heartburn
and anxiety are just some of the ‘culprits’. Vivid, and sometimes fright-
ening, dreams are also common especially in the final trimester. These
will all have an effect upon daytime functioning. Although a ‘normal’
occurrence, it can be frustrating, and can be seen as a ‘dress rehearsal’ for
the broken nights of motherhood ahead.
PRURITUS Distressing skin irritation sometimes presents during the third trimester.
The aetiology is uncertain.
mucosa, and this problem is increased by the upward pressure of the grow-
ing uterus. The physiotherapist working in women’s health is often asked
what can be ‘done’ about it, though this is not strictly within her remit.
MORNING SICKNESS Nausea and vomiting are perhaps the most troublesome of all the symp-
toms during the first trimester, though not necessarily restricted to the
morning! The raised level of HCG at this stage has been suggested as the
cause, and it is often more severe in multiple pregnancies.
• acupressure (De Aloysio & Penacchioni 1992) between the flexor carpi
radialis and palmaris longus, at the wrist
• acupressure ‘bands’ may be effective
• TENS (Kahn 1988) – 120 Hz 150 m/s to the web space between thumb
and forefinger on the right arm
• eating ginger, e.g. biscuits, especially before rising, and crystallised ginger.
URINARY FREQUENCY During the first trimester, when the still anteverted growing uterus presses
against the bladder, and again in the final trimester when bladder com-
pression between the abdominal wall and the much enlarged uterus pre-
vents normal volumes of urine being comfortably contained, frequency of
micturition is a common and often annoying problem. Nocturia in the first
trimester is often a sign of pregnancy to many women who are unused to
having to empty their bladder at night. Additionally, the increased volume
of urine produced during pregnancy is partly responsible for frequency.
Urge and stress This troublesome and embarrassing symptom can present during preg-
incontinence nancy, particularly in the third trimester. It is a condition that should be
discussed regularly by the physiotherapist. Very few people have the
courage to volunteer that they are experiencing bladder leakage. It can be
reassuring for them to realise that they are not alone. For most women it
will be a transitory problem, but for some it can continue after the birth of
their baby and it can be treated. Persistence should be referred postnatally.
References
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the pelvic joints in pregnancy. Surgical Gynaecology and in pregnancy. Journal of Bone and Joint Surgery
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during pregnancy. Obstetrics and Gynaecology 71:71–75. active as a single treatment for low back pain and sciatica
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and Rehabilitation: State of the Art Review 12(3):509–519. Norén L, Östgaard S, Johansson G, Östgaard H C 2002
Fisher A P, Hanna M 1987 Transcutaneous electrical nerve Lumbar back and posterior pelvic pain during pregnancy:
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of Obstetrics and Gynecology 11:1199–1203. in pregnancy. Lancet i:1178–1180.
164 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Smith R, Athanasou N A, Ostlere S J et al 1995 Pregnancy- Voitk A E, Mueller J C, Faringer D E et al 1983 Carpal tunnel
associated osteoporosis. Quarterly Journal of Medicine syndrome in pregnancy. Canadian Medical Journal
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Tulder M W van, Malmivaara A, Esmail R et al 2002 Young G, Jewell D 2002 Interventions for preventing and
Exercise therapy for low back pain (Cochrane review). treating pelvic and back pain in pregnancy, Cochrane
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Oxford. Oxford.
Further reading
Carlstedt-Duke B, Gustavsson P 2002 Pregnancy and work Vleeming A, Mooney V, Dorman T et al (eds) 1997
environment. Practical guidelines for risk assessment. Movement, stability and low back pain. The essential role
Lakartidningen 10;99(1–2):34–38. of the pelvis. Churchill Livingstone, Edinburgh.
Grieve E 1980 The biomechanical characterisation of sacroiliac Watkins Y 1998 Current concepts in dynamic stabilization of
joint motion. MSc Thesis, University of Strathclyde. the spine and pelvis: their relevance to obstetrics. Journal
Grieve G P 1976 The sacroiliac joint. Physiotherapy 62:384–400. of the Association of Chartered Physiotherapists in
Lee D 1996 Instability of the sacroiliac joint and the Women’s Health 83:16–26.
consequences to gait. Journal of Manual and Wilder E (ed) 1988 Obstetric and gynecologic physical
Manipulation Therapy 4:22–29. therapy. Churchill Livingstone, Edinburgh.
Useful websites
At work, and pregnant www.hse.gov.uk.
Leaflets
ACPWH Symphysis Pubis Dysfunction. Obtainable from Professional
Fit for Pregnancy (antenatal), Fit for Birth, Fit for Motherhood Affairs, CSP, 14 Bedford Row, London WC1R 4ED,
(postnatal), The Mitchell Method of Simple Relaxation Tel: 020 7306 666.
(revised). Obtainable from Ralph Allen Press, 22 Milk
Street, Bath BA1 1UT, Tel: 01225 461888.
165
Chapter 6
CHAPTER CONTENTS
Introduction 165 Other coping strategies 184
Preparation 166 Pain relief in labour 184
Relaxation 167 The third stage of labour 196
Breathing 170 Birth plans 197
Positions in labour 177 Variations in labour 198
Massage in labour 180 The puerperium 199
INTRODUCTION
PREPARATION
Preparation for childbirth will not alter the fact that labour, for the major-
ity of women, is painful, but it can modify women’s perception and inter-
pretation of the process. Providing women with the ‘tools’ to counteract
the ‘problems’ will increase their confidence, and that of the birth partner.
This ‘tool kit’ of coping skills, non-invasive and without deleterious side-
effects, can make the difference between confidence and fear, satisfaction
and disappointment. Childbirth has become safer for mother and baby
and the expected outcome is for both mother and baby to be in good
health. Attention has therefore turned towards making it a physically
and psychologically rewarding experience for all involved.
Preparation for labour 167
RELAXATION
TECHNIQUES The use of relaxation techniques, as part of a coping strategy, has evolved
over the years. Grantly Dick Read, one of the pioneers in this field, advo-
cated the use of relaxation as a means of breaking the vicious cycle of
pain–fear–tension (Dick-Read 1942) and began teaching it as early as 1933.
168 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Heardman (1951) said that by giving a positive idea to the mind the dis-
turbing and worrying thoughts would be displaced. Rhythm is a mental
release, and the natural breathing rhythm is incorporated in her scheme
of progressive relaxation. These three authors used the ‘tense–relax’ tech-
nique of relaxation. Jacobson (1938), also used a tense–release approach
that activates both antagonists and agonists maximally. This approach is
often used where rest is prescribed, the maximal contraction gaining
maximal release. Concerns with regard to use of this approach during
labour might be:
The Mitchell method Since 1963 the Mitchell method of physiological relaxation has been
widely used by physiotherapists in women’s health. This method is
widely practised as a stress-relieving strategy, and therefore a useful
‘tool’ during labour. Mitchell suggested that a woman should practise
the approach, prelabour, whilst experiencing Braxton Hicks contractions.
She claimed that the approach was successful in conserving the mother’s
energy during the first stage ready for the ‘hardest work she will ever
do’. Mitchell’s method (1987) activates only antagonists, and moderately;
therefore there are not the same concerns as with Jacobson if using dur-
ing labour. Movements, once learnt, are performed in such a way that
‘trigger’ areas are put into positions of ease and comfort in a matter of
seconds.
Dissociation and Noble (1996) says that relaxation is more than rest or stillness; it involves
unblocking recognising and releasing excess tension – whatever the cause. The pas-
sive relaxation practised in pregnancy should be replaced by an alert, but
‘non-striving’, state of relaxation in labour. She describes a sequence of
‘dissociation’ – selective relaxation which develops the body’s ability
to maintain a state of general release when one part of it (the uterus) is
working hard. In 1983 Noble wrote that ‘relaxation is the key to aware-
ness and energy’ (Noble 1983). ‘Unblocking’ the muscular system and
breathing freely can be a blissful release when tension has developed. She
points to the fact that women who have found ways to release tension in
labour experience contractions that are very different to those felt by
women without this ‘safety valve’ – the contractions are said to be almost
pleasurable.
Preparation for labour 169
Touch relaxation Kitzinger (1987) discusses the concept of ‘touch relaxation’, where a
woman relaxes towards the touch of her partner. However many women
cannot bear to be touched during labour contractions, it can also increase
tension if inappropriately applied or, if the person administering it is
tense, this may be relayed through to the woman.
Whatever the approach chosen for use during labour it is essential that
it ‘fits’ the woman’s needs. It is not advantageous to induce sleep when
the woman is required to be alert and prepare for second stage, but sleep
may conserve energy if there is a delay in progression.
Relaxation techniques can be learnt by anyone, can be applied to all
aspects of daily living, there are no drugs involved, no strenuous exer-
cise and there is no cost: it sounds too good to be true. In order for the
approach to be successful, according to Madders (1998), there must be an
understanding of the principles, practice and confidence. Relaxation
techniques have not only been shown to have a positive effect upon the
coping mechanism during labour; Janke’s work (1999) showed that daily
relaxation therapy has a positive effect upon preterm labour outcomes.
IMAGERY This approach should come with a health warning. It is essential that phys-
iotherapists are fully aware of the potentially ‘major’ emotional response
that the woman might have. Imagery has the power to initiate an emotional
reaction linked with a prior occurrence in people’s lives.
A person’s thoughts and emotions can produce powerful effects on
their physiology, and imagery is a way of harnessing these thoughts to
complement physical relaxation. Vivid personal thoughts can aid the
process of relaxation. If it has the power to do this then it also has the
power to do the exact opposite and perhaps trigger a negative experience.
The suggestions should be made while people are relaxing. They are
instructed to imagine they are somewhere that makes them happy, some-
where they feel safe, doing things that they enjoy … wherever and what-
ever that might be. Examples can be given for those that might be finding
it difficult, for example imagining a spring meadow, birds singing, walk-
ing with friends, or lying on a beach, watching the clouds moving, think-
ing of good times.
BREATHING
volume, cardiac output and blood volume are all increased. The whole
system is ‘perfectly’ designed to enable adequate exchange of maternal
and foetal blood gases. It is difficult, she says, to understand the justifica-
tion for altering something as fundamental as normal breathing, espe-
cially during the increased metabolic demands that occur in labour. Yet,
over the years, this is precisely what some authorities have recommended:
‘controlled’ respiration, with both the rate and depth consciously altered.
In some cases breathing techniques are even dictated by a labour coach.
Historically, different authors have suggested different ways of using
breathing during labour.
THE EFFECTS OF Breathing is primarily controlled by carbon dioxide levels via the brain
ALTERATION OF stem. Rises in carbon dioxide levels are not tolerated and are followed by
‘BREATHING PATTERN’ hyperventilation to wash out the excess and restore normal levels.
Hypocapnia (a low level of carbon dioxide) is tolerated, however, and
results from voluntary or involuntary hyperventilation. Rises in oxygen
levels are tolerated, but not falls. Carbon dioxide is acid; low levels will
cause respiratory alkalosis (raised pH) leading to a decrease in calcium
ionisation, which can affect nerve conductivity (Table 6.1).
The symptoms of hyperventilation can be relieved and the condition
reversed if the mother breathes into her cupped hands or a paper bag,
thus replacing carbon dioxide.
Theoretically, maternal hyperventilation could affect the foetus in
two ways:
1. Low maternal carbon dioxide levels lead to reduced uterine blood
flow (caused by lowered blood pressure and uterine vasoconstriction).
2. Haemoglobin ‘hangs on’ to oxygen when the blood is alkalotic; this
reduces the amount of oxygen available to the foetus in the placenta.
However, it has not been shown that hyperventilation, which probably
occurs physiologically in all labouring women, actually affects the nor-
mal, uncompromised foetus. Maternal apnoea (sometimes prolonged) fol-
lows periods of hyperventilation. It is this that may possibly affect the
foetus. As the carbon dioxide level falls the oxygen level rises; neither of
these states stimulate the brain to continue respiration. Until the carbon
dioxide level rises again, the message ‘breathe’ will not be given – it is this
apnoeic episode that could add to distress in the compromised foetus.
BREATHING FOR Breathing for labour (along with relaxation) is classified as one of the
LABOUR main reasons for attendance at antenatal classes. It can now be seen that
teaching specific breathing patterns has a negative effect upon respira-
tory function, and may even produce negative symptoms.
Breathing awareness is, today, what the health professional should be
aiming for in terms of breathing preparation for labour. This can be
taught alongside relaxation with positive results.
• Ask them to notice what happens when they breathe at rest – cool air
can be felt entering the nostrils, warm air coming out.
• Ask them to focus on their own individual pattern of breathing: a
breath in – momentary tidal pause – a breath out – and then a rest
between breaths.
• Ask them to feel where movement takes place as they breathe; resting
their fingers lightly on their ‘babies’, can they feel a rise and fall of the
abdomen? Explain how slow, ‘low’, or ‘deep’, calm ‘abdominal’
breathing has a soothing, tension-releasing effect at times of stress.
• Tell the class to move their hands to the lower rib cage and ask what
happens here as they breathe.
Mention that our bodies receive more oxygen when our breathing is slow
and deep rather than fast and shallow, and this will be better for their
babies in labour.
Once the slow, calm, easy breathing has been mastered it can be incorp-
orated into relaxation practice. Explain how expiration can increase the
depth of relaxation and relieve tension. When people are under stress, as
well as adopting the ‘tension’ posture to a greater or lesser extent, they
will tighten or pull in their abdominal muscles.
• Can they feel the ease and release gained from allowing the abdominal
wall to swell and fall back instead?
• Ask them to practise calm, easy breathing when they relax at home
and during stressful situations.
BREATHING AND Labour contractions may be painful, but it is essential to emphasise their
CONTRACTIONS positive, productive nature. Contractions are an ‘absolute’ certainly, they
will happen. The course of each contraction will be identical.
Preparation for labour 173
First stage Deep, slow, easy breathing – pausing between expiration and inspiration –
may be all that some women use in the first stage. Most, however, will be
unable to maintain this and a modification will be needed. Untrained
women may either hold their breath or uncontrollably hyperventilate
when contractions progressively become stronger and more painful. The
respiratory response to exercise and effort is for breathing to become
faster. This can be introduced as gentle ‘feather’ or ‘candle’ breathing.
They could imagine that an ostrich feather or a candle is in front of their
faces, and that they are very gently breathing in and out (this will prob-
ably be more comfortable through the mouth) so that the feather or candle
flame would barely move on the outward breath. Each contraction will
still start with the outward, relaxing, welcoming breath and continue
with slow, deep, calm breathing; the lighter breaths will only be used at
174 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Transition stage The end of the first stage (or transition) is a very special time for the labour-
ing woman. The contractions are probably unremitting in strength and
ferocity; the pain may well be intense. The woman may feel desperation,
hopelessness, exhaustion, anger and perhaps irritation, and be aggravated
by annoying symptoms such as limb shaking, nausea or belching. She will
become withdrawn and find it difficult to articulate her needs. Occasionally
she may feel the urge to bear down before full cervical dilatation is
achieved. For a great many women this is the worst and most difficult time
of all. Nothing seems to work; they are convinced labour will never end;
their body cannot ‘do it’; they want pethidine, an epidural, forceps or a cae-
sarean delivery. For some women it is the point at which they decide that
they have ‘had enough’, and attempt to go home. It is important to reassure
women that this is a normal and positive response. They are signs that the
second stage of labour is not far away. It is essential that vaginal assess-
ment is carried out before pain relief is administered as it could delay
imminent second stage if the cervix is almost fully dilated.
It is at this point in labour that hyperventilation, with its unpleasant
side-effects, will be most noticeable, so thought must be given to not
making the respiratory situation worse when suggesting ‘coping’ tech-
niques. Various strategies have been recommended:
• SOS – ‘sigh out softly’ – gentle expiratory sighs, released at the peak of
contractions.
• Sighing the breath out while saying ‘hoo-hoo-hah’ gently and slowly.
Breathing in and out continues; only the ‘hah’ is a long expiration.
• Saying ‘I won’t push’; breathing in and out for the first two words, and
giving a long sigh out for the word ‘push’. This should also be gentle,
and as slow as possible.
• ‘Puff, puff, blow’; this should be a gentle panting interspersed
with a sharp blow out, and is useful to overcome premature
pushing urges.
Stage two Many women will be relieved with the start of the second stage that at
long last there is something active that they can do; they may actually
enjoy the wonderful feeling of working with the immensely powerful
‘piston’ that has developed within their body.
The pain of the first stage recedes and all becomes purposeful effort with
stage two. Some women will be frightened of ‘joining in’. They may fear
that by pushing they will tear the perineum, cause themselves more pain,
defaecate, or even harm their baby. For others the embarrassment of expos-
ing this very private part of their body in that most threatening and vulner-
able of postures (e.g. the lithotomy position) will be immensely inhibiting.
Reassurance and the opportunity to voice their apprehensions antenatally,
together with sympathetic and empathetic encouragement and support
during labour, will go a long way towards helping women achieve normal
delivery. It is difficult for some women to ‘tune in’ to their internal body
sensations and to respond to these by pushing effectively. It must be men-
tioned during antenatal classes that several contractions may go by before
the woman realises how to push her baby down and out. Each mother
should be encouraged to work with her own internal expulsive urge, rather
than have to push just because the cervix is fully dilated and the uterus con-
tracting. The desire to bear down usually comes in waves, perhaps three or
four ‘emptying’ urges per contraction, and she may not be able to push well
until she actually experiences this. It is essential that she is in a position that
is comfortable and feels right to her during this time, but also advantageous
as far as effective expulsion is concerned (i.e. pushing ‘down hill’).
The length of time that a women is actively ‘pushing’ should be moni-
tored and the physiotherapist must be aware of local procedures with
regard to this phase so that she can communicate this accurately to the
women she is preparing.
176 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
BREATHING AND Breathing awareness can be used to facilitate pushing. The woman can be
‘PUSHING’ trained to breathe in, then slowly out on exertion (e.g. during defaeca-
tion) so that it will become instinctive to ‘breathe’ out as she pushes, and
to maintain the push at the same time as she breathes in. Each push
should last about 5 to 10 seconds, and each contraction may demand
three to four pushes. The deep inhalation provides mother and foetus
with a good supply of oxygen. Exhalation on exertion works with the
muscular contraction of the uterus to best effect. It is absolutely essential
that the push is ‘felt’ through the perineum.
Another option is to breathe in, and out, then in again and ‘hold’, for
no more than 6 seconds, whilst ‘pushing’.
At the end of the contraction, one or two deep breaths will redress the
physiological balance, and initiate the relaxation/preparation phase for
the next contraction. During this time movement is recommended, and
‘mopping of the brow’ will be welcomed.
The midwife will ‘conduct deliveries on her own responsibility’
(Midwives code of practice (Nursing and Midwifery Council 1998)), she
will take the ‘lead’, for the delivery. It will be a combination of short
pushes, longer pushes and a gentle sighing and panting – the best combin-
ation to enable the midwife to control the birth of the head and then the
shoulders. With the mouth relaxed, the diaphragm moves rhythmically,
thereby preventing an increase in intra-abdominal pressure. Awareness of
these different approaches is vital to the effectiveness of the delivery and
should be included in antenatal classes. Vocalisation is an integral part of
the birthing process – women should expect to hear themselves making
noises and not feel they must continually apologise for crying out.
Preparation for labour 177
The mother is likely to be also asked to push to assist with the delivery
of the placenta.
POSITIONS IN LABOUR
worse. Roberts et al (1983) showed that it is actually the change from one
position to another that stimulates efficient uterine activity.
Sometimes the cervix dilates unevenly, so that towards the end of the
first stage of labour an anterior lip or rim remains between the presenting
part and the pubis while the rest of the cervix is well drawn up. If this is
the case the woman should be discouraged from pushing; lying on her
side with the foot of the bed raised or adopting the prone kneel fall
(pr.kn.fall) position can be helpful in this situation (Fig. 6.3).
Throughout history women have been depicted giving birth in many
postures, but rarely recumbent. And yet the ‘stranded beetle’ position
(sometimes with the additional ‘benefit’ of lithotomy stirrups) is how
countless women may have been expected to give birth. There is no
doubt that women have found it impossible to perform well in this pos-
ture; after all, defaecation is not normally carried out in the supine pos-
ition, and birth is another form of body ‘emptying’. It is hoped that, today,
this posture would only be adopted in case of intervention. Russell (1982)
demonstrated the increase in pelvic outlet size in the squatting posture,
and any position that allows the pelvic joints to move freely during deliv-
ery must be preferable to those that restrict such activity. Gardosi et al
(1989a) showed that the use of a ‘birth cushion’, which allowed the
woman to adopt an upright ‘supported squatting’ posture, led to signifi-
cantly fewer forceps deliveries and significantly shorter second stages.
There were also fewer perineal but more labial tears. In a second paper
Gardosi et al (1989b) reports that women who adopted upright positions
(squatting, kneeling, sitting or standing) also had a higher rate of intact
perineums and there was a reduction of forceps deliveries in the ‘upright’
group as compared with a ‘semirecumbent’ or ‘lateral’ group. What
could be an important factor in the problem of pelvic floor muscle dener-
vation was the fact that the mean duration of perineal distension before
delivery, taken from the time when the head stopped receding between
contractions, was shorter if the woman was kneeling than if she was
semirecumbent. Once again, the comfort of each woman must be the
prime consideration rather than the convenience of her carers during the
second stage of labour; and it is also important that possible pushing and
delivery positions be demonstrated and practised antenatally (Fig. 6.4).
Preparation for labour 179
Avoid
if symptoms of SPD
Figure 6.4
Suggested positions
for second stage
labour.
MASSAGE IN LABOUR
Massage in labour is a very personal thing. Women who found the expe-
rience a positive one during pregnancy may find it aggravating during
labour, and vice versa.
Preparation for labour 181
MASSAGE TO THE Back pain can be very demoralising, particularly when it is associated
BACK with a prolonged first stage of labour or where the foetus is in the occipi-
toposterior position. As shown in Figure 6.5, back pain in the first stage is
experienced in the lumbosacral region, and it intensifies as labour pro-
gresses. Stationary kneading, either single handed or reinforced, applied
slowly and deeply to the painful area is often helpful (Fig. 6.6). Elbows
should be bent, and the masseur should use his, or her, own body weight
combined with a gentle rotary movement to apply comfortable pressure,
without fatigue, for a long period. Partners and midwives must be
warned how easy it is to increase pain by overenthusiastic and vigorous
application. Hands should be relaxed and moulded to the part. Uneven
pressure, particularly with the heel of the hand, and straight arm applica-
tion must be avoided especially over the bony sacroiliac region. Practice is
essential both in antenatal classes and at home. Double-handed kneading,
with loosely clenched fists, directly over the sacroiliac joints may be neces-
sary as the pain becomes more severe (Fig. 6.7). Hand-held tennis balls
can be a useful alternative where hands are small or become fatigued.
Figure 6.5 The site of possible Figure 6.6 Deep, reinforced Figure 6.7 Double-handed kneading may
back pain in first stage labour. kneading to the painful area. be required if the pain becomes severe.
182 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Effleurage from the sacrococcygeal area, up and over the iliac crests,
will be even more soothing if a little oil is used to overcome the effects of
sweating (Fig. 6.8). Slow, rhythmical longitudinal stroking, from occiput
to coccyx, single or double handed, can relieve tension and facilitate
relaxation. The strokes may be applied with the whole hands or the fin-
gertips, actually over the spine or parallel to it. Pressure can become
slightly deeper as the hands descend.
MASSAGE TO THE Pain is most commonly experienced over the lower half of the abdomen,
ABDOMEN particularly in the suprapubic region (Fig. 6.9). It is often described as nau-
seating. Deep massage will be totally unacceptable, but light finger-
stroking or brushing from one anterior superior iliac spine to the other,
passing under the bulge and over the pain, is often well received (Fig. 6.10).
Another technique, best performed by the mother herself, is double-
handed stroking ascending either side of the midline and across to the iliac
crests (Fig. 6.11); this can be synchronised with easy breathing. Women
often spontaneously and instinctively massage themselves; this should
most certainly be encouraged and supplemented if it proves helpful.
MASSAGE TO THE Occasionally labour pain may be perceived in the thighs, and cramp in
LEGS the calf or foot may also occur; effleurage or kneading can relieve this.
PERINEAL MASSAGE Some midwives will massage a mother’s perineum in the second stage of
labour in an effort to encourage stretching of the skin and muscle and
thus prevent tearing or episiotomy. Grandmothers in some Eastern cul-
tures also encourage their pregnant daughters or daughters-in-law to
practise this simple stretching technique during pregnancy. The sugges-
tion that it is possible to prepare the perineum for birth could be made
during an antenatal class while discussing the second stage of labour,
and how the mother can best help herself and her midwife to complete
the delivery with an intact perineum.
Preparation for labour 183
Figure 6.9 The lower half of Figure 6.10 Lateral stroking, over the Figure 6.11 Double-handed kneading,
the abdomen is the most site of the pain, may give relief. self-administered and synchronised
common site for pain. with breathing, may relieve pain.
Until the middle of the nineteenth century there were no really effective
methods of anaesthesia, or analgesia, that eased labour pain. With the
discovery of ether and chloroform, doctors were finally able to relieve the
pain of the ‘poor, suffering mother’. Many felt and some still feel that, as
Sir James Young Simpson wrote in 1848, ‘it is our duty as well as our priv-
ilege to use all legitimate means to mitigate and remove the physical
sufferings of the mother during parturition’ (Moir 1986).
The intensity of labour pain experienced varies from woman to
woman, and from labour to labour in the same woman. The three P’s:
power (uterine contractions), pelvis (its shape and size) and passenger (the
presentation and size of the baby), will all play a part in the length of
labour and therefore the ability of a mother to manage without invasive
analgesia. The level of anxiety experienced during pregnancy is also said
to have a bearing on the analgesic needs of a labouring woman (Haddad &
Morris 1985).
Wuitchik et al (1989) showed that the levels of pain and distress-
related thoughts experienced during the latent phase of labour were pre-
dictive of the length of labour and obstetric outcome. Women registering
high pain scores and distress-related thoughts during labour’s latent
phase had longer labours and were more likely to need instrumental
delivery. Maternal distress during this time was also related to higher
incidences of abnormal foetal heart-rate patterns and the need for neo-
natal assistance.
Preparation for labour 185
TRANSCUTANEOUS TENS can be an additional tool that the women’s health physiotherapist
ELECTRICAL NERVE is able to offer to women in labour. Its non-invasive mode of action and
STIMULATION (TENS) absence of side-effects are very attractive to the woman hoping to cope
with labour by relying on her own resources. TENS is a method of acute,
or chronic, pain relief that is used widely throughout physiotherapy.
Johnson (1997) surveyed 17 896 women who hired Spembly Medical
TENS units (PULSAR® TENS) which had a TENS and labour question-
naire enclosed. After labour 10 077 women returned completed question-
naires with their units (56.3%); of these 6733 were primiparas (73%), and
the rest were multiparas or their parity was unknown. Forty per cent
(4141) relied solely on the written instructions supplied with the unit and
received no instruction from a health professional. Ninety-one per cent
(9160) said they would use TENS again in labour. However, the fact that
7122 (71%) claimed excellent or good pain relief should be treated with
caution as 6125 of these received additional analgesics. Johnson (1997)
contends that TENS does have a role to play in the relief of pain in labour.
186 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Modes of stimulation TENS involves the transmission of electrical energy through the skin to
the nervous system. Since it first became available in the mid 1960s, it has
developed as a modality in its own right and is now more than just a
model for the proof of the gate theory of pain (Melzack & Wall 1965). Two
of the TENS parameters described by Walsh (1997) are used for labour.
These are burst train TENS and brief intense TENS.
These two modes of stimulation are used for the specific instance of
labour because they suit the specific nature of labour pain. Labour pain
consists of dull, aching period-type pains that are due to stretching of and
pressure on the abdominal and pelvic viscera; these include the structure
of the uterus, cervix, walls of the vagina and the pelvic floor muscles and
fascia. Visceral pain is conducted to the spinal segment via C fibres and
this type of pain is best ameliorated by the use of endorphin mechanisms
and closing the pain gate. This is why burst train TENS is used all the time
during labour. Brief intense TENS is also used as it acts quickly and has a
strong counterirritant and nerve-blocking effect; this makes it suitable for
the increased pain experienced during contractions (Crothers 1992).
Most TENS units that are used specifically for labour have these two
types of stimulation. The burst train mode is the type of stimulation used
all the time during labour and the brief intense mode is activated by the
use of a press button mechanism when the woman experiences the begin-
nings of a contraction. The brief intense mode is then de-activated by
pressing the same boost button so that the burst train mode is resumed.
Placement of the The electrodes can be placed either over the relevant vertebral segments
electrodes that receive nociceptive information from the painful areas or over the
area that is giving pain. Bonica (1984) demonstrated that during the first
stage of labour the pain information is transmitted to the dorsal horn of
spinal segments T11–T12. Following ‘intensity theory’, the more intense
the pain the more nociceptors are recruited to fire and eventually two
additional segments are also transmitting pain information. Therefore,
during the first stage, labour pain information, when pain is at its most
intense, will be entering segments T10–L1. The information from the
parasympathetic nerves and the pudendal nerve arrives at the spinal seg-
ments S2–S4. When choosing electrodes these will need to be long
enough to cover these spinal segments. Each pair of electrodes will be
placed on either side of the spinal column, one pair covering either side
of the spinous processes of T10–L1 and the other pair covering either side
of the spinous processes of S2–S4.
Some women feel considerable pain over the anterior aspects of the
abdomen, especially during the late first stage. However, there is no
research evidence to support or refute the safety of moving the sacral pair of
electrodes to the abdomen.
Safety limits There are only three papers that exist that were specifically designed to
examine the effects on the foetus of the use of TENS as a method of pain
relief during labour.
Bundsen & Klas (1982) suggested that the foetus was most at risk if:
for the foetus would be 3 cm from the surface. They used both 60–80 Hz
and 5 Hz frequencies and intensities of 20–40 mA, and they decided that
the most important feature would be current density and suggested
that this should not exceed 0.5 A per mm2 (hence the large electrodes that
were used).
Bundsen et al (1982) tested these assertions on women during their
labour and stated that ‘no adverse effect upon the neonate by TENS is
demonstrable by clinical laboratory or neurological examination of the
infants after pain relief by TENS’.
The current density of the machines and electrodes in use in the
department can be checked by dividing the average current output of the
TENS unit by the area of the electrodes that are in contact with the skin
(Low & Reed 2000).
Practical considerations Ideally women should be introduced to the TENS unit during a class with
in the use of TENS a health professional, preferably a physiotherapist. It should be clearly
stated that:
• the unit should not be placed over the carotid sinus (the anterior
neck)
• the unit should not be placed over the area where a pacemaker has
been fitted
• the electrodes and the TENS unit should be removed before going into
the bath or birthing pool
• the unit should only be used for the woman herself, and for her
labour, unless she has been given instructions otherwise by a health
professional
The placement of the electrodes, especially for the woman who is by her-
self at home, can be difficult. Practice before the ‘event’ is essential if the
woman is to feel confident in the units’ use. The following ‘self-help’ tips
may be useful:
TENS units There are a great variety of TENS units. The TENS unit should have a
press release button (not press and hold) to enable switching to the brief
intense mode. It should be described as an ‘Obstetric TENS unit.’ Units
can be bought from the internet, or over the counter from many large
retail stores, and can be hired without the involvement of any health pro-
fessional. The woman will not necessarily have had any instruction in its
use other than a written leaflet. If the unit is borrowed from a maternity
unit, instruction will be given either ‘one to one’ or in the form of a ‘spe-
cial’ TENS antenatal class. Instruction in use is strongly recommended.
Midwives and TENS In June 1986 the UK Central Council (UKCC) accepted the recommenda-
tion of its Midwifery Committee that midwives should not, on their own
responsibility, use TENS for the relief of pain in labour. However, they are
allowed to use TENS under supervision provided that they have been
instructed in its use in accordance with Rule 41(1) and (3) of the Nurses
Midwives and Health Visitors (Midwives Amendment) Rule 1986. In
many centres this is taken to mean that, within a ‘blanket’ referral from
the consultants in charge of the obstetric unit, and with proper tuition
and constant updating from women’s health physiotherapists, midwives
are able to use TENS in labour for those mothers who wish to use it as a
form of analgesia.
HOMEOPATHY/ Much work has been done in recent years looking at complementary
AROMOTHERAPY therapies in the relief of pain in labour. In a review of clinical trials
(Kleijnen et al 1991) of homeopathy, 77% yielded positive results and
were therefore worthy of further research. In a trial conducted by Eid et al
(1993), using Cauphyllum, average labour time was found to have been
reduced by 90 minutes and the mother’s emotional state was said to have
been improved. Aromotherapy is a field that lends itself to physiothera-
pists, but it is essential that the therapist is fully trained in its use. It is
potentially dangerous in ‘untrained hands’. The reader is directed to
Supper (1998).
WATER Water births were first introduced in the UK in the 1980s and more than 200
hospitals (BBC press release 2002) now offer women the opportunity to
labour or deliver, or both, in a birthing pool. The Health Committee
(Maternity Services 1992) recommended that all hospitals ‘make full provi-
sion, whenever possible for women to choose the position which they pre-
fer for labour and birth and with the option of a birthing pool where it is
practicable’. Balaskas & Gordon (1990) describe a labour in water as some-
thing which is shorter, easier and more comfortable. Physiotherapists are
well aware of the positive mechanical and physiological effects of water, as
well as the potential risks. Safety guidelines must be in place, and all par-
ties must be fully aware of them before considering labouring or delivering
in water. Clinical guidelines for a hospital water birth pool facility were
revised in 1999 by Janet Balaskas and can be downloaded from the Active
Birth Centre website (see Useful Addresses, p. 203). Balanced information
to mothers is essential if they are to make an informed choice with regard
to labouring or delivering in water. In the UK the Royal College of
Obstetricians and Gynaecologists has published guidelines (RCOG 2001)
on how to minimise the chances of complications. However, the American
College of Obstetricians and Gynecologists has not endorsed the tech-
nique, quoting insufficient data to prove safety (BBC press release 2002).
be all she needs to help her cope with it. Maximum analgesia will be
reached after 45–60 seconds, and the effects wear off rapidly. The Entonox
is usually administered via a plastic mouthpiece. A hissing noise will be
heard if the apparatus is being used correctly.
Some women complain of nausea as a result of using Entonox, and
some will find that the analgesia is insufficient or non-existent. Its use for
long periods can also result in dehydration since breathing is through the
mouth.
Maternal side-effects Pethidine can cause maternal nausea and sometimes vomiting; an
antiemetic is often given simultaneously because of this. Other side-effects
include drowsiness, distressing hallucinations and dysphoria, which can
interfere with the mother’s concentration on her own ‘coping’ techniques
and affect her cooperation with her attendants. Pethidine is said to reduce
the tone of the lower oesophageal sphincter and delay gastric emptying,
which could have implications if a general anaesthetic has to be given. It
could also give rise to hypotension and respiratory depression.
Foetal and neonatal In common with other drugs, what affects the mother will also affect her
side-effects baby, and although pethidine can be metabolised in the maternal liver and
is eventually excreted from the mother’s body, this may not be the case for
the newborn infant. Because there will be a high concentration of peth-
idine and its metabolite norpethidine in the mother’s bloodstream, the
drugs will cross the placenta into the baby; in the first 2 to 3 hours follow-
ing an injection, up to 70% of the dose plus some norpethidine will have
accumulated in the foetus. Even at term the neonate’s liver and kidneys
are too immature to metabolise and excrete the drug effectively. After 3
hours, when the level of pethidine has fallen in the mother, the drug again
crosses the placenta into the mother where it can be dealt with. Where
192 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
labour is premature the problems are intensified. The preterm baby, being
much smaller, will receive a proportionately larger dose of pethidine, and
its more immature organs are even less able to deal with the drug.
Consequently, if the mother receives her dose of pethidine between 1 and
4 hours before the birth, it is possible (because pethidine will still be in the
baby’s bloodstream) that prolonged side-effects will be apparent in the
neonate in addition to those observed in the foetus before delivery; foetal
acidosis, a depressed foetal heart rate and a slower response to sound have
all been reported. Respiratory depression in the neonate can occur follow-
ing large or repeated doses; this can be reversed by the drug’s antagonist
naloxone, but, as naloxone has a shorter duration of action than pethidine,
repeated doses may be required. Adverse neurobehavioural effects have
been reported which are potentiated in the preterm infant; these include
drowsiness (Richards & Bernal 1972) which can interfere with the early
bonding process, and difficulties in establishing breastfeeding (Belsey et al
1981). Other, more subtle, side-effects have been observed, including the
baby being less alert, more easily startled, less easily comforted, fretful and
slower to respond to faces and sounds. It is easy to dismiss these changes
as unimportant, but they could be distressing to new mothers who can lose
confidence in themselves unless they have been warned in advance that
they may need to persevere and devote more time to establishing breast-
feeding and their new relationship.
It is advisable, therefore, for women to have pethidine at the times in
their labour that can give them maximum help with least effect on their
baby. More than 4 hours before delivery is said to be reasonably safe for
the baby, who will then have low levels of pethidine in its bloodstream at
birth – and, although it is difficult to predict exactly when a baby will be
born, it is probably advisable for pethidine to be given following vaginal
assessment in order to avoid severe neonatal side-effects.
Moir (1986) said that none of the narcotic analgesics provides complete
pain relief to all labouring women when given in safe doses, and women
must be prepared to feel some labour pain following an injection of
pethidine.
Side-effects and 1. There appears to be an increased rate of forceps delivery with its
complications of attendant maternal and foetal trauma. This could be due to three
epidural anaesthesia main factors:
(a) There is normally a physiological increase in maternal oxytocin
during the second stage of labour. This neuroendocrine response
194 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
3. The mother’s legs may feel ‘heavy’ and she may be unable to move
them easily; walking will not be possible initially.
5. Urinary retention may occur if the mother is unable to feel her bladder
filling. She should try to micturate every 2 hours; a catheter will be
passed if retention of urine becomes obvious. The mother must be
encouraged to report any loss of sensation, or abnormality in micturition
pattern. In some areas it is becoming standard practice to pass a catheter
for women with retention, though this can be a contentious issue. The
reader is directed to Maclean & Cardozo (2002) for further detail.
It is recommended that physiotherapists be fully aware of ward protocol
in their own area with regard to this issue.
6. Unblocked segments and unilateral blocks are common problems
and can prove distressing for the woman who was hoping for total
pain relief. They can sometimes be relieved by top-up doses in
appropriate positions – but women should be warned antenatally
that this may happen, also that it takes time to work.
Preparation for labour 195
7. The accidental puncture of the dura and consequent release of CSF can
give rise to severe postpartum headache. In the past the mother was
usually nursed flat for at least 24 hours and the intravenous drip of
Hartmann’s solution remained in place. In current practice, the drip
may remain and the mother is encouraged to drink; she may not be
required to remain supine. If the problem is prolonged and severe the
anaesthetist may inject a ‘blood patch’ of the mother’s own venous
blood into the epidural space at the site of the damage. Women suffer-
ing from postepidural headache are usually distressed at their immo-
bility and their inability to care for their baby and respond
spontaneously and comfortably to its needs. They will need extra sup-
port and assistance, and the reassurance that the condition will resolve
and that this initial problem will not interfere with the bonding process
between them and their baby.
8. Many women complain of pain and tenderness postpartum at the
epidural site, and for some this can be intolerable. The suggestion has
been made that a tiny haematoma forms in the epidural space with
consequent pressure on sensitive tissues, and women can be reas-
sured if they are reminded that bruising often occurs around ordi-
nary injection sites. The women’s health physiotherapist can help
alleviate this problem by offering a ‘hot pack’ or TENS, and suggest-
ing that the mother rests in prone lying with appropriate pillows.
9. Total spinal anaesthesia can occur if the dose of local anaesthetic is
accidentally injected into the subarachnoid space. This potentially
fatal condition (severe hypotension and cessation of spontaneous
respiration can occur very quickly) requires instant artificial respir-
ation, the injection of vasopressor drugs and rapid fluid infusion.
Rarely, spinal anaesthesia may follow a top-up.
10. Neurological complications may persist following epidural anaesthe-
sia. Muscle weakness in a leg or foot, loss of sensation in an area of
skin and paralysis occur.
11. Fusi et al (1989) have shown that women receiving epidural anal-
gesia during labour are at increased risk of developing pyrexia. It is
thought that this may be due to vascular and thermoregulatory
modifications induced by epidural analgesia.
12. Bupivacaine, like other local analgesics, enters the maternal blood-
stream from the epidural space, crosses the placenta and can be
found in measurable (but clinically unimportant) concentrations in
the foetal circulation within 10 minutes of injection (Caldwell et al
1977, Rosenblatt et al 1981). The neurobehavioural effects are clin-
ically unimportant, unlike those of pethidine.
13. The issue of the possibility of long-term backache following epidural
anaesthesia has been raised (MacArthur et al 1990), but later studies
(MacArthur et al 1997, Russell et al 1996) show that there is no evi-
dence to support new long-term backache. Previous reports may
reflect high-dose epidurals, and stressed posture during labour.
196 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Epidural anaesthesia Epidural anaesthesia for caesarean delivery has become an increasingly
for caesarean delivery safer and more popular option. The woman is conscious, and is therefore
‘present’ at the birth. Often her partner is able to be there too, which, psy-
chologically, has great advantages in that the new family unit is together
from the beginning.
When preparing women for an elective caesarean delivery, under
epidural anaesthesia, it is important to mention that, because of the pro-
found block required to achieve total analgesia, they may experience some
side-effects. Hypotension can give rise to a feeling of faintness, shivering
and vomiting can also be troublesome, and the mother may feel very cold.
Babies born by caesarean intervention do not expect to be delivered
through the abdomen and it can come as a ‘bit of a shock’. A paediatrician
will be present at the operation to help the baby in whatever way neces-
sary, for instance assisting in clearing mucus and liquor from the lungs,
or giving some assistance to initiate breathing. It is important to warn
women that, because of this, it may not be possible for them to hold
the baby immediately after delivery but all being well they will be able to
very soon.
Although epidural anaesthesia blocks pain, the woman must be made
aware of the fact that she may feel sensations of pulling and tugging. One
mother described her epidural caesarean delivery as being similar to hav-
ing ‘the washing-up done in my tummy’. It is also important, where pos-
sible, to prepare the father for this type of delivery.
Spinal anaesthesia is also used for caesarean delivery.
The third stage of labour has been called the most dangerous (Sleep 1989)
because of the risk of maternal haemorrhage. It can be managed actively
or passively, and it is important to prepare women antenatally for what is
likely to happen and what may be expected of them. Couples are usually
so overwhelmed by joy and excitement, and the wonder of actually see-
ing and touching their new baby, that this phase often passes by in a blur.
If the third stage is actively managed, a method in widespread use
because it is said to reduce blood loss (Prendiville et al 1988), the mother
will receive an injection of syntocinon and ergometrine as the anterior
shoulder is delivered. She will be asked to lie back so that the midwife
can palpate the uterine fundus, and the placenta will be delivered by con-
tinuous cord traction once it has separated from the wall of the uterus,
which is achieved by strong uterine contractions (see p. 72).
Where passive physiological management is used to deliver the pla-
centa, now considered a safe option if the mother has had a ‘normal’
delivery and accepted criteria are followed (Hobbs 2001), the mother will
probably have to adopt an upright posture so that gravity and intra-
abdominal pressure can play their part in helping the process. Once the
midwife feels the strong uterine contraction that results in placental sep-
aration and its descent into the lower uterine segment, the mother will be
asked to bear down in order to help push the placenta out.
Preparation for labour 197
BIRTH PLANS
The birth plans which many hospitals now suggest their clients should
prepare evolved from a reaction to the managerial approach of some
obstetricians and midwives. The professionals thought that they ‘knew
best’ when it came to childbirth. Women who felt that their needs and
wishes would not be met by their carers wrote down their requests for the
management of their labours and the care of their new baby. Because these
early birth plans were sometimes written in an aggressive and demanding
manner they were often met with hostility. But, as is often the case, the
establishment began to realise that it was on the losing side in this con-
frontation, and hospitals began to produce their own formal printed plans
for women to complete. This, of course, does make it seem as if women are
being consulted and given choices, but in many cases, hospitals’ ready-
printed birth plans do nothing of the sort. They are often just a series of
statements requiring a yes/no answer or a tick in the relevant box, and the
kind of questions women are asked deal only with trivial, superficial mat-
ters. Furthermore, these birth plans are frequently handed out in ante-
natal clinics, without explanation, before women have started their course
of antenatal classes – as early as 26–28 weeks. They will not yet have dis-
covered what options are available to them. Kitzinger (1987) has written
wisely of the special importance of birth plans where women do not know
in advance who will be caring for them in labour, and also how they can
help midwives and doctors understand what matters to each mother. She
also mentions the anxiety some professionals feel when they are con-
fronted by a birth plan that has been compiled by a well-informed
woman. Articulate women and their partners tend to read widely and also
attend the sort of antenatal class that questions interventionist obstetric
practices. Some have very pronounced views on labour and how they
hope their own experience will be managed.
Time should be devoted, during preparation for labour courses, to the
consideration of birth plans and how they can be used to communicate to
the caring staff not only each woman’s feelings about her labour, but how
she hopes necessary interventions such as caesarean delivery would be
managed (e.g. epidural versus general anaesthesia), and also how she
would like her baby to be handled after the birth. Within the birth plan
should also be the mother’s preferred choice of feeding. If birth plans are
198 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
discussed within a class, women who find it difficult to express their feel-
ings, needs and preferences can be helped by the encouragement of their
fellows and the teacher. However, women and their partners must
understand that, as obstetricians and midwives are responsible for the
consequences of their decisions, so too are they.
While birth plans are particularly relevant for those women who have
specific requests, very many expectant mothers will be happy to accept
whatever their carers offer.
VARIATIONS IN LABOUR
The passages Cephalopelvic disproportion The pelvis is too small for the foetus.
Squatting may help overcome this in the second stage. (See p. 77.)
Cervical dystocia There is failure of the cervix to dilate.
Placenta praevia This can obstruct descent. (See p. 44.)
between contractions, pelvic rocking and circling may help alter pressure
within the pelvis. Deep back massage or pressure, heat or ice packs and rest-
ing in a warm bath may relieve discomfort. The foetus may rotate or be
delivered face to pubes. An epidural anaesthetic may be necessary.
Breech birth Labour may be no different to a vertex presentation, but is
likely to be actively managed with epidural anaesthetic in most hospitals.
Pelvimetry and an ultrasound scan at 38 weeks will attempt to identify
women whose babies will need delivery by elective caesarean section.
Malpositions or malpresentation These may be associated with an
obstruction, such as disproportion or placenta praevia. (See pp. 75 and 43.)
SECOND STAGE Episiotomy The possibility of this being used must be discussed
antenatally.
Ventouse delivery This is the method of choice for assisted delivery as
there is thought to be less risk of damage to mother and baby. A cap,
attached to a suction pump, is fitted on to the baby’s head whilst in the
birth canal, and held in place by suction. Women should be shown the
lithotomy position in antenatal classes.
Forceps delivery Most forceps deliveries today will be ‘lift-out’ proced-
ures. It sometimes helps to describe the use of forceps as a ‘shoe-horn’,
helping a baby out of a tight fit.
Caesarean delivery Women must be prepared for this eventuality; the
reasons for both elective and emergency operations should be described.
It is most important that women know how they may feel postopera-
tively, and how they can best help themselves in the immediate postpar-
tum period.
THIRD STAGE Lacerations and tears These must be mentioned, also the role of pelvic
floor exercises in the relief of postpartum discomfort.
Retained placenta Although this is uncommon, women should be
aware of its possible occurrence. A regional block or short general anaes-
thetic may be necessary to remove the placenta.
THE PUERPERIUM
LOSS OF A BABY Tragedies can and do occur. Little can be done to prepare a couple for
coping with their baby’s illness or death, yet the possibility of such a
trauma occurring should be mentioned, and discussed if necessary, in
antenatal classes.
200 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
PREMATURE DELIVERY Premature babies are those born after the 24th week and before the 36th
AND ILL BABIES week of pregnancy. With intensive care, the majority of tiny, early infants
now survive, though some may have a physical or mental defect as a
result. Mothers-to-be are encouraged to visit the special care baby unit
(SCBU), in a positive way, to familiarise themselves ‘just in case’. Those
who are hospitalised because of the risk of preterm birth are often accli-
matised to the unit before the birth.
An unexpected admission to SCBU can be emotionally traumatic for
the parents. This, today, is acknowledged and the parents are given sup-
port in every way possible. There may be the added stress to the mother
in terms of guilt. She may well feel a failure, and she may also be fright-
ened to bond with a baby who might not survive.
Women need immense empathetic support at this time and often turn
to their physiotherapist, whom they may already know from antenatal
classes, for reassurance. Almost certainly, the last thing they will have a
mind for will be themselves. Many will have had an elective caesarean
delivery to prevent damage to very undersized or ill babies, and they will
have to cope with their own physical discomfort as well as their emo-
tional distress and anxiety.
STILLBIRTH This is not an easy subject, but one that must be raised at some stage ante-
natally. Occasionally a baby dies in utero (IUD) and the mother will have
to cope with the knowledge that her baby, although still within her body,
is dead; sometimes a baby will die during the course of labour. A stillborn
baby is one born dead after 24 weeks. This catastrophic experience is
something no parent believes will happen to them, and one which the
extended family often find very difficult to cope with themselves.
Very great care is taken today to make sure that the parents’ wishes are
adhered to. A humane, therapeutic approach is recommended. Parents are
encouraged to look at and hold their baby, and photographs are often
taken to provide a memento of the baby. It is essential that the parents are
given the time or are encouraged to allow the normal grieving process to
take its natural course. Bourne & Lewis (1983) described some of the long-
term problems that may follow the inability to grieve properly. These
include mothering difficulties with subsequent babies, marital problems,
severe disturbances at anniversaries, puerperal psychosis in the next
Preparation for labour 201
COT DEATH There can be very little that is worse than the discovery that the baby who
was apparently healthy a short while ago is cold and dead in its cot or
pram. There are many causes for cot death or sudden infant death syn-
drome (SIDS). This unthinkable eventuality does happen and, while the
women’s health physiotherapist may not be in contact with women
when it does, the subject often arises in antenatal classes if a woman has
experienced this, or a stillbirth, previously.
Professionals undoubtedly have difficulty coping with the distress
experienced by parents whose babies are ill, and more particularly with
the despair of those whose babies are stillborn, handicapped or have
died. Junior staff may not have received guidance in dealing with the
anguish such tragic events can cause, and may well avoid bereaved and
suffering parents. Great care should be taken when talking to these
women avoiding thoughtless remarks, but at the same time not avoiding
or ignoring them. Parents often appreciate the opportunity to talk about
their lost baby and the events leading to the death, and, although this can
be upsetting for others, the knowledge that it helps those who are dis-
tressed makes the discomfort easier to bear.
There are courses available for professionals who may be involved in
the care of those who have experienced a miscarriage, stillbirth, neonatal,
or cot death, and women’s health physiotherapists would be well advised
to attend.
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Further reading
Alexander J, Levy V, Roth C (eds) 1997 Midwifery in practice: Sweet B, Tinan D 1997 Mayes’ midwifery, 2nd edn. Baillière
core topics 2. Macmillan, London. Tindall, London.
Balaskas J 1989 New active birth. Unwin Hyman, London. Wall P D, Melzack R (eds) 1989 Textbook of pain. Churchill
Maclean A D, Cardozo L 2002 Incontinence in women. RCOG Livingstone, Edinburgh.
Press, London.
Useful addresses
Active Birth Centre National Childbirth Trust
25 Bickerton Road, London N19 5JT Alexandra House, Oldham Terrace, Acton, London W3 6NH
Websites: www.activebirthcentre.com; Website: www.nctpregnancyandbabycare.com
www.homebirth.org.uk/homebirthlinks2htm SANDS (Stillbirth & Neonatal Death Society)
Cot Death Society 28 Portland Place, London W1B 1LY
4 West Mills Yard, Kennet Road, Newbury, Berkshire RG14 5LP Website: www.uk-sands.org
Websites: www.SIDS.org; www.cotdeathsociety.org.uk Twins and Multiple Births Association (TAMBA)
Miscarriage Association 41 Fortuna Way, Grimsby, South Humberside DW37 95J
c/o Clayton Hospital, Wakefield, West Yorkshire WF1 3JS Website: www.tamba.org.uk
Website: www.agob71.care4free.net
Useful websites
www.csp.org.uk www.rcog.org.uk
www.interactivecsp.org.uk www.nelh.nhs.uk
www.rcm.org.uk www.nice.org.uk
205
Chapter 7
CHAPTER CONTENTS
Introduction 205 Immediate postnatal problems 221
Postpartum physical/mental condition 206 Long-term postnatal problems 240
Postnatal care 208
INTRODUCTION
It is in this period that the new mother’s body begins its period of recov-
ery and its return to ‘normal’. However, the normality following the birth
of a first baby will not be identical to that of prepregnancy. It will be a
new normality: that of a mature female body that has undergone the
process of pregnancy and birth. The pregnancy process will have resulted
in a gradual change of body shape and function. At ‘term’ the woman
sees a ripely swollen abdomen, enlarged breasts, possibly oedema of the
face, hands and legs, deposits of fat on her upper arms, hips, buttocks
and thighs, and even, perhaps, stretch marks. Although in the first few
postpartum hours she may be thrilled with the softness and relative
flatness of her abdomen, once she is mobile and sees herself in a mirror
she will be confronted with a different image: an empty, sagging and still
enlarged abdomen, maybe with ‘tripe-like’ wrinkled skin. As she moves,
talks and laughs she may become aware of an almost complete lack of
abdominal muscle control. She may have undergone an episiotomy, or a
tear, which may be made more painful by bruising and oedema of the
perineum; she may have difficulty in initiating micturition, or may expe-
rience retention of urine; she may also experience leakage when the
intra-abdominal pressure is raised by coughing, sneezing or laughing.
206 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Muscles and ligaments The body’s ligaments and collagenous connective tissue will still be
softer and more elastic than prepregnancy and it will take 4 to 5 months
(Calguneri et al 1982) for full recovery to take place.
The abdominal muscles, which will have been stretched, are now elong-
ated, and a separation between the two recti abdominis muscles (known
as a diastasis or divarification) will almost certainly be apparent in any
woman who was at ‘term’ prior to labour. This can vary between a small
vertical gap 2–3 cm wide and 12–15 cm long to a space measuring
12–20 cm in width and extending nearly the whole length of the recti
muscles (Fig. 7.1). As a result, the entire abdominal ‘corset’ will be weakened
Oedema Many women will complain of heavy, oedematous, aching legs, swollen
feet and ankles in the immediate postpartum period that may not have
been apparent before the baby was born. This may be unilateral or bilat-
eral. The cause can only be speculated as probably prolonged pushing
during labour, pelvic congestion, dysfunctional urinary tract, or the tem-
perature on the postnatal ward.
Back pain Back pain may not have been a symptom during pregnancy, but it fre-
quently develops following the birth. The passage of the foetus through
the pelvis, and the resultant stretching and movement of the lax joints,
epidural anaesthesia, lithotomy position (especially if the legs were not
placed and removed from the stirrups simultaneously), poor feeding or
nappy-changing postures, tension and fatigue may all be causative factors.
Breasts The breasts may become engorged, feel hot, full and painful (even up
into the axilla where a ‘tail’ of breast tissue lies) when lactation begins on
the 3rd or 4th postnatal day.
POSTNATAL CARE
ROUTINE CARE The length of time before return to ‘normal’ activities has, over the years,
become less and less, to the current expectation (if all has ‘gone to plan’)
of a few days. The concern must be the wider picture (e.g. other children,
a partner who works away, an elderly dependent relative, family support
200 miles away). Along with the reduction in the postnatal ‘resting’
period has come a much earlier discharge from care; the mother’s return
to home (if hospital delivery) may be within 6 hours following normal
delivery, or up to 5 days if intervention has been necessary. The average
discharge time is 24 to 72 hours, all being well.
There is a mandatory requirement for a midwife to attend the mother
for the first 10 postpartum days as necessary; this can be extended to
28 days. The midwife will be concerned with the mother’s well-being, the
establishment of lactation, and the status of the baby. She will monitor the
mother’s vital signs, assess the mother’s breasts, abdomen and peri-
neum, check on the haemoglobin level at 24 hours postdelivery and
repeat this at a later date as a preventative measure against anaemia.
If there are no complications the mother may not see a doctor during
her hospital stay. The mother may need reassurance that this is ‘normal’
and that she would be referred to a doctor if it were found to be
necessary.
ESTABLISHING The primary aim in the immediate postpartum period is the establish-
BREASTFEEDING ment of breastfeeding. For some women, and their babies, this is an
instinctive activity. For others it will have to be ‘learned’, and for them to
achieve it may require expert help, encouragement, support and advice
from the midwife. Whenever, or however, the mother chooses to feed her
baby it is essential that her positioning is not detrimental to her, phys-
ically. The baby must lie on its side facing the breast, not on its back with
its head turned to the mother. Although it may be advantageous initially
for the mother to lean forward so that the baby can be properly pos-
itioned on the breast, she should be encouraged to relax back on adequate
support as soon as the baby is feeding well. A study by Ingram et al
(2002) looked at a ‘hands-off’ (in terms of midwifery input) breastfeeding
technique to see if it had any impact upon the success rate. They found it
to be significant in empowering the mother and in improving breastfeed-
ing rates.
Though not the province of the women’s health physiotherapist, it can
be useful to have some knowledge of the skills leading to successful feed-
ing to avoid any conflicting advice. The nipple should be drawn into the
baby’s mouth against the hard palate, and the tongue should be under-
neath. To be properly ‘fixed’ on the breast the baby’s mouth needs to be
well open, with the chin resting on the breast and the lower lip curling
down. The mother should not need to support her breast unless it is very
heavy, in which case she can slip her hand underneath. Colostrum, and
later milk, is drawn out by a wave of pressure from the baby’s tongue on
The postnatal period 209
Pain management The women’s health physiotherapist must be alert to the pain of women
who have experienced intervention deliveries, as this can often prevent the
mother being relaxed and comfortable. A major role of the physiotherapist
is to use her specialist knowledge, skills and experience to assist, in what-
ever way she can, for example with support, positioning, transcutaneous
electrical nerve stimulation (TENS), ice, pulsed electromagnetic energy
(PEME), pressure-relieving cushions, etc., to establish breastfeeding.
The postnatal check It is traditional for a woman to be examined and assessed by a member of
the obstetric team 6 weeks’ postpartum. However, there is no good physio-
logical reason for this timing apart from the fact that the uterus should
have returned to its prepregnancy size by then, lochia should have
ceased and any wounds healed. The negative side of this is if there are
any problems they will already be well established.
The conscientious practitioner will also be interested in the mother’s
emotional state and how she and her family are adapting to, and coping
with, the stress a new baby can bring, as well as her physical recovery.
Women are extremely vulnerable postnatally; they have experienced a
tremendous life change, and, particularly for primiparae, nothing will
ever be quite the same for them again. Maintenance of links with sup-
port, in whatever form – groups, clinics, GP – are essential so that the
woman does not feel abandoned. The women’s health physiotherapist, is
in an ideal position to reinforce issues and ‘pick up’ problems, at a post-
natal reunion group.
210 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
The postnatal check should take the form of: assessing the mother’s
blood pressure, breasts, abdominal status, uterine involution and status
of the cervix, performing a smear test, and discussing contraception and
any problems that the woman may be experiencing. The women’s health
physiotherapist’s knowledge, skills and experience are invaluable at this
stage but it is unrealistic for her to expect to be present at all postnatal
checks. Thus it is important that she ensures that those conducting the
checks have the knowledge and skills to detect and refer for physiother-
apy those women who may benefit. The physiotherapist will then be able
to assess, treat and advise appropriately.
The women’s health physiotherapist is not responsible for giving
information and advice about contraception, but it is a subject that many
women feel able to discuss in the friendly atmosphere of the antenatal or
postnatal class. Misunderstandings, and ‘young wives’ tales’, about this
vitally important subject abound; physiotherapists, working with
women of reproductive age, need access to up-to-date information about
the methods, and their availability, that may be used to prevent concep-
tion in their area and need to be able to refer on.
It is essential that the physiotherapist make the important links with
other health professionals in their area to, for example, learn from, know
who to refer on to, acquire up-to-date leaflets, and invite to join postnatal
group sessions. Time is ‘well spent’ with fellow professionals learning
how they ‘fit into’ the wider picture. This time should not be seen as ‘low’
on the ‘priority list’, it should be an ‘absolute’ essential.
• the physiotherapist or midwife risk assesses the client from clear crite-
ria formulated by the women’s health physiotherapist
• group assessment/individual assessment is undertaken proportional
to risk factors, e.g. medical, obstetric, social, etc.
• the physiotherapist or midwife implements the risk assessment
following education (updated regularly) from the women’s health
physiotherapist
• a facility for referral is made available dependent upon risk assessment
• ‘support’ (not replacement) of all intervention is made available with
literature.
Until we can fund having a 24-hour day or 7 days per week physiother-
apy presence on the postnatal units, can we truly justify our existence on
the unit? Should we be, therefore, redeploying some of our skills to other
professionals, or should we be ‘bidding’ for more staff or hours? Unless
physiotherapists are prepared to work the same hours as midwives there
will have to be some rethinking of approaches.
Assessment Ideally, the women’s health physiotherapist should assess each new
mother as soon as possible postdelivery, in order to determine her prior-
ity needs. It may be that another health professional can be equipped
with the skills to perform a risk assessment, and the client, if necessary, be
referred on to the physiotherapist for specialist assessment. Awareness of
needs, proportional to mode of delivery, is essential. Thompson et al’s
(2002) study (n ⫽ 1295) showed for example, that:
Primiparas
• were more likely to report perineal pain, and sexual problems.
Caesarean births (when compared to unassisted vaginal deliveries)
• were more likely to suffer exhaustion and bowel problems
• reported less perineal pain and urinary incontinence
• were more likely to be readmitted.
Forceps and ventouse deliveries (when compared to unassisted vaginal
deliveries)
• reported more perineal pain.
212 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Individual versus group Immediate advice and initial exercise education is best given individu-
education ally, and specific interventions, where needed, should be commenced as
soon as possible.
In terms of cost effectiveness it may then be appropriate to continue
intervention in a group. Individual suitability will be determined by
assessment. The majority of new mothers enjoy the group approach, bene-
fiting from the group interaction. The group approach is particularly
useful in delivering the ‘hidden curriculum’ – the wealth of information
and advice, over and above simple exercise instruction, which is particu-
larly important for those women who did not attend antenatal classes.
Venue The venue for the postnatal group can only be determined by what is
available – within the ward, day room, or parent education room. Most
women are happy to participate, but the physiotherapist must be sympa-
thetic to the issues relating to the ‘new mother’, such as baby feeding,
changing nappies, health concerns, waiting for the doctor, etc., and plan
the group accordingly. If appropriate the baby can attend too. This pro-
vides an ideal opportunity to discuss functional activities, and their
potential effect upon physical symptoms (e.g. baby feeding and nappy
changing and their effect upon the neck and back). The benefits of group
activity far outweigh the difficulties (sometimes) involved in getting a
group together.
Exercise The new mother should be encouraged to be mobile and therefore reduce
the risk of circulatory and respiratory dysfunction. If she is confined to
bed for a prolonged period of time then ‘controlled’, and deep breathing
and ‘vigorous’ circulatory exercises should be encouraged.
Pelvic floor muscle exercises are valuable for their strengthening and
pain-relieving properties. They will also speed healing by reducing
oedema and encouraging good circulation. These exercises should be
taught antenatally. Slow, progressive, controlled contractions along with
fast, short, sharp contractions can be practised little and often. It will take
all the physiotherapist’s skill, and inventiveness to achieve compliance in
this area. The mother may have an acutely painful perineum or several
painful stitches and may be exceedingly reluctant to exercise these mus-
cles. In order to gain compliance it is essential that the mother under-
stand the benefits of performing the exercises. Three or four muscle
contractions will begin to give relief by virtue of the pumping action on
the local circulation. Finding the right starting position for the exercise
The postnatal period 213
will be the key to effectiveness (e.g. lean sitting increasing external pro-
prioception anteriorally, sitting on a gymnastic ball, crook lying, stand-
ing, prone kneeling). A more efficient contraction may be obtained by
contracting the transversus abdominis, before engaging the pelvic floor
(Watkins 1998).
Two essential pieces of early advice to achieve physical relief and
increase confidence are:
1. Contract the pelvic floor muscles (PFM) every time the intra-abdominal
pressure increases, e.g. on coughing, sneezing or laughing.
2. Support sutures by applying pressure (hand) to the perineum using a
sanitary pad or pad of soft toilet paper when defaecation is attempted,
and until the perineal pain subsides.
For some women the memory of the postpartum perineal pain is more
prominent than their memory of labour pain; it has been called the
‘fourth stage of labour’!
The principles of muscle re-education should be followed when exer-
cising the abdominal muscles, progressing from static (no joint move-
ment), through to dynamic (joint movement). Commence at whichever
starting position is appropriate for the individual, bearing comfort in
mind, that is:
• pelvic tilt
• flexion, in progressing ranges, of the lumbar spine.
It is important to include all muscles of the lumbar spine. Richardson
et al (1998) describe the importance of the transversus abdominis and
multifidus as stabilisers of the lumbar spine and these should therefore
be acknowledged in an exercise regime. Looking (at the movement) and
feeling (hand to abdomen) can increase facilitation of the contraction. It is
important to emphasise that once the exercises have been learnt it is not
necessary for them to be practised whilst lying down; they can be inte-
grated into the daily routine, for instance whilst waiting for the kettle to
boil. This increases compliance.
A static abdominal contraction followed by pelvic tilting, in crook
lying, can aid the relief of ‘after-pains’ or backache. The speed of action
can be varied from a slow ‘hold’ to a tilt/relax.
Rhythmical gluteal contractions may help ease the pain from haemor-
rhoids or bruising.
214 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
THE EARLY POSTNATAL Currently it is virtually impossible to set up a class within the hospital
CLASS setting, but there is no reason why this could not be achieved in the com-
munity. The postnatal woman requires input from the physiotherapist,
Setting up a class the expert in human function, in order to return to normal functioning
and enabling her to ‘manage’ her ‘new’ life. The women’s health physio-
therapist will know her own ‘patch’ best and needs to determine the pos-
sibility of having a postnatal class in the community. An advice leaflet
can greatly assist the scheme.
As with the ‘setting up’ of any class the client group should be taken
into account. Are all individuals ‘happy’ with being in a group situation
or are some likely to feel threatened? Appropriateness for inclusion
should be assessed.
Teaching points The arrangement of the group should enable all participants to: phys-
ically take part, interact with each other and the physiotherapist, see the
physiotherapist for the non-physical aspects of the class, and be seen by
the physiotherapist.
The starting position should minimise risk to participants, but enable
participation. Participants may be sitting, standing or lying. The points to
be covered in each position include:
Lying • Pillows and wedges for support and exercise progression, plus mats
(if there is no carpet) or rolls of disposable ‘couch covering’ paper (if
there is carpet)
• Teach checking for separation of recti abdominis muscles
• Raise awareness regarding ‘at risk’ movements or exercises – strong side
flexions and trunk rotations while lying should be omitted until the
anterior abdominal wall is strong enough to allow these movements
without shearing
• Exercises – abdominal muscle
– abdominal muscle contraction, emphasis on transversus abdominis,
increasing length of ‘hold’, with pelvic tilting, progressing to include
active trunk movement, e.g. head raising and then head and shoul-
ders raising
– raise awareness regarding ‘abdominal doming’
The postnatal period 215
• best from taking part, i.e. doing the exercise (if space, time, ability of the
client allows); they are less likely to be afraid to do the exercises at
home if they have ‘tried’ them under supervision
• next best from watching (if space, time, ability of the client does not
allow participation); a demonstration of the exercise, with visual aids
in the form of charts, diagrams, models, will increase the mothers’
understanding of the purpose behind performing the exercises and
therefore aid compliance
• least best from listening alone (last resort in terms of compliance)
• and all retain information better if there is a combination of the above
and it is supported by literature.
Advice with regard to everyday functional activity such as baby bathing,
lifting or carrying, cot or pram heights (Figs 4.4, 4.5, 7.2) etc. should be
given by the expert – the physiotherapist. The physiotherapist has the
knowledge and skills to teach the mother approaches that will minimise
the effects on the musculoskeletal system. It is essential the women’s
health physiotherapist ‘does her homework’ – researches the ‘in vogue’
products on the market and is prepared with appropriate advice for the
parents, for example on baby slings (Fig. 7.2) or car seats.
It is essential that the mothers be ‘educated’ not ‘instructed’ for the
exercise programme or advice to be meaningful and lifelong.
216 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Teaching ergonomic The new mother can experience cumulative physical trauma as a result of
principles her new role. It is essential the women’s health physiotherapist educate
the mother in relation to ergonomic principles.
Sitting (sitt.) • Thighs fully supported (at least ⁄3) and horizontal – the sitting surface
2
Standing (st.) • Feet slightly apart, and angled (lateral rotation at the hips following
‘true’ line of femur) slightly (not like a ballerina!)
• Weight evenly distributed over both feet
• ‘Soft’ knees (not flexed, just ‘off’ full extension – do not ‘lock’ them
back)
• Shoulders relaxed (not retracted or elevated)
• Arms held loosely at the side
• Maintain natural curves of the spine
• Head in line with trunk.
Lying (ly.) • Fully supported (s.ly., pr.ly., ly.) with pillows – head, knees, low back, etc.
• Legs not crossed.
The postnatal period 217
• Unilateral – sitting on one heel, other hip forward flexed with foot flat
on the floor.
Feeding The new mother may be feeding (Fig. 7.3) her baby eight or more times
each day. However, what should be a happy, relaxed, shared time
between mother and baby has the potential for resulting in musculoskele-
tal symptoms if she is positioned inappropriately. The women’s health
physiotherapist is the best person to teach the mother with regard to
‘good’ positioning, but the midwife is the person who is best able to rein-
force this on a regular basis, so sharing of knowledge and skills between
218 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
the professions is essential for the benefit of the mother. Whether the
mother is breastfeeding or bottle feeding, and whether in sitting or lying,
ergonomic principles must be followed to avoid musculoskeletal dis-
comfort, or maybe even pain. She may be there for some time!
Nappy changing Nappy changing (Fig. 7.4) is another activity that can result in incapacitat-
ing pain. A mother can change a nappy 10 times a day or more, and it is
therefore considered a frequent activity. Frequent activities carry muscu-
loskeletal risk if ergonomic principles are not followed. Positions that
increase the risk to the mother should be avoided (e.g. st., knees extended,
trunk flexed, and twisted). It is the role of the physiotherapist to teach not
only the mother but other health professionals so that they are able to
reinforce the principles. Many hospitals today insist that nappy changing
is carried out in the baby’s cot. The physiotherapist should be involved in
the development of ‘policies’ that not only follow infection control guide-
lines, but also reduce the physical risk to the mother.
Suggested positioning for nappy changing could be:
Bath time Bath time should be ‘fun’ for all parties, but can be another source of mus-
culoskeletal problems. Risk factors are as follows:
Points to remember • It is important that the women’s health physiotherapist has a belief in
what she is doing, has the ability to motivate and encourage the mother,
and is, above all, enthusiastic.
• Many women will not want to exercise, and may have to be persuaded
to participate.
• Do not burden new mothers with too many exercises – prioritise the
essentials.
• Encourage movement. Reassure them that the stitches will not ‘pop’ if
they move about.
• Although birth is usually a joyous experience, stillbirths, abnormal
or ill babies and neonatal deaths do occur. These are difficult for all
staff but, especially for the young and inexperienced. The women’s
health physiotherapist should establish the priorities and teach the
mother exercises that are appropriate. She should not be afraid of
empathising with parents in their anxieties or even joining them in their
grief.
Postnatal ‘home’ To improve circulation during the first few weeks the new mother should
exercises try to have a daily walk with her baby in a sling or a pram: the change of
scene will also benefit her emotionally. Pelvic floor muscle exercises can be
done around the house. They should become routinely part of other
activities. Reminders may be needed: post-it notes in obvious places –
inside kitchen cupboards, by the phone, in the nursery.
Only when the recti muscles are closing satisfactorily can abdominal
exercise be progressed to include side flexion and rotation exercises as
well as ‘curl-downs’ (curling down halfway from crook sitting, holding
briefly, and returning to the upright position), if the mother’s perineum
is not too painful.
220 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Return to sport and Even the athlete, dancer or dedicated sportswoman will have reduced the
exercise intensity and amount of exercise by the end of her pregnancy. After the
postnatal period of recovery and gradual restoration of muscle strength,
these women will be ready to return to their prepregnancy activity. Where
the prepregnancy level of activity considerably decreased prior to deliv-
ery, a gradual reintroduction of sport and training schedules is essential.
This is particularly important for the non-athletic woman who feels that
she should be ‘doing something’ once her baby has settled down; she
should be discouraged from joining a mass aerobics class at the local
leisure centre, jogging long distances, or cycling many miles if she has not
exercised for a long time. It is important that qualified instructors who
understand the limitations of the postpregnancy woman supervise classes
and activities – a communicative role here for the women’s health physio-
therapist. Swimming, an ideal activity for the fit and for those hoping to
become fitter, may be resumed after the postnatal check.
Baby massage In the same way that adults enjoy, and feel relaxed by, skilful massage,
many babies respond with pleasure to simple stroking or kneading tech-
niques. In the East and amongst many ethnic groups in this country, baby
massage is practised regularly. In its simplest form, most mothers include
The postnatal period 221
a stroking movement when smoothing oil into their baby’s skin follow-
ing a bath or nappy change. A short baby massage session could enjoy-
ably be included in a mother and baby exercise class or postnatal group;
while massage is most successfully performed on the naked body (the
room would have to be very warm in this case, and plenty of nappies
available), it is perfectly possible to teach this form of massage where the
baby is wearing a stretch, all-in-one suit. In some regions there are spe-
cific baby massage classes. Payne (1999) suggests that a baby massage
class may in fact reduce the possibility of postnatal depression. Simple
effleurage and stroking over the babies’ backs, chests, abdomens, arms,
legs, hands and feet can be taught, and practised by the group together.
Mothers are probably most comfortable sitting on the floor with their
backs supported by a wall, and baby lying across their lap. If baby starts
to cry, for a feed or because of a wet nappy, and is therefore uncomfort-
able, the mother should feel sufficiently confident to halt the massage
session. At home, mothers should be encouraged to massage their babies
at appropriate times (i.e. when the baby is not hungry, and therefore
likely to enjoy it). If baby is distressed despite having been fed, has a
clean nappy and has been winded, a simple back and abdominal mas-
sage can sometimes soothe. Suitable oil can be used sparingly. The most
important factor to remember is it should be enjoyed by both the baby
and the masseur (mother, father, grandparent, friend), and that it should
not become a chore. Experienced physiotherapists can easily adapt con-
ventional massage strokes to their tiny clients.
Studies into sudden infant death syndrome (Gantley & Davies 1993)
suggest that by increasing the ‘sensory rich environment’ its incidence
may be reduced – another ‘plus’ for massage.
Mother and baby postnatal exercise classes in the community provide an
excellent forum for introducing education on preventative health care,
not only for the mother and her baby, but for all the family. This has the
capacity to prevent, or alleviate, such ‘problems’ as backache, mild pro-
lapse, stress incontinence and osteoporosis in later life. This education is
of great importance and is an investment for their future.
PERINEAL Visible problems can include bruising, oedema, labial tears, haematoma,
DYSFUNCTION/PAIN tight stitches, infection, breakdown of suturing and haemorrhoids.
These may or may not cause varying degrees of pain. A vaginal
haematoma will not be visible, but may, nevertheless, be intensely
painful.
The physiotherapist has much skill, knowledge and experience in
the treatment of pain, swelling, bruising, haematoma and infection. The
women’s health physiotherapist has in-depth knowledge of anatomy,
physiology and human mechanics, and the changes that take place dur-
ing and after pregnancy. Who better to treat these symptoms following
a complete and thorough assessment?
222 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Treatment One of the most physiologically sound self-help techniques for the relief
of perineal pain must be the repeated contraction and relaxation of the
Pelvic floor muscle voluntary component of the pelvic floor musculature. The resulting
exercises pumping action assists venous and lymphatic drainage and the removal
of traumatic exudate, thus relieving stiffness and restoring function. It
is also theoretically possible that the muscle activity triggers the ‘pain-
gating’ mechanism and may also stimulate the production of endogenous
opiates. Pain tends to be maximal with the first contraction and decreases
with repetition as oedema disperses. It is essential that the woman is
comfortable whilst performing the exercises. The appropriate position
will be proportional to symptoms. Possible positions are: stride crook
lying, prone lying, stride standing, or stride sitting.
Functional Activity It is essential that the women find comfortable positions for feeding,
relaxation and sleep, and they should be encouraged to experiment using
pillows and pressure-relieving cushions. Pain relief can occur rapidly if
positioning is appropriate.
Warm baths and bidets These are used principally to promote good hygiene. Although not
strictly physiotherapeutic, most women experience relief of pain and a
relaxed feeling of well-being following the traditional use of a warm
bath. Women should be actively discouraged from staying in the bath too
long, however, as traumatised skin quickly becomes ‘soggy’. Warm water
can also be poured over the perineum from a jug while the woman is sit-
ting on the toilet. This eases the burning sensation some women experi-
ence when urinating, if they have sustained lacerations. The use of a
bidet, as well as promoting hygiene, can also be soothing.
Ultrasound Ultrasound has been shown to increase tissue temperature, which in turn
leads to increased blood flow and increased repair (McMeehen 1994). It
should be used in accordance with agreed local infection control proced-
ures; each hospital should have a written protocol for its use and this
should be checked on a regular basis.
Following assessment, treatment should commence as soon as pos-
sible after delivery and should continue twice daily until the woman is
able to carry out functional activities without pain. The treatment is best
given in the crook-lying or side-lying position as it is most important to
be able to see the perineum and buttock area clearly. Using a cotton-wool
swab and warm water, and swabbing from front to back, any lochia
should be gently washed away. Using an appropriate cover, the ultra-
sound head is then applied through a coupling gel medium, and in
accordance with local infection control guidelines. Normally pulsed
ultrasound is used for its analgesic and exudates-removing properties,
although it has been shown that the thermal and non-thermal effects of
ultrasound are beneficial to all stages of tissue repair (Dyson 1987). For an
initial treatment, a dosage of 3 MHz, 0.5 W/cm and 2 minutes per head-
sized area of trauma was used by McIntosh (1988). It is thought unneces-
sary to increase the dosage if there is improvement in pain and decrease
in swelling. Where the pain is too intense for direct contact a condom can
be successfully used as a water bag – with couplant applied to the
patient’s skin, the bag and the treatment head. This also makes the appli-
cation of ultrasound to haemorrhoids much more comfortable.
224 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
GENITOURINARY There is a close relationship between the pelvic organs, therefore an alter-
DYSFUNCTION/PAIN ation in urinary and faecal control can occur following difficult forceps
deliveries; even a normal birth can result in voiding problems.
Incontinence Thompson et al (2002), in a study of 1295 women, showed that bowel and
bladder problems generally resolved between 8 and 24 weeks postpar-
tum. Women who had caesarean births reported more bowel problems
compared with those having unassisted vaginal deliveries, but reported
less urinary problems. Fratton & Jacquetin (1999) suggest that the rela-
tionship between first childbirth and obstetric trauma is strong and may
contribute to the development of stress incontinence (urinary and anal),
and genital prolapse. Mørkved & Bø (2000) clearly show that physiother-
apeutic input in the immediate postpartum period is effective in increas-
ing pelvic floor muscle strength and reducing urge incontinence.
Faecal incontinence In a study carried out on women who delivered vaginally between 1996
and 1997, Signorello et al (2000) showed that those women who experi-
enced a midline episiotomy had a higher risk of faecal incontinence at 3
and 6 months postpartum compared with women with an intact peri-
neum. Compared with spontaneous laceration, episiotomy tripled the
risk of faecal incontinence at 3 months and 6 months. The effect of the
episiotomy was independent of other influencing factors. It used to be
thought that this highly embarrassing and distressing condition was only
due to direct sphincter division or muscle stretching. However, research
by Snooks et al (1985) suggests that this incontinence can result from
damage to the innervation of the pelvic floor muscles during perineal
descent in the second stage of labour. It is more common in women who
have experienced difficult instrumental deliveries and in multiparae.
Neuropraxia normally resolves by 2 months, but some women will be left
with a long-term problem. Explanation, encouragement and pelvic floor
muscle exercise instruction is the role of the women’s health physio-
therapist in the early treatment of a condition which most women are
The postnatal period 225
Constipation Constipation is extremely common during the early puerperium and its
cause is varied. It may be the result of weak abdominal muscles – a large
diastasis recti abdominis would compound this, together with relaxation
of the smooth intestinal muscles, the change from home to hospital diet
(lack of fibre and fluid), iron medication, and the fear of increasing peri-
neal pain or reopening the episiotomy wound or tears. As well as a full
explanation of these causes (understanding a problem is often halfway to
solving it), and their remedies, the suggestion that the perineum is sup-
ported with a pad of soft toilet paper during defaecation can be of great
help. It should be impressed on the new mother that improving the
strength of her abdominal muscles will help in relieving constipation. It
is important that women realise that lifelong constipation can lead to the
‘descending perineum’ syndrome. Henry et al (1982) described this, and
pointed out that repeated strain can lead to urinary stress incontinence
and faecal incontinence (see Chs 11 and 12).
Urinary retention It is most important that all health professionals involved in the care of
the postpartum woman be fully aware of the problem a newly delivered
woman may be experiencing in initiating and completing the act of mic-
turition, and therefore showing symptoms of urine retention. There is
some evidence to show that a single episode of bladder overdistension
can produce chronic changes as a result of irreversible damage to the
detrusor muscle (Toozs-Hobson & Cutner 2001). If retention of urine
should occur, catheterisation can be necessary and the mother may need
to have an indwelling catheter for several days.
Urinary retention can be caused by a prolonged second stage of labour,
a large baby, instrumental delivery, or total/dense block from epidural.
The urethra, being embedded in the anterior wall of the vagina, may be
226 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Assessment technique With the woman in crook lying (one pillow), the physiotherapist faces her
and places the fingertips of one hand widthways on the abdomen, across
The postnatal period 227
the midline just below the umbilicus. The woman is asked to raise her head
off the pillow and reach with her hands toward her feet. The medial edges
of the two rectus abdominus muscles are then palpable and the distance
between them is measurable in finger-widths. The length of any separation
is also noted. The procedure is repeated palpating above the umbilicus.
The woman is encouraged to assess herself, palpating with one hand
reaching with the other. It is important to explain that the gap is not
dangerous – nothing will fall out. However careful re-education to gain
closure is crucial as the linea alba does not regenerate but strong muscles
compensate for this and assist good functioning of the abdominal wall.
Back pain Östgaard & Anderson (1992) in a study of 817 women found that 67%
of women had back pain directly after delivery and that 37% still had it
228 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Low back pain Low back pain may be relieved initially with a double-layered Tubigrip
(sizes K or L) to support weak abdominal muscles. Resting in prone
lying, well supported with pillows that allow a space for the enlarged
breasts, is helpful for the mother. Ergonomic principles should be used in
all functional activities. If the principles are followed then symptoms
may abate. Specific mobilisation techniques for the sacroiliac, lumbar or
lumbosacral regions may be appropriate.
Pain in the It has been postulated that pain in the epidural site can be due to a tiny
epidural site haematoma in the dura and epidural space. Heat, in the form of a hot pack,
can be soothing, or alternatively an ice pack can be used. Appropriate
warnings should be given about the use of both heat and ice.
Thoracic pain Thoracic pain may be relieved by paying attention to postures during
functional activity. Active exercises may give relief. Hot or ice packs may
be effective.
Symphysis pubis pain Pain in the region of the symphysis pubis is present in an ever-increasing
proportion of postpartum women, and is under-recognised, suggests Fry
et al (1997). Symphysiolysis or diastasis symphysis pubis may have
occurred antenatally, or may follow a traumatic delivery. This joint sep-
aration, of either sudden or gradual onset, will give rise to varying degrees
of pain from mild to moderate to severe and disabling. The pain distri-
bution can be pubic, groin, inner thigh and suprapubic areas. It may be
accompanied by sacroiliac joint pain or low back pain, or both, and it may
be unilateral or bilateral. On occasions ‘clicking’ or ‘grinding’ may be
audible and felt by the woman. The symptoms are aggravated by getting
in or out of a car, walking, turning in bed, stairs, weight-bearing activities,
hip abduction, and unilateral standing. (see Further Reading, p. 246.)
It is essential that the woman, and her family, fully understand her
symptoms. Depending on the severity of pain, Fry et al (1997) advise
24–48 hours bed rest with analgesia and full assistance with baby care.
Mobilisation will be gradual with walking aids if necessary. It is essential
that weight-bearing stresses on the pelvis are minimised until symptoms
resolve. Regaining functional spinal and pelvic stability is the main object-
ive, with gradual progression in the re-education of applicable muscle
groups. It is essential that the woman’s pain level is ‘managed’ using
whatever modalities are appropriate.
The women’s health physiotherapist will have a great deal to offer by
way of advice and treatment, for example:
relieved pain in 40% of the primiparous but only 16% of the multiparous
women. Sleep, oral analgesics, a change in position and passing urine
were also helpful. It is important that the woman understands where her
pain is coming from. Practising the relaxation and breathing techniques
used during labour may assist in its management. Where ‘after-pains’ are
severe, TENS applied over the nerve roots innervating the uterus and
perineum (T10–Ll and S2–S4) may be helpful.
CIRCULATORY Most women are pleasantly surprised by the appearance of their varicose
DYSFUNCTION/PAIN veins after their babies are born, although some may experience pain
along the length of the long saphenous vein. As a result, many do not
Varicose veins appreciate the necessity for maintenance of circulatory leg care. There is
an improvement in the severity of varicose veins following delivery, but,
particularly in multiparae, once veins have become badly varicosed they
will never recover completely.
Vigorous, and frequent, alternate dorsi and plantarflexion (at least 30
‘pumps’ at a time) will prevent stasis. Today’s new mother is rarely con-
fined to bed, but she is not as active as she would normally be. She will
also be sitting feeding her baby for several long periods every day.
Support tights or antiembolic stockings may be necessary for severe
cases; advice about beneficial sitting positions with the legs raised, and
the need to avoid crossing the legs, should be given. This should also be
reinforced, and care taken to see that it is implemented.
Oedema Although there is a massive diuresis following delivery, it can take several
days (and even weeks) for the fluid retention of pregnancy to be reversed.
Severely oedematous legs should be supported with antiembolic support
stockings; the mother should rest with her legs in elevation. She should be
encouraged to feed her baby with her legs raised, and vigorous foot and
ankle exercises should be carried out half-hourly. Occasionally swelling of
the feet and legs occurs for the first time after the baby is born, which can
be upsetting and uncomfortable. Reassurance, explanation and encour-
agement from the women’s health physiotherapist can turn what seems to
be a major catastrophe into a transient inconvenience.
Superficial vein The mother may complain of tenderness over a palpable, superficial
thrombosis vein, and there may be redness of the overlying skin. This is often associ-
ated with varicose veins. The mother should be encouraged to remain
mobile and to exercise her legs frequently. She may be more comfortable
in support tights or antiembolic stockings until the condition subsides.
Deep vein thrombosis With deep vein thrombosis (DVT) the mother will complain of pain and dis-
comfort in her calf or thigh, and swelling may be present if the vein is
occluded. Homans’ sign (calf pain with ankle dorsiflexion and knee exten-
sion) may be positive. The main danger to the mother is the potential of a
thromboembolism. Any woman showing signs should immediately be
The postnatal period 231
Haemorrhoids Haemorrhoids are distended, and sometimes thrombosed, veins in the anal
passage and can be a source of acute discomfort, and distress, in the imme-
diate postpartum period. They may have been a problem antenatally, or
may have appeared for the first time after the birth. Pushing in the second
stage of labour can cause the veins to prolapse; on examination the
swellings can resemble small to large bunches of grapes. The pain experi-
enced by some newly delivered mothers is often described as excruciating.
Apart from doing the utmost to ensure the comfort of the woman
while feeding, with a pressure-relieving cushion or strategically placed
cushions, the women’s health physiotherapist can use ultrasound (per-
haps through a water-filled condom if the haemorrhoids are too tender to
allow treatment in direct contact) and PEME, although Grant et al (1989)
did not find that these therapies helped. Crushed ice packs also alleviate
the pain and reduce the swelling. Frequent pelvic floor muscle contrac-
tions are probably the most helpful thing the mother can do as a self-help
therapy, although resting in prone or side lying, or with the end of the
bed raised may also be useful.
Steroid analgesic creams or foams are often prescribed, and if the
haemorrhoids have prolapsed a gentle attempt may be made to replace
them. The mother should be encouraged to drink plenty of fluid and
have a fibre-rich diet in order to produce soft, bulky stools, thus reducing
the pain caused by defaecation.
BREAST ‘PROBLEMS’ Occasionally a woman may present with severe breast engorgement in
the early puerperium, which is so acute that expression of milk using a
Breast engorgement breast pump or even by hand is too painful. Ultrasound, to the periphery
of the breast initially and then moving the treatment head towards the
232 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Sore and cracked The symptoms of sore and cracked nipples often lead to many new mothers
nipples abandoning breastfeeding in the immediate postpartum period. It has
been suggested that the symptoms are directly related to the position of
the baby on the breast. Sore or cracked nipples are not due to the
mother’s colouring, nor the ‘toughness’ of her skin, nor to the shape of
her nipple. The position of the baby – facing the mother’s body, with neck
slightly extended, mouth well open with the lower lip curled down, and
the nipple extending as far back as the soft palate (RCM 2003) – is all-
important. If the baby is correctly attached, there should be no friction of
the tongue, or gum on the nipple and no movement of the breast tissue
in and out of the baby’s mouth. Thus the baby’s sucking will not trauma-
tise the nipple and there will be no soreness. The women’s health physio-
therapist will advise a fully supported position for feeding, but it may be
necessary for the mother to lean forward initially in order to obtain the
most favourable position of her breast for the baby to ‘latch-on’ to and
then feed successfully. If the mother is lying back in bed or on a chair, the
naturally pointed shape of the breast is flattened and the baby is unable
to take the nipple to the back of the throat. Experimentation may be neces-
sary before the best feeding position for the individual mother and baby
is found, and the situation will need constant review as the baby grows.
The women’s health physiotherapist will not be directly involved in the
active treatment of sore nipples, but should be aware of the pain and dis-
comfort that the woman is experiencing as it may have an impact on her
recovery. The women’s health physiotherapist should also make herself
aware of current, local policies with regard to treatment and manage-
ment of the ‘problem’, so that she is fully informed with regard to the
mother’s status.
The importance of technique cannot be emphasised enough and the
midwife may spend many hours assisting the new mother to achieve
what is ‘right’ for her and her baby. The women’s health physiotherapist
must be aware of the potential risk to the midwife in this situation. ‘At
risk’ postures can be held for long periods of time and education in this
‘scenario’ is the role of the physiotherapist in order to maintain the ‘team’
effectively and efficiently.
• Rest and sleep while the baby sleeps – household duties are not a
priority.
• Ask the partner or a friend to take the baby for a long walk so that the
mother can ‘catch up’ on sleep – not ‘catch up’ on household duties.
• Go to bed, if possible, after the early evening feed, and sleep until the
baby wakes for the next feed. An understanding partner could bring
the baby to her – she can breastfeed in bed – and then he can change
and settle the child whilst she goes back to sleep. If the baby is bottle-
fed they can share the task.
• prioritise household duties … accept offers of help.
Women who are used to being ‘in charge’ of their lives often find the first
few weeks of life with a new baby (particularly if it is their first), totally
exhausting. Society has acknowledged this fact with the introduction of
paternity leave and extended maternity leave. It is important to reinforce
suggestions for managing postnatal fatigue.
There will be an emotional, as well as a physical, aspect to the fatigue,
and it is important for stress-coping strategies to be discussed. Even a
simple thing like breast feeding lying down instead of sitting in a chair
can be helpful, although falling is dangerous (see Fig. 7.3).
PSYCHOLOGICAL Symptoms of postnatal depression (PND) and anxiety are ones that the
SYMPTOMS woman herself may not recognise, but can be readily identified by family or
health professional. Realising that the woman is not alone in her situation;
suggestions for more rest, time on her own, daily outings with the baby in
adult company, the occasional evening out with the partner (perhaps a
friend or relative could babysit) are all self-help therapies. The midwife and
the heath visitor can be a source of great support; then if the situation does
not resolve, the general practitioner should be consulted, with possible
referral to a psychiatrist to help the woman regain her mental health.
The emotional and psychiatric illnesses that can arise in normal, healthy
women who have recently given birth are only now being recognised as
234 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
The ‘maternity’, ‘baby’ These occur in the first 2 to 3 weeks after delivery. The depression often
or ‘third day’ blues follows a latent period of about 3 to 4 days, and is usually mild and tran-
sitory, but can be more intense. The mother is weepy, anxious and per-
haps agitated. Maximum tearfulness and depression occur on the 5th
postpartum day (Kendall et al 1981). A sore perineum, uncomfortable
breasts, and fatigue from broken nights and endless visitors often aggra-
vate the condition. A woman’s sense of success or failure about her
labour, delivery and baby, as well as thoughtless comments from hospital
staff, can be triggering factors too.
The mother’s response to her baby may not have been what she had
expected; perhaps the automatic surge of love did not materialise, and
the sudden realisation of the never-ending responsibility for the small,
new life can be overwhelming. The fact that friends, relations and hos-
pital staff seem more interested in the baby than in her, and her situation
(being in hospital perhaps for the first time in her life, with strange food,
bed and people), add to her sense of isolation, and maybe her guilt that
she is not enjoying her baby. Any or all of these can play a part in the
‘blues’, which are experienced by as many as 80% of newly delivered
mothers. Research suggests that about 25% of mothers experiencing
severe postnatal ‘blues’ will go on to develop PND (Cox 1986).
Puerperal psychosis Puerperal psychosis is a much more severe illness. The mother may seem to
lose contact with reality, have delusions, hallucinations or extreme mood
swings and behave abnormally. She can suffer from intense agitation and
anxiety; insomnia and very early waking are also signs of this cata-
strophic illness.
Suicidal and infanticidal thoughts may also occur and, in its worst form,
puerperal psychosis may require hospitalisation – ideally in a special
The postnatal period 235
mother and baby unit. There is a very high likelihood of its recurrence
following future pregnancies.
Postnatal depression Postnatal depression may also begin in the early postpartum period, but
it can start, or become obvious, much later too. It presents in a variety of
ways, and with varying degrees of severity. The mother may feel sad and
depressed; she may worry constantly about herself and her baby, feel
unable to cope and have a sense of futility and hopelessness. She may be
tired to the point of exhaustion, but may be unable to sleep. She will
probably suffer from a loss of libido and may have a delayed return of
menstruation. Physical symptoms such as ankle swelling, loss of hair and
a non-dietary weight gain may also be present. In very severe PND
the mother may feel suicidal or may be frightened that she will harm
her baby.
Sexual problems The all-consuming role of new motherhood, and the fatigue with which
it is accompanied, often result in a complete loss of libido. This can be
made worse if the woman is still experiencing perineal or vaginal dis-
comfort and is frightened that intercourse will prove painful. A partner
who is demanding and lacking in consideration may add to her ‘prob-
lem’ and instill a sense of guilt – particularly if they had a good sex life
before pregnancy. Reassurance that eventually she should regain her
interest in sex, suggestions for the use of a lubricant where soreness is a
236 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
CAESAREAN SECTION Caesarean births are forever on the increase. Between 1997/8 and 2000/01
the caesarean rate has increased from 18.2% to 21.5%. In 2000/01 more
than half of these were emergencies (DoH 2002). The national level was
estimated at 14% in 1993 (Savage 1996). Medical reasons for this type of
intervention suggest a level of 6–8% and, even in a high-risk area, it can be
possible to achieve a rate of 9% (Savage 1996). In some areas the ‘maternal
request’ rate is as high as 48% (Lowden & Chippington-Derrick 2002).
Although it is considered a comparatively risk-free procedure, it is a
surgical procedure and not without problems for anaesthetists, obstetri-
cians, midwives, physiotherapists and, most importantly, for the woman
herself. It is the only major abdominal operation where there is little oppor-
tunity for an uninterrupted convalescence, and a new career (being a
mother) commences within hours of surgery. The procedure can be
carried out under general anaesthesia or epidural analgesia.
Danish research (Juul et al 1988) compared two groups of women who
had undergone this operation, one with a general anaesthetic and one
with epidural analgesia, for anaesthetic complications, postoperative
morbidity and birth experience. The puerperal period was less compli-
cated, there was quicker re-establishment of gastrointestinal function,
and the women mobilised more quickly and were less tired following
epidural analgesia. Eighty-six per cent of women would opt for an
epidural in case of a repeat caesarean.
A further paper (Lie & Juul 1988) showed an interesting result with
respect to breastfeeding following an epidural caesarean birth; these
women breastfed significantly more frequently, and for a longer period
after birth, than a similar group who had general anaesthesia.
The mother’s reaction to this method of delivery will depend upon her
own expectations and aspirations with regard to labour and birth. The
relative issues are: planned/elective procedure or an emergency proced-
ure during labour, conscious or unconscious, partner presence or absence;
all are important factors in determining her degree of satisfaction. Post-
operative status will be influenced by all these issues along with the
woman’s personal responses to surgery and pain. Women undergoing an
elective procedure with epidural generally cope without difficulty, and
will be readily mobile and able to care for their baby with minimal dis-
comfort. Women undergoing the procedure following other previously
failed interventions, may be in fear of moving, incapacitated by pain and
able to care for their baby only minimally.
(they may have had the symptoms of a common cold at the time!).
Coughing after any abdominal operative procedure is painful, but fol-
lowing a caesarean birth it can be complicated by the exceptionally
‘slack’ abdominal wall. Support is paramount, as is positioning. It is vir-
tually impossible to cough comfortably and effectively in bed no matter
what devices are used. The woman should be assisted to sit on the side of
the bed with her feet supported on the floor or a stool. Her legs should be
wide apart (but only if not experiencing SPD symptoms), a soft pillow
should be clasped to her lower abdomen (to equalise internal pressure)
and she should be encouraged to lean as far forward as possible.
Coughing can be reduced to a minimum by using forced expiration or
‘huffing’ as an alternative or prelude.
Routine postnatal care is applicable to the postcaesarean woman, but
must be introduced and progressed more slowly. Whilst immobile the
priorities are the prevention of circulatory and respiratory dysfunction.
Feeding Whatever abdominal incision has been performed, the mother will be
‘guarding’ the area, anxious that any external touch or pressure will be
painful. She will be particularly anxious when feeding. The baby can
be positioned in such a way as to allay her fears, For example tucking the
baby’s feet under her arm to avoid potential kicking, or positioning pil-
lows to protect the wound (Fig. 7.5).
Wound healing Some women may experience problems with wound healing. Those with
pendulous abdomens, where loose flesh overhangs the wound, are particu-
larly at risk. The skin may become unhealthily moist, providing a ‘prime’
site for the development of infection, thus delaying healing. These women
should be risk assessed, and managed, in order to prevent infection at the
wound site. Management should take the form of advice; encourage
the woman to rest in extended positions that will expose the wound to
the air, ‘rearrange’ superfluous flesh up and away from the wound for
short periods, and consciously keep the area dry. PEME can be used,
where infection is suspected, to relieve pain, improve local circulation and
The postnatal period 239
Postoperative pain The majority of surgical procedures are followed by a period of conva-
lescence. This is not the case following a caesarean birth since women
have a responsibility to another, completely dependent, human being.
Postoperative pain should not be such that it detracts from the woman
being able to care for her baby. There is no reason today why this pain
cannot be clinically controlled, either with medication or with physio-
therapeutic modalities, to enable her to function comfortably.
MULTIPLE BIRTH Mothers who have had a multiple birth, and who have had the joy of
delivering more than one baby, will not only have very much weaker
abdominal muscles, and possibly a larger diastasis recti abdominis, but
they will also have less time to devote to themselves. Feeding demands
will be greater, and they will be very tired. The women’s health physio-
therapist will need to introduce the idea of exercising a little and often,
and should point out the importance of extra help at home and plentiful
rest in the early postpartum period. Where possible these women should
be seen in the community once they have adjusted to their new and
demanding lifestyle, so that postnatal exercises can progress (or even
commence if pressure at home has been too intense initially).
240 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Parents coping with more than one baby at a time will appreciate the
help, guidance and support they can receive from local branches of the
Twins and Multiple Birth Association (TAMBA) (see Useful Addresses,
p. 247).
PERINEAL/VAGINAL For several weeks following the birth of a baby this can be a serious cause
PAIN OR DISCOMFORT of anxiety, fatigue and even depression, as well as an obstacle to the
resumption of sexual intercourse. Perineal pain can present up to 6
months postdelivery (Glazner et al 1995). The wound-healing rate varies
from person to person, but no woman should be expected to cope with
long-term perineal or vaginal pain. If no help is gained from ‘self-help’
techniques, such as warm baths, small disposable ice packs, the use of a
pressure-relieving cushion or two pillows with a space between them,
repeated pelvic floor muscle contractions or gentle self-massage with a
bland vegetable oil (as long as the possibility of infection and a broken-
down wound has been eliminated), then the mother must be encouraged
to visit her GP in the first instance, with referral back to her obstetrician
or gynaecologist as the next option. She should mention the continuing
pain at the 6-week postnatal check and insist on a follow-up appoint-
ment. A rare source of postpartum discomfort and dyspareunia is the
excessive formation of granulation tissue in the line of the episiotomy or
tear (granuloma). Where this occurs it can be successfully treated by
cautery. Painful scar tissue may also be helped by steroid injection.
Ultrasound to external scar tissue may be useful in resolving pain which
is not due to infection (Fieldhouse 1979, Hay-Smith & Mantle 1994).
Clinical trials suggest that there is insufficient evidence as to the benefits
or harms of using ultrasound (Hay-Smith 1999). However, those on the
receiving end of the intervention are more likely to report improvement
than those receiving a placebo. The trials reviewed by Hay-Smith (1999)
suggest that there is little to support ultrasound, or PEME, but she sug-
gests that at present there is insufficient evidence either way.
INCONTINENCE It has been shown that there is a dramatic drop in the strength of the
pelvic floor muscles measured at 6 weeks’ postpartum, compared with
Stress incontinence prepregnancy, and a slight, possibly physiological, recovery to levels still
well below those prepregnancy by 12 weeks (Dougherty et al 1989).
Stress incontinence (see Ch. 11) is probably the condition most readily
accepted as a ‘women’s lot’ by sufferers of all ages and parity. Mothers,
and grandmothers, of recently delivered women often say that bladder
leakage is a ‘normal’ consequence of childbirth, they have suffered from
it themselves since their families were born, and nothing can be done
about it other than surgery, so it has to be lived with. Researchers have
demonstrated, however, that stress incontinence can be alleviated by a
rigorous programme of PFM exercises (Berghmans et al 1998). Dougherty
et al (1989) showed a dramatic improvement in pelvic floor strength and
endurance following their programme of 6 weeks’ intensive exercise
with or without vaginal resistance. Too many women practise PFM exer-
cises intermittently (‘when I think of it’), too infrequently (‘ten times after
breakfast’) or not at all (‘I haven’t got time’).
Before embarking on a further programme of rehabilitative exercise, it
is of prime importance for a full assessment to be made of each woman’s
PFM, including a vaginal examination; in addition a urine test to elim-
inate infection may be appropriate. Some women are unable to produce
a PFM contraction, or are unable to maintain it for more than 3 seconds at
best. The possibility of pelvic floor denervation must be considered. The
experienced women’s health physiotherapist should be able to grade the
strength of the muscle contraction digitally.
Routines of PFM exercises must be tailored to each individual, and
assessed and revised regularly. Progression should include the number
of repetitions and the length of the ‘hold’. The woman should be encour-
aged to exercise whenever she feeds her baby, and to counter-brace her
pelvic floor on coughing, sneezing, laughing, blowing her nose, etc. If fre-
quency and urgency are also problems, a strong pelvic floor contraction
should be used to inhibit detrusor activity (McGuire 1979). If a woman is
unable to produce a reasonable PFM contraction, electrical stimulation
is an additional method of treatment which may be useful (see p. 375). It
is vitally important that each woman knows, on her discharge from hos-
pital, that she has an ‘open door’ to her women’s health physiotherapist
should urinary problems fail to resolve. A protocol should be in place to
facilitate this. Where these are long lasting, a full urodynamic assessment
will be necessary.
242 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Faecal incontinence Faecal incontinence does not, fortunately, affect as many women as urin-
ary stress incontinence, though it is an intensely humiliating and embar-
rassing problem (see Ch. 12).
DIASTASIS RECTI The size of this intermuscular gap will reduce in most women as physical
ABDOMINIS recovery from pregnancy and labour takes place; however, it may not
disappear altogether without a careful exercise programme. It is most
important for the correct mechanical function of the abdominal wall that
the diastasis is eliminated. A great deal of encouragement may be neces-
sary to stimulate women to keep exercising – those with multiple births
will, understandably, have very little time or energy for themselves.
CARPAL TUNNEL If occurring during pregnancy this usually resolves shortly after delivery.
SYNDROME It can, however, ‘develop’ in the puerperium and appears then to be closely
associated with breastfeeding. Wand (1989) described a study of 27 women
who developed carpal tunnel syndrome, on average, 31⁄2 weeks following
delivery. In three women who were bottle-feeding, the symptoms were
mild and quickly resolved; the remaining four experienced painful paraes-
thesia, and 16 had such severe symptoms that their ability to care for their
baby was affected. Complete resolution of the condition did not take place
until breastfeeding had totally stopped; improvement began approxi-
mately 14 days following the beginning of weaning. Although this study
shows the close association between the onset of symptoms and the estab-
lishment of lactation, and their disappearance following its cessation, the
author did not offer any physiological reason for this. The suggestion
therefore is that it is functionally related; maybe the breastfeeding tech-
nique is a contributable cause? Wrist splints, reassurance, diuretics, non-
steroidal anti-inflammatory drugs and steroid injections have been used to
treat the condition with varying results. The women’s health physiother-
apist who encounters carpal tunnel syndrome in the postpartum period
could use exercise, elevation, positioning, ultrasound or ice.
MASTITIS AND These may not present in the immediate postpartum period. Non-infec-
BREAST ABSCESSES tive mastitis could arise if milk is not removed from the breast at the rate
at which it is produced, or as a result of an obstruction (e.g. blocked duct,
bruising following trauma or rough handling, or compression from fin-
gers holding the breast, or a tight brassiere). Incorrect positioning of the
baby could lead to ineffective breast emptying. Infection may occur
externally, in the skin, and reach the inner tissue of the breast via dam-
aged nipples. Unless mastitis is quickly treated, abscess formation requir-
ing surgical incision and drainage can result. Apart from pain and
redness or lumpiness in the breast, the woman may become pyrexial,
develop a rigor and feel quite ill. Gentle massage towards the nipple to
reduce lumpiness and encourage drainage can help relieve non-infective
mastitis. Ultrasound has been used apparently beneficially in the treat-
ment of these problems (Semmler 1982).
If surgery for a breast abscess is required, it is not thought necessary to
abandon breastfeeding. It can be continued on the affected side so long as
the position of the incision allows this. The baby may continue to feed
normally on the unaffected side (RCM 2003).
HAIR LOSS Hair is produced by hair follicles, which are epidermal structures. In the
scalp the growing phase for hair (anagen) lasts for up to 3 years. The rest-
ing phase (telogen) lasts for a few weeks, after which the hair falls out.
During pregnancy the number of hair follicles in telogen decreases and
the woman’s hair often seems thicker. After the baby is born, 3 to 4
months later the proportion of telogen follicles increases rapidly and
there can be much hair loss, leading to thinning. In most women this will
be temporary, and they will regain their scalp hair (Myatt 1988).
244 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
POSTNATAL For the 10% of all recently delivered women (Cox 1986) affected, the dis-
DEPRESSION turbing disorder of postnatal depression may not present until the baby
is several weeks old. Symon et al (2002) found that at 8 months’ postpar-
tum, physical issues were a ‘small’ issue, but social and psychological
issues were significant irrespective of age, parity or mode of delivery.
Carers should watch for signs of its presence in any woman who
expresses strong anxieties about herself or her baby, is sad and depressed,
feels unable to cope, and is overwhelmingly tired yet suffers from sleep
disturbances. The women’s health physiotherapist is ideally placed to
recognise this distressing condition, which can last for many months if
not recognised and treated. Appropriate support in the community can
decrease the prevalence of postpartum depression (Watt et al 2002). It is
worth noting that depression can present in different ways: physical
‘aches and pains’ (somatisation) may in fact be a cry for help.
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Journal of Obstetrics and Gynaecology 105(2):156–161. maternal morbidity. British Journal of Obstetrics and
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Cox J L 1986 Postnatal Depression. Churchill Livingstone, lactation on bone mineral content in healthy postpartum
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England. 1998–99 to 2000–01. Stationary Office, London. postpartum perineal pain and dyspareunia. Journal of
Dougherty M C, Bishop K R, Abrams R M et al 1989 The the Association of Chartered Physiotherapists in
effect of exercise on the circumvaginal muscles in Women’s Health 85:7–11.
The postnatal period 245
Physiotherapy Association. National Obstetrics and Toozs-Hobson P, Cutner A 2001 Pregnancy and childbirth.
Gynaecology Journal, July. In: Cardozo L, Staskin D (eds) Textbook of female
Signorello L B, Harlow B L, Chekos A K et al 2000 Midline urology and urogynaecology. Isis Medical Media,
episiotomy and anal incontinence: retrospective cohort London, p 486–487.
study. British Medical Journal 320:86–90. Wand J S 1989 The natural history of carpal tunnel
Smaill F, Hofmeyer G 2002 Antibiotic prophylaxis for syndrome in lactation. Journal of the Royal Society of
caesarean section. Cochrane Library. Update software, Medicine 82:349–350.
Oxford. Watkins Y 1998 Current concepts in dynamic stabilisation of
Snooks S J, Setchell M, Swash M et al 1984 Injury to the spine and pelvis: their relevance in obstetrics. Journal
innervation of the pelvic floor sphincter musculature in of the Association of Chartered Physiotherapists in
childbirth. Lancet, ii:546–550. Women’s Health 83:16–26.
Snooks S J, Swash M, Henry M M et al 1985 Risk factors in Watt S, Sword W, Krueger P et al 2002 A cross sectional
childbirth causing damage to the pelvic floor innervation. study of early identification of postpartum depression:
British Journal of Surgery 72(suppl):515–517. Implications for primary care providers. BMC Family
Symon A, MacDonald A, Ruta D 2002 Postnatal quality of Practice 113:5.
life assessment: introducing the mother generated index. Wellock V 2002 The ever widening gap – symphysis
Birth 29(1):40–46. pubis dysfunction. British Journal of Midwifery
Thompson J F, Roberts C L, Currie M et al 2002 Prevalence 10(6):348–353.
and persistence of health problems after childbirth: Winnicot D W 1987 Babies and their mothers. Addison-Wesley,
associations with parity and method of birth. Birth New York, p 93.
29(2):83–94.
Further Reading
Henchel D, Inch S 2000 Breast feeding: a guide for midwives, Price F V 1990 Report to parents of triplets, quads and quins.
2nd edn. Butterworth Heinemann, Oxford. Child Care and Development Group, University of
Linney J 1983 Multiple births: preparation – birth – Cambridge.
managing afterwards. John Wiley, Chichester. Price J 1988 Motherhood – what it does to your mind.
Livingstone L 1998 Women’s health: a textbook for Pandora, London.
physiotherapists. W B Saunders, London. Sweet B, Turan D (eds) 1997 Mayes’ midwifery, 12th edn.
MacLean A D, Cardozo L 2002 Incontinence in women. Ballière Tindall, London.
RCOG Press, London.
Nielsen C A, Sigsgaard J, Olsen M et al 1988 Trainability of Symphysis Pubis Dysfunction leaflet, published by ACPWH,
the pelvic floor. Acta Obstetrica et Gynecologica obtainable from Professional Affairs, CSP, 14 Bedford
Scandinavica 67:437–440. Row, London WC1R 4ED.
Useful addresses
Association of Breastfeeding Mothers Episiotomy Support Group
PO Box 207, Bridgewater, Somerset TA6 7YT 232 Ifleld Road, West Green, Crawley,
Email [email protected] West Sussex RH11 7HY
PMS & PND Support Foundation for the Study of Infant Deaths
c/o University St, Belfast BT17 1HP Artillery House, 11-19 Artillery Row, London SW1P 1RT
Email [email protected] Website: www.sids.org.uk
Chapter 8
The climacteric
Pauline Walsh
CHAPTER CONTENTS
Introduction 249 Sexuality in the climacteric 253
Physical symptoms 251 Postmenopausal problems 254
Psychological and emotional symptoms 253
INTRODUCTION
The term menopause is used for the last menstrual flow experienced by a
woman, and can be judged only retrospectively. The menopause occurs at
some time between the ages of 45 and 55 years, with a mean of 50 3⁄4 years
(Rymer & Morris 2000). Age at menopause is remarkably consistent world-
wide, but there are variations with race, economic status and nutrition.
For example, in India, on anecdotal grounds, menopause occurs about
3–5 years earlier (IMS 2002) than in Europe; women living at high alti-
tudes tend to have an earlier menopause and cigarette smoking reduces
menopausal age by almost 2 years (Spector 2002). Regardless of these fac-
tors, a few women experience a premature menopause before 40 years.
Menstruation may stop suddenly, or may be heralded by menstrual
periods becoming more closely or more widely spaced. Alternatively a
single menstruation, then two or three consecutive ones, may be missed,
the flow may vary from cycle to cycle, or the flow may become progres-
sively less with successive cycles. It is important for women to be able to
discriminate between these normal variations and signs of disease. For
example, bleeding that occurs more than 1 year after the menopause is
known as postmenopausal bleeding, and may be indicative of pathology.
Any such bleeding must be investigated. Prior to the actual menopause,
250 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
M
E
N
O
Premenopause P Postmenopause
A
U
S
E
Perimenopause
who are distressed by their loss of fertility. They experience some or all of
the following: hot flushes, night sweats, vaginal soreness, dyspareunia,
urinary disorders, dry skin, reduced concentration, loss of memory,
inability to make decisions, anxiety, mood swings, irritability, tiredness
and depression. Such unpleasant symptoms may begin premenopausally
and can continue for several years after the menopause. Increasingly,
doctors are administering hormone replacement therapy (HRT) through
the worst of the unpredictable undulations in hormonal levels, with the
option of gradually withdrawing therapy when body levels have sta-
bilised. This usually prevents the worst of the symptoms, but some dis-
comfort may be experienced when treatment stops.
Women who have a hysterectomy before their natural menopause but
who retain at least one functioning ovary will cease to menstruate immedi-
ately but will not experience other menopausal symptoms until the ovaries
naturally stop functioning. However, even with ovarian conservation,
symptoms of oestrogen depletion are likely to become evident following
hysterectomy (Khastgir & Studd 1998); the mechanism of this premature
ovarian failure following hysterectomy is poorly understood, but it may be
that circulation to the ovaries is compromised during surgery. If the ovaries
are surgically removed or a woman has therapeutic irradiation of the pelvis
she will experience an abrupt menopause, and severe climacteric symp-
toms may occur immediately and last for an indeterminate period. Since
bilateral oophorectomy results in depletion not only of oestrogen, but also
of endogenous androgens, women who undergo this procedure may
become aware of a loss of confidence, energy, drive and libido, all of which
are influenced by the presence of circulating testosterone.
PHYSICAL SYMPTOMS
HOT FLUSHES AND Flushing and sweating occur, usually over the upper chest, neck and face.
NIGHT SWEATS Sometimes this is triggered by a stressful situation, a hot drink or hot,
spicy food; often, however, there is little or no apparent reason for these
embarrassing and inconvenient events, which may happen occasionally
or many times a day. The pulse rate rises and there may be palpitations. In
addition (or alternatively) women may waken in the night soaked in per-
spiration, often needing to change their nightwear. These symptoms are
known to be associated with low or falling levels of oestrogens in the
blood, and may also be due to temporary rises in the levels of FSH and
LH. They are certainly alleviated by HRT but may return as soon as it is
stopped; for most women they will disappear, or diminish significantly,
over time. The cause of this vasomotor instability is complex and unclear
(Bachmann 2001) and severity varies widely between individuals.
VAGINAL SORENESS – Vaginal and cervical secretions are decreased and become less acid; the
ATROPHIC VAGINITIS vaginal lining becomes thin, dry and less elastic. As a result, the vagina
becomes more prone to infection and vulnerable to soreness, irritation,
252 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
URINARY DISORDERS Oestrogen receptors are present in the vagina, urethra, trigone and the
pelvic floor (Hextall 2000). It is widely accepted that urogenital problems
are associated with vaginal delivery (Wilson et al 1996), predisposing a
woman to the development of urinary incontinence (stress and/or urge)
or prolapse, or both. Toozs-Hobson (1998) suggests that vaginal delivery
may not be the only culprit, but that pregnancy itself may have some
causal significance. Although these disorders may develop at any time,
symptoms commonly present, or are exacerbated, at menopause when
declining ovarian function results in oestrogen depletion. Atrophy,
inflammation and infection of the vagina may have secondary effects on
the urethra and bladder. The vagina and urethra have a common embryo-
logical origin, both arising from the primitive urogenital sinus, and
the presence of atrophic vaginitis suggests a concomitant urethritis. Oes-
trogen deficiency may have a role to play in atrophy of the trigone and
associated supportive ligaments, and has been shown to result in a reduc-
tion in turgidity of the cells forming the urethra. These facts should be
borne in mind if a woman complains of cystitis, urethritis, frequency,
urgency and dysuria following the climacteric; this cluster of urogeni-
tal symptoms which presents postmenopausally is known as urethral
syndrome (Gittes & Nakamura 1996, Wesselmann et al 1997). Oestrogen
replacement may help to alleviate this problem.
DRY SKIN The majority of age-related changes in the skin are secondary to chronic
ultraviolet radiation exposure (Hawk 1998). There is also a reduction in
epidermal cell turnover rate (up to 50% reduction by the age of 70),
resulting in decreased ability of the skin to withstand and repair damage.
Although oestrogen receptors are present in the skin, the precise mechan-
ism by which, and the extent to which, this hormone is involved in pre-
venting the pathophysiological changes of skin ageing is unclear.
Maheux et al (1994) found that HRT administered to postmenopausal
women resulted in increased dermal thickness, and a study by Pierard et al
(1995) demonstrated improved dermal elasticity and deformability, and
therefore a preventative effect on skin slackness. Some early work by
Brincat et al (1987) found that the collagen content of skin was increased
by 48% in women receiving HRT compared with those who were not.
However, a more recent study, using oestrogen either alone or com-
bined with a progestogen, failed to show a change in the amount of skin
collagen or its rate of synthesis in postmenopausal women (Haapasaari
et al 1997). Nevertheless it does appear that the decrease in oestrogen
levels is partly responsible for the dryness, thinning and reduced elasticity
of skin, and that use of HRT has been shown to improve some of these
parameters (Bleiker & Graham-Brown 1999).
The climacteric 253
Women blame the menopause for a great deal and complain of a variety
of psychological and emotional difficulties. It is known that cholinergic
neurons within the brain contain oestrogen receptors, and that a declin-
ing oestrogen level in postmenopausal women is likely to contribute
to impaired cognitive performance and increased incidence of dementias
(Genazzani et al 1998, Perry 1998). It is unsurprising that women report a
general loss of well-being and diminished quality of life, since this sex
steroid has a role to play in numerous physiological functions within the
body. Many women experience an improvement in their psychological
well-being after starting oestrogen therapy, although it should be noted
that most double-blind placebo-controlled trials demonstrate a large
placebo effect (Rees & Purdie 2002). It is worth considering, too, the other
life stresses the average woman experiences through her late 40s and early
50s. For example, a mother’s role has to change considerably as children go
through teens and leave home, and the behaviour of some children causes
huge stress; partners may seek other relationships, become ill or even die;
redundancy or early retirement of self or partner alters status; and older rela-
tives may need increasing time and support. These and other normal life
events may well affect a climacteric woman. Gaining insight into the whole
picture, understanding stress and having a selection of coping strategies
may enable the woman to come to terms with these many, and sometimes
very distressing, changes in her life – perhaps obviating the need for HRT.
Some couples, as they age, may find that the physical aspect of their
relationship becomes less important and that they are happy to enjoy
shared interests and companionship. Other couples remain sexually
active into old age, each enjoying their physical relationship. However,
many couples experience problems and, sadly, some men place the blame
for their difficulties in sexual performance on their partner, further
undermining her confidence. This is not an easy area to address, since a
man may interpret any allusion to there being difficulties relating to his
performance rather than to his partner’s as an assault on his very man-
hood. If the lines of communication can be maintained, a woman, with
understanding, sympathy and without attributing blame, may be able to
persuade her partner to seek help, because treatment is available for
many of the causes of male sexual dysfunction. The adoption of a health-
ier lifestyle may result in improvement: for example, reducing alcohol
intake, giving up smoking, taking moderate exercise including PFM exer-
cises (Dorey 2003), and perhaps learning relaxation techniques, which will
help in reducing stress; a review of medication might be appropriate; and
some couples are likely to benefit from relationship or psychosexual coun-
selling. There is also available a range of medical options, including oral
agents, surgery and a number of prosthetic devices (Kalsi et al 2002). If her
partner refuses to seek help, as is often the case, a woman may need pro-
fessional support; physiotherapists are good, non-judgmental listeners,
but need to be aware of their limitations in this field, and of the sources of
help that are available. (see Ch. 9 and Useful Addresses, p. 267).
POSTMENOPAUSAL PROBLEMS
Prevention of Box 8.1 shows the risk factors associated with osteoporosis. Prevention
osteoporosis begins in childhood with the establishment of a healthy lifestyle, and
the most significant aspects of this are diet (particularly calcium and vita-
min D intake) and exercise. The bone mineral status of children aged 2–16
Reduction of fracture risk Kannus et al (2000) have found that patients who are wearing hip protect-
ors at the time of a fall reduce their risk of hip fracture by 80%. However,
these have not proved popular with patients, since the size of the pads
creates a bulging appearance to both hips. Research is under way to
develop materials which have similar shock-absorbing properties but are
less bulky in size (Dubey et al 1998).
Falls are a particular problem in the elderly; with ageing comes vestibu-
lar impairment and loss of the righting reflex, so that the demands of a
changing environment cannot be met – for example, a slippery or uneven
surface (Hobeika 1999). Eyesight also deteriorates and avoiding obstacles
becomes more difficult. If urinary urgency is present, trying to reach
appropriate facilities quickly may precipitate a fall (Brown et al 2000,
Canadian Consensus Conference 2000). There may be articular changes
owing to a decrease in collagen content of ligaments and articular soft tis-
sues (Whitehead & Godfree 1992); an overall reduction in muscle mass,
with a decrease in both strength and endurance of muscle tissue, results in
an increased risk of falling. Eastell & Lambert (2002) suggest that a lack of
dietary protein contributes both to impaired bone mineral conservation
and an increased propensity to fall. Sleep patterns and response to medi-
cation (e.g. sedatives) are altered in ageing, and these factors, together
with an increase in nocturia, significantly increase the risk of falls at night
(Martin et al 1999). It may be necessary to supply an appropriate walking
aid, and it is important to ensure, as far as possible, that an elderly person
is in a safe environment in which the risk of falling is minimised.
Exercise Exercise has a vital role to play in the prevention and the management of
osteoporosis; during recent years, researchers have looked at different
exercise regimens and their effect both on prevention of falls and on bone
mass. It is suggested that women who experience frequent vasomotor
symptoms run a greater risk of balance disturbances, and therefore an
increased tendency to fall, than do women without symptoms (Ekblad
et al 2000).
260 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Province et al (1995) state that there are documented benefits from hav-
ing the mode of exercise incorporate movement for balance and flexibility,
both of which are major factors in fall prevention. Weight-bearing exercise
is popularly cited as the most valuable type of exercise for maintaining,
and perhaps increasing bone mineral, and this mode of exercise certainly
has a place. It is more appropriate, however, to refer to bone-loading exer-
cise, which may not necessarily be weight bearing. Low repetitions with
resistance (loading) are more effective than high repetitions with minimal
or low loading. Kerr et al (1996) state that exercise effects on bone mass in
postmenopausal women are site specific and load dependent.
The Chartered Society of Physiotherapy, in conjunction with the
National Osteoporosis Society, has produced a comprehensive document
(CSP/NOS 1999) on the management of osteoporosis, and consultation
with this document is required in order to make informed clinical deci-
sions. Exercise must be tailored to the individual, taking into account
bone mineral status, and these guidelines recommend in detail the man-
agement of three distinct target groups who are at different stages of the
disease. New research shows HRT is associated with an increased risk of
incident and fatal breast cancer (Beral 2003).
Pharmacological There is now a wide range of drugs which are licensed for the prevention
management and treatment of osteoporosis. Initial assessment of the patient includes a
review of diet, and if there is deficiency of calcium or vitamin D, or both,
supplementation will be required.
Hormone replacement There is strong evidence that long-term HRT is effective in reducing bone
therapy turnover by inhibiting osteoclast activity (Delmas et al 2000, Peel 2002, WHI
2002) and, unless there are contraindications to its use, it is the treatment of
choice (Iqbal 2000). In addition to its bone-sparing effects, there are other
well-documented benefits mentioned previously, which may enhance a
postmenopausal woman’s quality of life. However, HRT is not without cer-
tain risks: there is an increased incidence (although not mortality) of breast
cancer with duration of use, with a relative risk (RR) of more than 2 after
10 years’ therapy (Magnusson et al 1999), and the incidence of venous
thromboembolism is increased from 1 in 10 000 to 3 in 10 000 (Hulley et al
1998). Although the following regimen is no longer prescribed, unopposed
oestrogen in a non-hysterectomised woman increases the risk of endome-
trial carcinoma, and even with the addition of a cyclical progestogen this
risk is not reduced to unity; only with continuous combined oestrogen and
progestogen (CCEP) is the endometrium fully protected. Recent studies
have examined the association between oestrogen and ovarian cancer and
there are suggestions that there may be a link (Lacey et al 2002). The issue
remains unresolved, however, and requires further examination.
It is vital that the decision on whether or not a woman should take
HRT be made on an individual basis; each woman should be assessed,
informed, and allowed time to ask questions; her particular risk–benefit
profile should be explained fully to her, and her preferences taken into
account. There are many women for whom oestrogen replacement is
The climacteric 261
Non-HRT drug therapies All drug therapies which are recommended for the treatment of osteo-
porosis (including HRT) are antiresorptive, that is, they produce a
decrease in activation frequency of new remodelling sites by inhibiting
osteoclast activity. This allows infilling of the remodelling space, which is
reflected in a small increase in measured bone mineral density of 5–10%
over the first 2 years of treatment (Wasnich & Miller 2000).
Bisphosphonates This group of drugs includes etidronate, alendronate
and risedronate; the latter two appear to be the more effective at reducing
fracture risk (Black et al 1996, Harris et al 1999). They are characterised
by highly selective localisation and retention in bone, but unfortunately
demonstrate poor intestinal absorption. For this reason, they must be
taken during fasting, making compliance difficult for some patients.
Alendronate has recently become available in a once-weekly dose, which
should prove to be a more acceptable option. Bisphosphonates are now
the first choice of treatment for women unable or unwilling to take HRT.
Selective oestrogen receptor modulators (SERMS) Raloxifene is a
recent and second generation SERM (the first being tamoxifen). Its
advantage is that it is tissue specific: it has an oestrogen-agonist effect on
bone and the serum lipid profile, but an oestrogen-antagonist effect on
breast and endometrial tissue. Although it was not a primary end-point
in the trials, results demonstrated an unexpected 70% decrease in breast
cancer incidence. Prospective RCTs to examine this apparent reduction in
risk of breast cancer need to be undertaken. Although raloxifene reduces
the risk of vertebral fractures, it does not appear to have the same benefi-
cial effect on non-vertebral fractures; neither does it prevent the psycho-
logical or vasomotor symptoms of menopause. In fact, it may worsen the
latter, so it is not an appropriate choice of therapy for women who are
still experiencing climacteric symptoms.
Tibolone This is a synthetic steroid with oestrogenic, progestogenic and
androgenic effects; it is licensed for osteoporosis prevention and may be
used to treat the vasomotor, psychological and libido problems of the cli-
macteric. It is not appropriate for the perimenopausal woman, in whom
it may cause breakthrough bleeding, but for a woman who is at least 1
year past menopause it is an effective non-bleed regimen.
Calcitonin Calcitonin is a polypeptide hormone, which, although not
as effective in its antiresorptive action as other agents, has been shown to
reduce vertebral fracture risk (Kanis & McCloskey 1999). It may be
administered as a nasal spray or subcutaneously, but its use is limited by
unpleasant side-effects (nausea, diarrhoea, flushing). However, it does
have analgesic properties, which make it a useful short-term therapy in
patients with an acutely painful vertebral fracture.
Other non-oestrogen-based treatments There are several other drugs
which are available but are, at present, less frequently used for preven-
tion and treatment of osteoporosis. Parathyroid hormone (PTH), in combin-
ation with HRT, may be used in the initial treatment of women who
present with severe osteoporosis, although its precise mode of action in
264 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
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Maheux R, Naud F, Rioux M et al 1994 A randomised, Toozs-Hobson P 1998 Pelvic floor ultrasonography: the
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osteoporosis – indications for bone densitometry. Weidner, W, Altwein J, Hauck E et al 2001 Sexuality of the
National Osteoporosis Society, p 5. elderly. Urology International 66(4):181–184.
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which agent at what age. Journal of the British and rectal pain syndromes. Pain 73:269–294.
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PEPI 1996 Writing group for the PEPI trial. Effects of estrogen plus progestin in healthy postmenopausal
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the Postmenopausal Estrogen/Progestin Interventions Initiative Randomized Controlled Trial. Writing Group
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275:1389–1396. of the American Medical Association 288(3):321–333.
The climacteric 267
Whitehead M, Godfree V (eds) 1992 Consequences of months after delivery. British Journal of Obstetrics and
oestrogen deficiency. Hormone replacement therapy: Gynaecology 103:154–161.
your questions answered. Churchill Livingstone, WISDOM 2002 Women’s international study of long
Edinburgh, p 13–36. duration oestrogen after menopause. Medical Research
Wilson P D, Herbison R M, Herbison G P 1996 Obstetric Council Expert Panel. WISDOM, London.
practice and the prevalence of urinary incontinence three
Further reading
Bain C, Lumsden M A, Sattat N et al 2003 The menopause in Lobo R 2000 Menopause: biology and pathobiology.
practice. Royal Society of Medicine Press, London. Harcourt Brace, London.
Barlow D, Wren B 2003 Fast facts: menopause. Health Stewart D E, Robinson G E 1997 A clinician’s guide to
Press/Plymbridge Distributors, Plymouth. menopause. American Psychiatric Publishing, Arlington
CSP/NOS (Chartered Society of Physiotherapists/National VA.
Osteoporosis Society) Physiotherapy guidelines for the Woolf A 2002 The osteoporosis pocket book. Martin Dunitz,
management of osteoporosis. CSP London. London.
Henderson J E 2000 The osteoporosis primer. Cambridge Woolf A D, St John Dixon A 1998 Osteoporosis: a clinical
University Press, Cambridge. guide, 2nd edn. Martin Dunitz, London.
Useful addresses
Amarant Trust Institute of Psychosexual Medicine
A charity for women going through the menopause 12 Chandos Street, Cavendish Square, London W1G 9DR
The Amarant Trust Tel 0207 580 0631
Sycamore House, 5 Sycamore Street, London EC1Y 0SG Website: www.ipm.org.uk
Chapter 9
Common gynaecological
conditions
Jeanette Haslam
CHAPTER CONTENTS
Introduction 269 Further gynaecological conditions of relevance
Gynaecological health 269 to the physiotherapist 287
Gynaecological disorders 271 Sexuality 300
INTRODUCTION
GYNAECOLOGICAL HEALTH
BREAST AWARENESS Being breast aware means being aware of what is normal for yourself and
being able to detect anything that is unusual. A practice nurse sometimes
teaches breast awareness in the community-based well women clinics,
where early detection and treatment of disease, prevention and health
promotion are the chief objectives. However, it is acknowledged that the
woman herself is best placed to detect changes in her own breast tissue.
There are four stages of awareness often advocated. These are:
1. Observe any changes in appearance when standing in front of a mirror.
(Look for any changes in the outline or size of the breasts, changes in the
nipple position, shape or discharge, puckering or dimpling anywhere in
the breasts, changes in skin texture, colour or a rash, constant pain in one
part of the breast or axilla.)
2. Hands on hips, press down and tense the chest muscles; this will make
changes easier to see.
3. With hands and arms raised above the head, observe particularly the
upper tail of the breast towards the axilla.
4. Finally, palpate each breast in turn using the opposite hand spread flat,
with the hand on the breast side placed behind the head. Using gentle
pressure in a circular motion with the pads of the fingers, check the
whole breast to detect any lump or thickening in the breast. This may
be best done either lying flat on the bed or with a soapy hand in the
bath or shower.
If any changes are observed, an appointment should be made with the
GP for them to determine if a breast clinic appointment is necessary.
PHYSICAL CHECK-UPS A visit to a women’s health clinic is increasingly seen to be the ideal
opportunity for a regular physical check, which may realistically include:
CERVICAL CYTOLOGY All sexually active women are at risk of squamous cell carcinoma. It is rec-
ommended that a woman should have her first cervical smear at the age
of 20 years with 3-yearly follow-up until the age of 65 years (Symonds &
Symonds 1998). As a member of the well women or gynaecological team
Common gynaecological conditions 271
GYNAECOLOGICAL DISORDERS
The most common disorders of the female genital tract can be classified
as infections, cysts and new growths, or displacements and genital
prolapse.
INFECTIONS Full heed must be paid to infection control procedures with universal
precautions being taken at all times. When intimately examining a
woman, heed should always be paid to any visible abnormalities that
may be infectious in nature. If any such lesions are observed it is wise to
take medical advice before proceeding with a vaginal examination.
Vulva The continuous moist discharge from glands in the vulva supplemented
by that from the uterus, vagina and cervix, together with traces of urine
Vulvitis and faecal material, ensure that there is always a profusion of microor-
ganisms in the perineal area. Infection may track up the vagina or may
have tracted from it; thus vulvitis often becomes vulvovaginitis. It is sug-
gested by some that the wearing of nylon tights, the habitual wearing of
272 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
• Squamous VIN
• VIN I mild dysplasia
• VIN II moderate dysplasia
• VIN III severe dysplasia and carcinoma in situ
• Non-squamous VIN
• Paget’s disease
• melanoma in situ.
Infectious organisms Infections of the vulva may be fungal, bacterial, viral or parasitic.
Fungal Candida albicans is frequently implicated in vulvitis in preg-
nancy, especially if the renal threshold for glucose becomes lowered. It
is a yeast-like fungus, commonly called ‘thrush’, that flourishes in any
warm, moist mucous surface in an acid environment, especially in the
presence of glucose (Murray 1997). It is characterised by irritation, acute
inflammation, rawness and a curdy, white discharge; the vagina is often
also infected. The usual treatment is with Nystatin or Canestan vaginal
pessaries or cream. Other factors that have been implicated in both the
initial and recurrent disease are antibiotics, corticosteroids, immunosup-
pressive treatment, diabetes, orogenital contact and the presence of other
sexually transmitted diseases (Adler 1990a). If a woman is having recur-
rent symptoms, her sexual partner should also be investigated for canda-
diasis and treated appropriately if it is present.
Bacterial Staphylococcus bacteria infect sebaceous glands and hair fol-
licles on the perineum causing boils; gonorrhoea and syphilis are other
infections that may affect this area.
Common gynaecological conditions 273
Viral Human papilloma virus (HPV) is the cause of common warts of the
hands and feet as well as lesions of the genital area. As such it is one of
the most commonly sexually transmitted viruses. They can be treated by
cryotherapy or diathermy. They may be transient in nature but are poten-
tially serious in nature as HPV type 16 and 18 are carcinogenic and others
are reported to have a role in cervical carcinogenesis (Kjaer et al 2002).
HPV-18 is the type most strongly associated with adenocarcinoma of the
cervix (Woodman et al 2003). A Danish study followed up 10 758 cyto-
logically normal women aged 20–29 years for development of cytological
abnormalities (Kjaer et al 2002). It was found that infection with HPV
at enrolment predicted future development of high-grade squamous
intraepithelial lesions. Those women who were positive on repeated test-
ing were at greatest risk of high-grade cervical neoplasia lesions.
Genital herpes is a sexually transmitted viral infection which has been
linked with cervical cancer. Annual cervical cytology is recommended for
all women with this condition. It is a serious problem in pregnancy,
where it can cause abortion, and elective caesarean section may be indi-
cated if the mother has active herpes at term; otherwise the foetus could
become infected at delivery and subsequently die or suffer neurological
damage (see p. 46).
Parasitic Parasites such as lice can be transmitted from head hair to pubic
hair and can cause perineal irritation. Pediculosis pubis may have symptoms
of vulval irritation and is caused by infestation by the pubic louse.
Scabies is caused by a mite in which the female burrows into the upper
layer of the skin; laying eggs and defaecating. They are transmitted by
close but not necessarily sexual contact. They cause severe irritation and
itching, especially at night-time (Adler 1990b).
Vagina The Bartholin’s glands are located on the posterior and lateral aspect of the
vestibule of the vagina; the duct of each is narrow and easily becomes
blocked. If this occurs mucoid secretions distend the gland, forming an
often painless cyst. This may become infected forming an abscess, or an
infection of the gland can occur independently of any duct narrowing;
any such infection is excruciatingly painful. Cultures should be per-
formed as Gonorrhoea may be a cause of Bartholin’s abscess.
Gartner’s ducts are found lateral to the vagina and may cause problems
with dyspareunia if they become infected; they are usually treated by
incision.
Infectious organisms Organisms that commonly cause infective vaginal discharge are:
Cervix Erosions of the cervix are quite common; they can be infected but usually
are not. Normally, columnar epithelium partly or completely lines the
Cervicitis cervical canal and butts on to the stratified squamous epithelium which
lines the vagina and covers the vaginal aspect of the cervix. Where there
is an erosion, columnar epithelium appears to replace some of the cer-
vical stratified epithelium. Erosions sometimes appear in pregnancy and
in women taking oral contraceptives; they are rarely seen after the
climacteric and improve when oral contraceptives are discontinued. This
suggests a hormonal factor. Infections of the cervix are commonly caused
by sexually transmitted organisms such as Gonococcus or C. trachomatis,
and may follow trauma such as that which can occur at childbirth,
abortion or as a result of operative procedures requiring dilatation of
the cervix.
Acute cervicitis usually occurs associated with a generalised infection
of the genital tract. There may be purulent discharge, low back pain,
abdominal pain, dysuria and dyspareunia. The treatment depends on the
organism causing the infection.
Chronic cervicitis is extremely common, often with minimal sympto-
mology. However some women have more severe symptoms, such
Common gynaecological conditions 275
Uterus Infections of the uterus with resulting endometritis are less common
than those of other areas of the genital tract by virtue of the protection
Endometritis afforded by the vagina and cervix – that is, the length of the vagina, the
downward movement of secretions, the constriction formed by the cervix
and the viscosity for much of the time of its secretions – and also by the
cyclic shedding of the endometrium. However, infections do track
upwards. It is possible that sperm can act as carriers, the tails of intrauter-
ine devices have been implicated, and after delivery or abortion, the open
placental site, the lochia or retained products of conception all potentially
provide a superb culture medium. Any medical procedure that opens the
cervix has the potential to introduce infection.
Fallopian tubes Infection of the fallopian tubes, which is often associated with infection
of the ovary (salpingo-oophoritis), may result from ascending infection
Salpingitis but can also occur following infection of the gut or other abdominal
organs. Salpingitis may be acute or chronic and can be a cause of infertil-
ity (e.g. ectopic pregnancy) when scarring and adhesions block the tube,
or damage muscle and cilia.
The principal organisms causing acute salpingitis are the sexually
transmitted N. gonorrhoeae or Chlamydia. The symptoms can include low
abdominal pain, purulent vaginal discharge, pyrexia, vomiting and diar-
rhoea; the signs can include tachycardia, signs of peritonitis and acute
pain on pelvic examination (Symonds & Symonds 1998).
PELVIC The close proximity of structures particularly within the true pelvis, and
INFLAMMATORY their interconnection via ligaments and peritoneum, means that infection
DISEASE is able to spread to involve other organs and produce what is known as
pelvic inflammatory disease (PID). It is a combination of infection of
the fallopian tubes, ovaries and peritoneum and may be a cause of
ectopic pregnancies. In the UK a variety of bacteria can be responsible for
PID, but C. trachomatis is the commonest cause, and N. gonorrhoeae and
Mycoplasma hominis are frequent causes. Such infections may occur inde-
pendently or concurrently, and are sexually transmitted. Since the United
Kingdom Health Statistics (Office for National Statistics 2001) show that
the annual number of new cases of Chlamydia continued to rise in the
period 1991–1999 from 622.5 to 1077.3 per million women, it is probable
that the number of cases of PID is also rising.
The infection causes inflammation, and the body’s response in the
highly vascular pelvic area is the production of adhesions (sometimes
profuse) and scarring, which contort structures and glue or bind them to
adjacent ones. In the acute phase women complain of pelvic or abdom-
inal pain and of feeling thoroughly unwell; they may even be pyrexial.
Sometimes there are difficulties in achieving an accurate clinical diag-
nosis owing to the problems in obtaining a sample from the infection
site and because the accuracy of tests has been poor. Consequently the
276 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
ACQUIRED IMMUNE AIDS is caused by a virus known as the human immunodeficiency virus
DEFICIENCY (HIV). Infected persons carry the virus in body fluids, and may be fit and
SYNDROME (AIDS) well for varying lengths of time. HIV is transmitted during intimate sex-
ual contact, or through direct contact via mucous membrane or broken
skin with infected blood or genital secretions from a carrier in any other
circumstances. The virus can be transmitted to the foetus across the pla-
centa and is present in the amniotic fluid of HIV carriers (see p. 46). The
infection is diagnosed by the presence in blood samples of the appropri-
ate antibodies. However, there is a time lag of months or years between
acquiring the infection and developing antibodies. It is not yet known
what determines if and when a carrier will develop the syndrome.
Common gynaecological conditions 277
CYSTS AND NEW The term ‘cyst’ usually signifies a pathological fluid-filled sac bounded by
GROWTHS a wall of cells. The fluid is often clear and colourless, and may be secreted
by the cells lining the cyst or derived from the tissue fluid of the area.
Cysts There are cysts peculiar to each organ, and these may be congenital or
acquired. Congenital cysts occur in vestigial remnants of embryonic tis-
sue; they are common in the genitourinary tract and the broad ligament
is a frequent site. Acquired cysts may be caused by obstruction to the out-
flow of a duct and consequent retention of secretions (e.g. Bartholin’s
gland). Alternatively, distension cysts form in natural enclosed spaces;
they are common in graafian follicles and corpora lutea.
Benign tumours Benign tumours are formed by a mass of well-defined cells, which are still
recognisably similar to the originating tissue, and the mass is encapsu-
lated by a layer of normal cells so the tumour cells cannot escape. Benign
tumours tend not to be troublesome and do not generally threaten life.
Malignant tumours By contrast, the cells of malignant tumours show varying degrees of
reversion to the embryonic unspecialised state, and look less like the
original cells. They seem to lose control of cell division and divide repeat-
edly; they are less differentiated and lose the specialist function of their
parent cell. They have no containing capsule and so invade surrounding
tissue. Highly malignant cells lose the mature cell’s adhesiveness to its
neighbours, and regain the embryonic cell’s ability to detach and migrate
to form secondary deposits or metastases. They also have the ability to
stimulate the growth of new blood capillaries around and within the
growing cell mass, ensuring an adequate supply of nutrients. Thus
malignant tumours tend to be life threatening until successfully treated.
Gynaecological cancers have been classified and clearly defined in
stages by the International Federation of Gynaecology and Obstetrics
(FIGO). The most recent definitions with the relevant papers are obtain-
able on www.figo.org.
Bartholin’s glands In the sebaceous and Bartholin’s glands of the perineal area, benign cysts
can result from blockage of the ducts. They are of little significance unless
they become large or infected. Cysts may be excised and the ducts
opened (marsupialisation).
Vagina Cysts, and benign and malignant tumours can occur; carcinoma of the
vagina is rarely primary but most commonly spreads down from or via
the cervix. It may then involve the rectum and other tissues and be very
difficult to treat.
Uterus and cervix The most common benign tumour of the genital tract, found in 15–20%
of women over 35 years of age, is the so-called ‘fibroid’, which grows on
Benign tumours or within the wall of the uterus or cervix. In that it usually consists of
unstriped muscle as well as fibrous tissue, the term ‘fibromyoma’ is more
accurate. In the mature women, one or more fibroids of the uterus, with
accompanying heavy menstrual bleeding (menorrhagia), are grounds for
considering hysterectomy once childbearing is complete. In less severe
cases myomectomy may be sufficient. Fibroids vary hugely in size and
number and may develop on a pedicle, in which case the name ‘polyp’ is
more appropriate. They are uncommon in those under 20 years old but
then are found most often in the nulliparous, possibly because they are
causes of infertility and miscarriage. They occur three times more fre-
quently in black women than in white women, although the reason for
this is unknown.
In general fibroids grow slowly, and may atrophy following the meno-
pause; they are prone to secondary degenerative changes such as hyaline
degeneration, fatty degeneration and even calcification, all probably
associated with gradual inadequacy of the blood supply to a particular
Common gynaecological conditions 279
fibroid. In pregnancy they tend to hypertrophy, may cause pain, and may
be actually palpable and visible under the skin of the woman’s distended
abdominal wall in the third trimester. One particular type of degeneration –
red degeneration – occurs most commonly in pregnancy, although it can
occur at other times. This is the result of a rapidly renewed blood supply to
a fibroid that has previously undergone some fatty degeneration, resulting
in a degree of haemolysis and giving a local appearance of raw meat.
The abdominal pain it causes can be alarming for the mother-to-be, but
reassurance and palliative treatment only is required.
Malignant tumours Cervix Malignant tumours of the cervix most commonly arise in women
between 45 and 55 years of age, but are apparently increasing among
younger women. Almost all sufferers will have had sexual intercourse,
but there is a more potentially significant correlation with those women
who began to be sexually active very early and who have had several sex-
ual partners. Once sexual activity has been commenced a woman must be
encouraged to have regular cervical smears taken. Precancerous dysplasic
changes in the cervical epithelium, if recognised, can be treated and the
development of cancerous changes prevented.
Established carcinoma of the cervix is classified in stages by FIGO
(Benedet et al 2001):
In the UK about 4000 new cases of invasive cervical cancer are diagnosed
each year. Cauterisation, cryosurgery and laser treatment effectively
destroy tissue, and constitute conservative treatments suitable for women
with early cervical changes (CIN 1). Cone biopsy may be used for CIN 2
and 3 (see p. 313).
The more serious stages of cervical carcinoma may be arrested and
usually cured by radiotherapy or surgery, or a combination of the two.
The surgery used is hysterectomy, extended where necessary. Surgery
particularly for stage i cervical carcinoma may be preceded by treatment
280 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Fallopian tubes Despite being prone to infections, the fallopian tubes rarely support a
primary carcinoma, although metastases or extensions of growths from
the ovaries, uterus or gut do occur. Primary carcinoma is a relatively silent
condition and therefore may either be found unexpectedly at surgery or
not diagnosed until the condition is advanced.
Cysts Follicular cysts are one of the most common types; most resolve spon-
taneously, while others can be surgically removed. Bleeding may occur into
cysts, and if present for some time the altered blood will become tar-like,
making the cyst look dark. Reports of surgery or laparoscopy may refer
to ‘chocolate’ cysts. ‘Oyster’ ovaries indicate that the ovaries may appear
enlarged, shiny and pearly; this is a sign of polycystic ovarian disease.
Cancer Amongst women who die of cancer of the genital tract, ovarian cancer is
the most common primary site, affecting about 4000 women per annum.
The overall lifetime risk for developing ovarian cancer is 1 in 120 for the
general female population. However, women with a first degree relative
with a history of ovarian cancer before the age of 50 years have an
increased risk at 1 in 40. If there are two affected first degree relatives this
becomes a 1 in 3 risk. Both ovarian and endometrial cancer occur more
often in families with breast or bowel cancer. Women in such families
need to be particularly vigilant and avail themselves of any screening
and family genetic counselling (Redman 1997). A major problem in early
detection is that it is a silent cancer, often without symptoms until the
tumour has extended into the peritoneum. In an attempt to combat this,
voluntary ovarian screening by ultrasound and blood test is being
offered in some centres. However unnecessary anxiety has been caused
in some cases by false positive results, not least because with ultrasound
scanning it is not easy to discriminate between benign and malignant
structures.
Common gynaecological conditions 281
pain, women often find that they need to take increasing amounts of time
off work.
Whatever the cause, it has been estimated that 10 million women in
the USA and 2 million women in Britain suffer with the condition.
Aetiology The cause is unknown but there are several theories as to how this condi-
tion arises (see Further Reading, p. 306):
1. The transportation theory. In 1921 John Sampson (cited in Brentkopf &
Bakoulis 1988) first used the term ‘endometriosis’. He postulated that
during menstruation there was reflux of endometrial debris and blood
through the fallopian tubes and into the peritoneal cavity; endometrial
cells could thus be deposited outside the uterus. In 1927 Halban (cited
in Brentkopf & Bakoulis 1988) suggested instead that fragments of
endometrium could be transported as emboli in veins and lymphatics.
2. The metaplastic theory. Meyer, (cited in Brentkopf & Bakoulis 1988) a con-
temporary of Sampson, suggested that repeated irritation (for example
due to recurrent infection) might cause cells derived from the same
embryological tissue as the endometrium to change and differentiate
abnormally. A similar theory suggests that a chemical substance, perhaps
environmentally derived, acts on cells outside the uterus causing them to
be transformed into endometrial cells.
3. Immune deficiency theory. A further hypothesis is that women with
endometriosis suffer from an immune deficiency such that the body
does not reject and dispose of endometrial cells if they become dis-
placed elsewhere in the body, as it would normally be expected to.
Treatment The fact that endometriosis runs in families supports this theory.
Pharmacological therapy In primary care the first treatments to be
considered should be non-steroidal anti-inflammatory drugs (NSAIDs)
and the combined oral contraceptive (Prentice 2001). The NSAIDs have,
however, the side-effect of possibly causing gastric irritation. Medical
treatment may be hormonal, aimed at producing a pseudopregnancy or
pseudomenopausal state of amenorrhoea. However some of the side-
effects – bloating, fluid retention, breast tenderness, nausea, seborrhoea,
acne, muscle cramps, weight gain and menopausal symptoms – are diffi-
cult to tolerate. Medical treatments have an 80–85% improvement rate for
symptoms but the efficacy is dependent on the patient’s ability to tolerate
side-effects. It has, however, been claimed that many women are not
treated adequately by laparoscopy because of the emphasis on medical
management (Jones & Sutton 2002); they recommend that medical care
should be used in primary care and then, only if unsuccessful, should
patients be referred to a surgical unit.
Investigations It is recommended that women presenting with pelvic
pain, dyspareunia or dysmenorrhoea should have a transvaginal or
abdominal ultrasound examination (Amso 2002).
Surgery It is desirable to be referred to a unit where laparoscopic diag-
nosis and surgery can be carried out during the same operation. The
laparoscopic surgery may be conservative, excisional or ablative, depend-
ing on the findings (Jones & Sutton 2002).
Common gynaecological conditions 283
DISPLACEMENTS AND The word ‘prolapse’ is from the latin prolapsus, meaning a slipping forth
GENITAL PROLAPSE (Thakar & Stanton 2002). Therefore genital prolapse refers to a slipping
of one of the pelvic organs into a displaced position. The woman may or
may not be symptom free, depending on the severity of the displace-
ment. Samuelsson et al (1999) reported that the symptomology and clin-
ical findings may not correlate well. It has been reported that 20% of
those on a waiting list for major gynaecological surgery are awaiting sur-
gery for genital prolapse (Cardozo 1997).
The uterus is free to move according to the changing volumes of blad-
der and rectum. The cervix is directed backwards and the uterus is said
to be ‘anteverted’. Where the uterus is further bent forwards on itself, it
is said to be ‘anteflexed’. If, however, the cervix is found to be pointing
284 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
forwards and the fundus of the uterus is directed backwards, the uterus
is said to be ‘retroverted’, and where the uterus is then further bent back-
wards on itself it is said to be ‘retroflexed’. Twenty per cent of normal
women have retroversion of the uterus; infertility, backache and dys-
pareunia have been attributed to it. The uterus may be drawn or held in
retroversion as a result of adhesions associated with endometriosis or
pelvic inflammatory disease.
As described in Chapter 1, the pelvic organs are maintained and sup-
ported in position by a combination of fascia and ligaments, and indir-
ectly by the pelvic floor and levator ani muscles. These vital supportive
components are sometimes congenitally weak, or are weakened, elong-
ated or actually damaged by childbirth. The factors at childbirth leading
to genitourinary prolapse are: large babies, long labours, assisted deliv-
ery and poor postnatal exercise regimens (Jackson & Smith 1997). The
same authors also cite connective tissue disease, hysterectomy, obesity,
chronic respiratory disease and pelvic masses as other possible causes.
Constipation is also considered to be a contributory factor to uterovagi-
nal prolapse (Spence-Jones et al 1994). Prolapse most commonly occurs
in women who have borne children, although it can occur in the nul-
liparous. It has been estimated that 50% of parous women have some pro-
lapse; however, only 10–20% seek treatment for their condition (Beck
1983, cited in Glowacki & Wall 2002). There is also an increased risk of
prolapse with age (Olsen et al 1997).
Following hysterectomy the vagina may be susceptible to prolapse
owing to a decrease in the support of the vaginal vault (Jackson & Smith
1997). This can be due to the unsuccessful attachment of the incised
uterosacral and transverse cervical ligaments for the conservation of the
vagina. Figures 9.1 and 9.2 (p. 285, 286) illustrate the most common types of
displacement and prolapse encountered by the physiotherapist, together
with a rough guide as to how they may present at perineal examination.
The symptoms are variable but patients may complain of a lump, a drag-
ging sensation, ‘something coming down’ or a feeling of heaviness when
they are standing, and as a progressive sensation through the day. It is ‘not
there’ when the patient is lying down. There may be complaint of backache
but it is not often caused by the prolapse. Sexual intercourse may be affected
by difficulty in penetration, dyspareunia (see p. 296) or lack of satisfaction
on the part of one or both partners. Displacement of the bladder (cystocoele)
(Fig. 9.1a) does not always affect continence but some patients complain
of frequency and urgency of micturition, and of stress incontinence, which
may be anything from very mild to severe. A rectocoele (Fig. 9.1b) and an
enterocoele may result in difficulty in defaecation, constipation and haem-
orrhoids. If there is concurrent urinary incontinence it should be fully inves-
tigated before any surgery (Jackson & Smith 1997). Any form of prolapse
may lead to coital problems as a result of altered vaginal sensation, and
dyspareunia and/or vaginal flatus (Jackson & Smith 1997).
Hormone replacement therapy in the form of postmenopausal oestro-
gen supplementation may be recommended to increase the skin collagen
content, but its efficacy in preventing genitourinary prolapse is unproven
(Jackson & Smith 1997).
Common gynaecological conditions 285
1. Anterior Weakness of the pubocervical fascia allows the bladder to displace down-
compartment wards and backwards against the anterior wall of the vagina. If this is
slack it will protrude. In more severe cases a pouch is formed in the blad-
Cystocoele (Fig. 9.1a) der which holds residual urine. Patients complain of frequency and
incomplete emptying of the bladder, which predisposes to infection; they
may also have stress incontinence. A cystocoele may occur in the absence
of uterine descent; but where there is uterine descent it will be accompan-
ied by some degree of cystocoele because of the intimate fascial connec-
tions between the bladder base and the cervix.
Urethrocoele (Fig. 9.1c) The urethra alone, being closely attached to the anterior wall of the
vagina, may sag backwards and downwards when it receives insuffi-
cient support from the vagina or surrounding fascia; it may also kink.
It is the least common form of genital prolapse (Thakar & Stanton
2002).
2. Middle compartment A descent of the vaginal vault frees the upper part of the posterior vaginal
wall to drop, bulge and protrude, allowing an extended pouch of Douglas
Enterocoele to be herniated; it may contain small bowel and omentum. Thus an ente-
rocoele usually accompanies a uterine prolapse.
Uterine prolapse When lack of adequate support allows the uterus to descend, it causes
the vaginal vault to descend also and the vagina to invert. Such a pro-
lapse will be associated with a cystocoele and enterocoele (see above).
Traditionally three degrees of uterine prolapse (Fig. 9.2) are used in clin-
ical description:
First degree The cervix remains within the vagina.
Second degree A descent of the cervix to the introitus, which may pro-
trude further on straining, with the possibility of damage, infection and
ulceration.
Third degree or procidentia The entire uterus descends outside the
introitus of the body, causing total inversion of the vagina. A procidentia
is almost inevitably associated with a cystocoele and an enterocoele.
However, it is now recommended that gynaecologists should use the
parameters for measuring pelvic organ prolapse as described by Bump
et al (1996) and agreed by the International Continence Society. This
method uses anatomical reference points defined in terms of vaginal wall
segments. There are six defined points located in the anterior, superior
and posterior vagina that are located in reference to the hymenal ring and
measurements taken.
Uterine prolapse is associated with backache and difficulty in using
tampons; procidentia may lead to ulceration (Jackson & Smith 1997).
3. Posterior Prolapse of the rectum forwards against the lower part of the posterior wall
compartment of the vagina is almost always associated with damage to the perineal body
and consequent loss of the support it provides. Inadequate or ineffective
Rectocoele (Fig. 9.1b) suturing of episiotomies and perineal tears associated with childbirth, or
lack of appreciation of the damage sustained, may contribute to this condi-
tion. Rectocoele is not necessarily associated with uterine prolapse because
the rectum is not directly connected to the cervix. A rectocoele may lead to
constipation and dyschezia (Jackson & Smith 1997). Faeces often ‘pocket’
in the rectocoele; women often report using perineal splinting or post-
vaginal-wall pressure in order to empty their bowels fully.
Physiotherapy in the Although not yet proven, it is believed that better education of women prior
treatment of genital to childbirth with active pelvic floor muscle education will help in the pre-
displacements and vention or delay of prolapse and its symptomology. Appropriate manage-
prolapse ment in labour should also reduce the obstetric risk factors. Most patients
with mild prolapse will benefit from physiotherapy directed at strengthen-
ing the pelvic floor muscles (see Chs 11, 12); this was recommended by both
Jackson & Smith (1997) and Thakar & Stanton (2002). A physiotherapist
should also consider giving attention to chest and other infections, obesity,
constipation and the woman’s workload. Considering the cost – both
human and financial – and the inherent risks associated with surgery, it
makes good sense for all patients to be offered an intensive 6–8-week period
of specialist physiotherapeutic treatment before surgery is mooted or once
they are placed on the surgical waiting list. In any case, surgery will be
delayed whenever practicable until childbearing is complete; physiother-
apy or a pessary may help to tide a woman over until then. For the more
resistant cases, surgery in the form of a repair or hysterectomy will eventu-
ally be required (see p. 309); however long-term results for prolapse surgery
are uncertain (Jackson & Smith 1997). It would seem sensible to teach all
women appropriate pelvic floor muscle exercises prior to any prolapse sur-
gery, in association with being taught ‘the knack’ (Miller et al 1998) and
being given advice on appropriate moving and handling techniques. It is
also advisable to teach defaecation technique (see p. 387) to any women pre-
senting with prolapse, particularly if they are suffering with constipation.
DISORDERS For most women, the onset of menstrual flow is a regular and reasonably
ASSOCIATED WITH predictable event, and the length of the menstrual cycle is individual and
MENSTRUATION constant – usually somewhere between 27 and 32 days. However, there
can be few women who do not, at some stage in their lives apart from
288 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
The menarche Menarche is the onset of menstruation, with a median age of 13 years in
Britain; this has recently been confirmed by a study of 1166 girls from ten
British towns (Whincup et al 2001). However the same study showed that
almost one in eight girls reaches menarche whilst still at primary school.
An early menarche tends to be followed by a late menopause, whereas a
late menarche is often followed by an early menopause (Lewis &
Chamberlain 1990). A girl’s first cycles are often irregular and are usually
painless, but may be anovular with the follicles failing to mature ade-
quately and perhaps with prolonged bleeding.
Primary amenorrhoea If a girl is developing secondary sexual characteristics, but has amenhor-
rhoea, there is no cause for concern. If she has no secondary sexual char-
acteristics developing at 14, or is still not menstruating by the age of 16
years regardless of sexual characteristics, the condition should be consid-
ered pathological; this is termed primary amenhorrhoea and it is believed by
some that investigations should take place (Tindall et al 1991). However,
others believe that if sexual characteristics are present then further inves-
tigation or management is not necessary, other than reassurance that nor-
mally developed girls will commence menstruation by the age of 18 years
(O’Brien & Doyle 1997). Steele (1997) also states that the age that investi-
gations take place should also depend on the family history and the level
of anxiety shown by the girl and her parents.
(Beals & Manore 2002) are all known to cause the missing of one or more
expected menstrual periods. Amenorrhoea or infrequent periods may also
occur with serious illness, starvation (e.g. anorexia nervosa, where amenor-
rhoea may occur before excess weight loss is obvious) and gross obesity.
Other possible causes of secondary amenorrhoea include: pregnancy and
breastfeeding, polycystic ovary syndrome (PCOS), premature ovarian fail-
ure, pituitary tumour, Asherman’s syndrome (uterine adhesions), radio-
therapy and chemotherapy (Steele 1997). If the menstrual pattern is
irregular but menstruation still present it is known as oligomenhoroea.
Dysmenorrhoea The term ‘dysmenorrhoea’ comes from the Greek meaning ‘difficult
monthly flow’ and it is used to describe pain associated with menstru-
ation. The condition may be primary or secondary. It has also been shown
in a small study of 18 women that those with dysmenorrhoea have symp-
toms of high nocturnal body temperatures and disturbed sleep through-
out the menstrual cycle (Baker et al 1999).
Primary or spasmodic This is the more common type; there is no apparent structural abnormal-
dysmenorrhoea ity or pathology. It is related to the increased production and release of
endometrial prostaglandins resulting in increased and abnormal uterine
activity (Pickrell 1997). The pain is felt over the lower abdomen and
sacral region in the first hours of a period, and may be colicky. When pain
is very severe, nausea, vomiting, headache, abdominal distension, irri-
tability and even diarrhoea may be experienced. Pain decreases with
increasing blood loss. Self-management is often by over-the-counter
medication such as ibuprofen (Fraser & McCarron 1987). Medical man-
agement consists of reassurance and either prostaglandin synthetase
inhibitors at the onset of menstruation or suppression of ovulation with
oral contraceptives (Pickrell 1997).
Secondary or congestive This is associated with some structural abnormality or pathology (e.g. a
dysmenorrhoea fibroid, endometriosis or infection). The pain, which may be unilateral or
bilateral, begins 3 days before menstruation and is relieved or temporar-
ily exacerbated as bleeding commences. It may increase with activity.
The physiotherapist must assess every referral with care. Primary dys-
menorrhoea may be managed using pain-coping strategies such as
relaxation, breathing awareness, acupuncture, transcutaneous electrical
nerve stimulation (TENS) and distraction techniques. A recent Cochrane
review (Proctor et al 2003) reviewed the use of TENS for primary dysmeno-
rrhoea; it concluded that high frequency TENS was found to be useful by
a number of small trials. However, there was insufficient evidence to
determine the effectiveness of low-frequency TENS. It also found from one
methodologically sound study that there appears to be a benefit from the
use of acupuncture in reducing dysmenorrhoea (Helms 1987). Where the
patient’s occupation and lifestyle are predominantly sedentary (as is often
the case), or fitness is in question, guidance as to ways of wisely increasing
physical activity may be helpful as exercise is known to produce endoge-
nous endorphins, which have natural pain-relieving properties.
290 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Premenstrual tension Premenstrual tension (PMT) is more common in women over 30 years of
age than in younger women; it is a diagnosis used to describe irritability,
depression, lumbar backache, tenderness and enlargement of breasts,
abdominal pain and distension, water retention, weight gain and insom-
nia associated with the menstrual cycle. In a sample of 1045 menstruating
women from the UK, USA and France, up to 80% experienced mood and
physical symptoms associated with their menstrual cycle; however, only
25% had ever sought treatment (Hylan et al 1999). Some or all of these
symptoms commence up to 10 days prior to menstruation, and usually
recede quickly once the menstrual flow has commenced. There is evi-
dence in some women that their cognitive ability decreases and that they
are more aggressive and accident prone at this time, which is relevant for
those with demanding and responsible employment. There have been
several legal cases where PMT has been used in defence.
The retention of fluid is thought by some to be due to a relative lack of
ovarian progesterone, but there is also an increased output of antidiuretic
hormone (ADH) by the posterior pituitary gland. There may also be
reduced serotonin levels leading to mood swings; selective serotonin
reuptake inhibitors (SSRI) may be an effective treatment.
Progesterone and progestegons have often been used in the manage-
ment of the syndrome, but a recent systematic review concluded that the
evidence does not support this treatment (Wyatt et al 2001). Another
recent German study of 170 women suggests that the dry extract of agnus
castor fruit is an effective and well-tolerated treatment for the relief of
symptoms (Schellenberg 2001). Many women also consider that gamma
linolenic acid, in the form of evening primrose oil, starflower oil or bor-
age seed oil, is beneficial. There are contradictory studies regarding their
efficacy, but as there are no reports of side-effects in their use, it may be
worthwhile considering them (Andrew 1997).
The women’s health physiotherapist has a role in helping women to
understand the condition and to consider ways of adjusting the stress
levels being placed on the body, both generally and at particular times.
The Mitchell method of relaxation should be taught as fatigue and stress
exaggerate the condition (see p. 111) (ACPWH 2002). Some women
also find it helpful to consume small, frequent meals of complex carbo-
hydrates, fruits and vegetables. Limiting salt intake can be helpful in
avoiding fluid retention, and avoiding caffeine may help towards decreas-
ing cyclic breast pain.
Common gynaecological conditions 291
BACKACHE AND Women with gynaecological conditions frequently assume that this is
ABDOMINAL PAIN also the source of their back pain. This is not always so, and much need-
less additional suffering could be avoided by appropriate physiothera-
peutic assessment and care. However, back and abdominal pain,
particularly chronic pain of gradual onset, may have a direct gynaeco-
logical origin (Fig. 9.3), and certainly gynaecological pain may coexist
with pain from the back and is a late symptom of malignant disease.
The physiotherapist can be an invaluable member of the gynaeco-
logical team in helping to analyse the cause, particularly of back pain,
and treating it where appropriate. Where pain cannot be cured but must
be endured, TENS may be helpful.
Acute lower Acute lower abdominal pain may be a sign of many conditions including
abdominal pain an ectopic pregnancy in someone who is in the early stages of pregnancy,
or a torsion, haemorrhage or rupture of an ovarian cyst. Any new abdom-
inal acute pain should be immediately referred for medical advice.
Over the abdomen, true gynaecological pain rarely extends above the
anterior superior iliac spines; when of uterine origin it may radiate to the
anterior aspect of the thighs. Pain may be exacerbated by abdominal
pressure over the site of the lesion. Posteriorly, it is usually located over
the upper half of the sacrum and may extend laterally to the glutei. When
involving lymphatic nodes around the sacral plexus, cervical cancer may
cause pain radiating down the back of the legs. Backache associated with
uterine prolapse is relieved by lying down; it becomes more severe on
prolonged standing and as the day progresses.
Chronic lower Beard et al (1984) suggested a cause for pelvic pain in women of repro-
abdominal pain with ductive age with no obvious somatic pathology; dilated veins and vas-
pelvic congestion cular congestion in the broad ligaments and ovarian plexuses were
apparent in 91% of the women in this study. When examining the clinical
features in women with pelvic pain and congestion, which was demon-
strable on pelvic venography, the following results were found (Beard
et al 1988):
POLYCYSTIC OVARIAN This syndrome is associated with menstrual disturbance and is the most
SYNDROME common form of anovulatory infertility (Frank 1995). Women with this
condition may also suffer with hirsutism, acne, obesity, increased testos-
terone activity, and elevated LH concentrations. It is thought that the
underlying disorder is one of insulin resistance, with the hyperinsuli-
naemia stimulating excess ovarian androgen production (Hopkinson
et al 1998). It is believed that insulin-sensitising agents such as metformin
can play a major role in its treatment (Hopkinson et al 1998).
Women with this condition may become very anxious regarding infer-
tility; the women’s health physiotherapist may have a role to play in
teaching stress control by relaxation techniques.
Common gynaecological conditions 293
INFERTILITY There have been increasing referrals for fertility investigations in recent
years. This rise may be due to increased media exposure of the subject,
but what is certain is that women are increasingly delaying childbirth
until their thirties, and this practice has doubled in the last 25 years
(Office for National Statistics 1997). Of those having regular intercourse
without contraception, 90% of fertile couples should achieve a pregnancy
within a year and this rises to 95% after 2 years. Therefore some people
have low normal fertility rather than subfertility (Cahill & Wardle 2002).
There are many causes of subfertility including sperm dysfunction, ovu-
lation disorder and fallopian tube damage. The causes of these problems
are many and varied and some couples may have more than one reason
for their subfertility. Increasing age of the women reduces the women’s
fertility further and hence reduces the likelihood of treatment success.
Primary infertility is that occurring in women that have never con-
ceived. If there has been a previous pregnancy it is termed as secondary
infertility. A previous full term conception has been found to give a
greater chance of conception either naturally or after treatment.
A couple should pursue early referral to a specialist infertility clinic if
they have been attempting conception for more than 3 years, or the woman
is over 38 years, has had serum Chlamydia antibody titre or has FSH con-
centrations or LH concentrations in the early follicular phase causing
concern. Other possible reasons would be if the partner’s sperm count,
motility or appearance was causing concern (Cahill & Wardle 2002).
Women’s health physiotherapists may encounter these patients only
during or after a resultant pregnancy. They should be cognisant of the
extra anxieties and concerns that these couples may have. Those that
have had fertility problems may be more questioning of all that is offered
to them and care must be taken to allay any of the very real anxieties that
they may have. Physiotherapy should be directed appropriately towards
any presenting condition.
PREMATURE OVARIAN This distressing condition cannot be prevented or cured but can be treated
FAILURE (POF), and managed. The ovarian failure occurs some time between the menar-
ALSO KNOWN AS che and the age of 40 years. The incidence is approximately 1% of women,
PREMATURE rising to 8–10% when including gynaecological surgery, chemotherapy
MENOPAUSE and radiotherapy (Farrell 2002). POF can be of different levels of severity
and can not only result in infertility but also have the long-term conse-
quences of a woman being at increased risk of osteoporosis and heart
disease. The possible causes are many: gonodal dysgenesis, genetic asso-
ciations, autoimmune disease, viral oophritis, or iatrogenic or idiopathic
causes. Some causes are more rare than others, many falling into the idio-
pathic group.
This group of women often reports high levels of depression and stress
and low levels of self-esteem and life satisfaction (Liao et al 2000). Those
women that have POF as a sequellae of chemotherapy or radiotherapy
may need effective crisis intervention (Pasquali 2002). It may be advis-
able to have a bone density scan as a baseline for future reference and
practice breast awareness. The women’s health physiotherapist must
294 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
PSYCHOSEXUAL The women’s health physiotherapist must be prepared for clients to want
PROBLEMS to discuss their sexual difficulties. Sometimes women may be directly
referred suffering from dyspareunia, but frequently the subject will arise
following surgery, or during treatment for various forms of incontinence
and weak pelvic floor muscles, and of course during pregnancy or fol-
lowing childbirth.
Although sex and sexuality are more openly discussed today, most
people have great difficulty in exposing their very personal sexual prob-
lems to outsiders. The physiotherapist must respect the woman’s want-
ing to confide in her, provide a non-judgmental listening ear and, if
unable to help directly, should know of further sources of psychosexual
counselling in the area. A questionnaire sent to health professionals (doc-
tors, nurses, physiotherapists and occupational therapists) revealed a lack
of training; there were 813 respondents who believed that sexual issues
needed to be addressed and discussed in the health service (Haboubi &
Lincoln 2003). However, they felt that they were poorly trained, ill pre-
pared and rarely had such discussions. The therapists in particular had
less training, lower comfort levels and less willingness to talk about
sexual issues than doctors and nurses; this needs to be addressed.
General sexual There is a decrease in libido, leading to a lack of erotic feelings and
dysfunction reduced vasocongestion in the arousal phase; vaginal lubrication and
expansion will not occur.
A lack of desire is often secondary to stress, fatigue, depression, phys-
ical illness, drugs, other sexual dysfunctions or relationship difficulties
(Watson 1990). Testosterone production is shared between the ovaries
and adrenal gland. If there has been surgery or chemotherapy affecting
these there may be a loss of sexual desire (Butcher 1999a). There are also
many drugs and other health problems that can affect sexual desire.
Orgasmic dysfunction Although erotic sensations and vasocongestion may occur, orgasm is not
experienced. This may be primary (orgasm has never been achieved) or
secondary (having experienced orgasm previously, a woman is no longer
able to reach a climax). Anorgasmia can be defined as an involuntary
inhibition of the orgasmic reflex (Butcher 1999b). It becomes a problem
only if the woman regards it to be one (Selby 1997). The media has some-
times made women have unreasonable expectations; ‘normality’ can
range from those women who never or rarely experience orgasm to those
who claim to have multiple orgasms. Treatment may start with the
woman but continues with her and her partner; it is aimed at the ‘hold-
ing back’ that the woman may feel. Sexual therapists can further treat
those women who are concerned by encouraging the use of ‘superstimu-
lation’ using aids and by reassurance (Watson 1990).
Superficial dyspareunia There are many causes of superficial (at or around the vaginal entrance)
dyspareunia:
Deep dyspareunia Deep dyspareunia is often described as pain as a result of pelvic thrust-
ing during sexual intercourse (Butcher 1999b). It is often associated with
pelvic pathology such as:
Treatment Treatment must always be directed first at any possible physical cause.
Cognitive behavioural programmes may also be used in which the
woman learns about her condition, and gradually feels that she has
gained control over her vagina and sexual activity (Butcher 1999b).
Increasingly physiotherapists are being asked to treat patients com-
plaining of dyspareunia, particularly postpartum. Usually the patient has
had an episiotomy or a considerable tear needing suture following a recent
delivery; occasionally this wound has become infected and broken down.
A raised and sensitive scar may be palpable in some cases; in others there
is nothing obvious. Obstetricians sometimes offer to excise such a scar
and resuture, with a 50/50 expectation of improvement. Understandably
women are reluctant to accept further trauma at such low odds. If the
introitus has apparently been sutured ‘too tightly’, dilators may be
suggested.
Physiotherapists are finding that they are able to treat many such
patients very successfully using a combination of ‘tender loving care’, lis-
tening, counselling, education, ultrasound to soften scar tissue, and the
teaching of self-massage and pelvic floor muscle exercises. No scientific
evaluation of these techniques has so far been undertaken but the grati-
tude of patients and their partners is significant.
There are a few patients who, after childbirth or pelvic surgery, will be
found to have fantasies concerning their pelvic floor, fearing trauma and
deformity that make intercourse impossible. Often all that is needed is
examination and reassurance by someone empathetic whom they trust,
for example the postnatal class or clinic midwife or physiotherapist,
insight into the fact that childbirth or surgery may have caused minimal
changes, and guidance to self-examination using a mirror.
VULVODYNIA In 1983 the International Society for the Study of Vulvar Diseases (ISSVD)
developed the term ‘vulvodynia’ for a chronic condition with symptoms
of burning and sometimes stinging, irritation and rawness in the vulval
area previously known as ‘burning vulva syndrome’ (McKay 1984). It is
different to pruritis vulvae in that there is no desire to scratch.
Vulvodynia includes several disorders resulting in chronic vulval pain:
vulvar dermatosis, cyclic vulvovaginitis, vulvar vestibulitis, vulvar
papillomatosis and essential vulvodynia (McKay 1989). Sexual problems
are quite common in patients with vulval pain and a psychosexual refer-
ral may be appropriate after the medical part of the condition has been
appropriately treated.
being comparatively mild to such a severe pain that the woman may
even have a problem sitting comfortably. However, there are often no vis-
ible signs. Treatment may be with tricyclic antidepressants, but unfortu-
nately these may have the side-effects of tiredness, dry mouth, constipation
and occasionally blurred vision. Vaginal lubricants may make inter-
course easier; aqueous cream is recommended for improving general
skin condition.
Chronic vulvodynia may have an acute onset such as with vaginal
infection, or after a change in pattern of sexual activity, or there may be
nothing specific recollected by the woman prior to its commencement
(Wesselmann et al 1997).
Glazer (2000) reported on the long-term follow-up of patients who had
been treated with surface electromyography-assisted pelvic floor muscle
rehabilitation; 38 out of 43 patients reported that they had suffered no
further vulvar pain since completion of treatment more than 3 years pre-
viously. Vulvodynia has also been successfully treated with acupuncture
(Powell & Wojnarowska 1999).
Vulvar vestibulitis This is a subgroup of those with vulvodynia in which the pain is usually
felt in the vaginal introitus from below the clitoris to the fourchette
on any degree of touch. The characteristics of vulvar vestibulitis have
been described as: severe pain on vestibular touch, or attempted penetra-
tion, tenderness to pressure in the vestibule, and vestibular erythema
(Friedrich 1987), although not all women have visible signs. The simple
swab test for the condition consists of elicitation or exacerbation of a
sharp burning pain on touching the vulvar vestibule with a moist cotton-
wool swab.
Unfortunately symptoms are often wrongly diagnosed as being a
monilial infection. Women suffering from the condition with inappropri-
ate treatment can then suffer with isolation, fear and self-treatment
(Nunns & Hamdy 1998). As a result of this the Vulval Pain Society was
founded in 1996 to give unbiased accurate information on the subject (for
contact details see Useful Addresses on p. 307).
Treatment Medical treatment can involve local anaesthetic creams and gels, tricyclic
antidepressants, psychosexual counselling and vaginal dilators.
Physiotherapy has been used for the condition, with some degree of
success. Glazer et al (1995) demonstrated an 83% improvement rate with
17 out of 33 women reporting pain-free intercourse at 6 months follow
up. The ‘Glazer’ protocol includes a prebaseline 1-minute rest, five fast
PFM contractions with 10 seconds rest between each, five 10-second con-
tractions with 10 seconds rest between each, a single endurance contrac-
tion of 60 seconds and a 1-minute rest postbaseline (Glazer 1997).
Shelley et al (2002) describe fully the aetiology, physiotherapy assess-
ment and treatment of many types of pelvic pain. The treatment methods
include posture, body mechanics, relaxation, biofeedback, stress man-
agement and manual therapies. The women’s health physiotherapist is
well placed to learn and utilise these methods of treatment.
300 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
SEXUALITY
IN THE PUERPERIUM Female sexuality is often adversely affected in the puerperium and there
are probably multiple reasons for this, including perineal trauma, hor-
monal readjustments, fatigue and psychological causes including anxiety
and depression. Perineal pain and dyspareunia are common; there is a
general decrease in desire for and frequency of sexual intercourse (Klein
et al 1994). In a study of 796 women by questionnaire 6 months post-
delivery, there was a 61% (494) response rate (Barrett et al 2000).
Interestingly, six women refused to participate as they felt that the ques-
tionnaire was too personal. It was found that 67% of the women reported
less frequent intercourse, with variability in the quality of intercourse.
Problems with pain, lack of vaginal lubrication and loss of sexual desire
all increased in the first 3 months after delivery. Dyspareunia was particu-
larly common (see p. 296). Over 80% of women in the study experienced
at least one postnatal sexual problem. Glazener (1997) found that 53% of
women found problems with intercourse in the first 8 weeks postdeliv-
ery and 49% in the subsequent year.
Extreme tiredness, anxiety and depression can all contribute to the
problem and make a women feel even more guilty for not complying with
the expected image of being healthy, happy and coping (Saurel-Cubizolles
et al 2000).
Common gynaecological conditions 301
PREMENOPAUSAL The late forties is a time when many women are achieving much in their
WOMEN professional lives but also having to cope with children growing into young
adults, elderly parents and their own bodies starting to show some signs of
deterioration. However, in recent years women have become more inter-
ested in their own health and often attend health clubs and gymnasia; this
in itself may bring further pressures on their time. There are also expecta-
tions of a healthy sexual life. It has been found that a sexual self-rating (SSR)
scale is positively related to oestrogen levels and negatively related to
follicle-stimulating hormone (FSH) levels in women aged 45–49 years
(Garratt et al 1995). It was further found that women experiencing pain with
sex and dryness of the vagina had significantly lower SSR. It may be that a
woman attending a women’s health physiotherapist for problems of a uri-
nary or faecal nature may disclose that she is also having sexual problems.
Although simple problems of lack of vaginal lubrication or positioning for
intercourse can be addressed, care should be taken not to proffer other
advice unless appropriate training has been undertaken.
IN THE CLIMACTERIC There are several factors other than body chemistry that can influence
sexual fulfilment at the time of the climacteric. These include satisfaction
with a relationship, emotional stability and psychological well-being
(Abernethy 1997). The hormonal changes at the climacteric can significantly
affect and reduce sexual activity. The vaginal epithelium changes at this
time, with the vaginal walls becoming thinner and less elastic. Women may
experience atrophic vaginitis with problems of vaginal dryness, hot flushes,
night sweats, mood changes, weight gain and possibly bladder problems,
all of which can play a part in altering a woman’s sexual activity. Also, the
skin may become dryer, thinner, itchy and bruise more easily, hair may
become more sparse and dry, facial hair may increase, and the breasts start
to shrink and sag – none of which make a woman feel more desirable.
Ageing has also been shown to lead to a reduction in sexual interest, orgas-
mic capacity and coital frequency (Hallstrom 1980). This report also showed
that sexuality is affected by psychosocial as well as by biological factors;
higher social class was significantly related to normal sexual activity.
Hormone replacement therapy (HRT) may assist with those having
problems with vaginal dryness, loss of libido and dyspareunia; topical
application of oestrogens may be appropriate therapy (see p. 262). There is
302 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
also some evidence that testosterone can assist in increasing sexual desire
and is given alongside the oestrogen therapy (Floter et al 2002). However,
many women report that non-medical problems have more effect on their
sex lives than the actual menopausal changes (Pennell report 1998).
IN OLDER AGE Most women live one-third to one-half of their life after the menopause
(Pennell report 1998). More people of both sexes are reaching their 70s,
80s and even 90s, and many are in very good health. Continued sexual
activity and enjoyment will be possible for many. For some, neurological
damage or physical disability, or both, may affect it, needing thought and
care regarding appropriate positioning. Thus it is important that those
caring for the elderly should never assume that regular intercourse has
ceased, particularly when arranging accommodation.
It is logical to suppose that, for a woman, sexual activity with the
increased blood supply of arousal and muscular contraction of orgasm
can only be beneficial to the pelvic floor, and, by inference, to the mainten-
ance of continence. This contention appears to be supported by unsoli-
cited opinions which have been voiced to physiotherapists by recently
widowed women who experience incontinence, suggesting that it is
because they are not now having regular intercourse that they are ‘get-
ting weak underneath’. It has also been reported by many post-
menopausal women attending for PFM re-education that the sexual
satisfaction of both themselves and their partners has greatly improved
with increased PFM activity.
A German study reported that elderly and old women are increasingly
seeking a gynaecological consultation for sexual difficulties (Neises
2002). However, such consultations may be hindered by feelings of
shame, fear and embarrassment. The women’s health physiotherapist
may be of assistance by being prepared to lend a listening ear to any such
patient prior to her gynaecological appointment.
Physiotherapists who become interested in this field should approach
the Association of Chartered Physiotherapists in Women’s Health for
information regarding psychosexual counselling courses that will admit
physiotherapists.
THE PSYCHOLOGICAL Gynaecological disease strikes at the core of a woman’s psyche, sapping
AND EMOTIONAL her physical, mental and spiritual health. The effects are often covert and
IMPLICATIONS OF low grade, undermining a woman to the point that, although she goes
GYNAECOLOGICAL through the motions of living, she temporarily or permanently becomes a
DISEASE ‘second class citizen’. In more severe cases she tires easily and may not be
able to hold down a full-time job; she is often in pain and irritable; she
may not want or even be able to leave the house at times, and becomes
moody and depressed; her closest relationships are stressed and her
fertility threatened. She finds it hard to talk about her problems and
experiences rejection by most people unless they are fellow sufferers. The
partners of such women also have grave problems, for however much
they give to the relationship it is never enough. Such a couple’s social life
Common gynaecological conditions 303
SEXUALITY AND BODY Many people survive treatment for their malignancies. However, they
IMAGE AFTER CANCER can find that they have emotional and physical changes that can affect
their sexuality and sexual functioning (Sundquist & Yee 2003).
Patients with gynaecological cancers may feel shame and unease
when talking of their sexual problems (Neises 2002); however, 80% defin-
itely want to be informed of the possible consequences of the disease and
its treatment on their sexuality.
Breast surgery patients in particular may be concerned about their own
body image. It is common for women to have difficulties with sex and intim-
acy after their diagnosis (Love 2000). This may be a fear that their partner
will find them less attractive, a practical issue of discomfort in positioning
for sexual activity or a loss of libido after a chemical menopause. Tamoxifen
is prescribed for those women with an oestrogen positive tumour; this may
itself cause menopausal symptoms. Lymphoedema can bring additional
physical and psychological problems in both gynaecological and breast
cancer.
The psychological distress can bring about hormonal changes causing
more psychological distress. It has also been found that most of such
issues were resolved by 1 year, but somewhat bleakly, that if they were
not resolved by then, they were never resolved (Ganz et al 1998).
All health professionals, but in particular women’s health physiother-
apists, are in an ideal position to give time to women who may suffer
with these unmentioned fears. Therapeutic interventions where appro-
priate, listening and close liaison with the nurse specialist and other
members of the team can ensure that there is seamless care. Also to be
considered is the provision of information concerning patient self-help
groups; some appropriate addresses are at the end of this chapter (p. 306).
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Further reading
Andrews G (ed) 1997 Women’s sexual health. Baillière Luesley D M (ed) 1997 Common conditions in gynaecology:
Tindall, London. a problem solving approach. Chapman & Hall Medical,
Campbell S, Monga A (eds) 2000 Gynaecology by ten London.
teachers, 17th edn. Edward Arnold, London. Sampson J A 1927 Peritoneal endometriosis due to the
Govan A D T, McKay Hart D, Callander R (eds) 1993 menstrual dissemination of endometrial tissue into the
Gynaecology illustrated, 4th edn. Churchill Livingstone, peritoneal cavity. American Journal of Obstetrics and
London. Gynecology 143:422–469.
Laycock J, Haslam J (eds) 2002 Therapeutic management of Symonds E M, Symonds I M 1998 Essential obstetrics and
incontinence and pelvic pain, Springer, London, p 157–189. gynaecology, 3rd edn. Churchill Livingstone, London.
Useful addresses
Anorexics Anonymous Association of Chartered Physiotherapists in
45a Castelnau, Barnes, London SW13 Obstetrics and Gynaecology
Tel 020 8748 3994 c/o CSP, 14 Bedford Row, London WC1R 4ED
Website: www.womensphysio.com
Common gynaecological conditions 307
Chapter 10
Gynaecological surgery
Teresa Cook
CHAPTER CONTENTS
Introduction 309 Definitions of other useful terms and
Gynaecological excision surgery 309 procedures 320
Pelvic radiotherapy 314 Physiotherapy care of patients undergoing
Gynaecological repair surgery 314 gynaecological surgery 321
Surgical treatment of stress incontinence 317
INTRODUCTION
HYSTERECTOMY Hysterectomy is the surgical removal of the uterus, first successfully per-
formed in 1853. Originally an operation of last resort, hysterectomy is cur-
rently performed for a variety of conditions. These include uncontrollable
310 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Abdominal The abdominal route allows inspection of all the other pelvic organs and
hysterectomy surrounding tissue. For this reason it is used for carcinoma, but would
also be used to remove a large fibroid uterus or if there is restricted uter-
ine mobility. Full pelvic clearance (exenteration) can only be performed
by the abdominal route. Commonly a total abdominal hysterectomy
(TAH) is performed which removes the complete uterus, including the
cervix. It can be combined with the removal of one or both fallopian tubes
(salpingectomy) and/or ovaries (oophorectomy) (see p. 313).
Once the pelvic organs are exposed the fallopian tubes, ovarian liga-
ment and round ligament are divided on either side, at the top of the
broad ligament. The broad ligament is opened to expose the uterine ves-
sels, which are then ligated and cut. The cervix is excised from the vagina,
leaving as much vagina as possible, and from the transverse cervical and
uterosacral ligaments. This allows the removal of the entire uterus. Care
must be taken to avoid trauma to the ureters, which run forward below
the uterine arteries adjacent to the cervix. The upper end of the vagina
is closed and attached to the ligaments for support and the abdominal
cavity is closed in layers.
• Subtotal hysterectomy – this is the removal of the fundus and body of the
uterus, but leaving the cervix, and may reduce postoperative complica-
tions. For example, it may be performed where there is a known diagno-
sis of overactive bladder or where the woman is concerned that removal
of the cervix will reduce sexual function (Grimes 1999, van der Vaart et al
2002). It has been suggested that women have an increased risk of develop-
ing urge incontinence symptoms following hysterectomy. Where a diag-
nosis of overactive bladder has been confirmed preoperatively, some
surgeons will opt to avoid aggravating these symptoms by performing a
subtotal hysterectomy. This procedure requires less bladder mobilisation
and therefore less disruption to bladder innervation. In the late 1990s
there was a flurry of media activity relating to the effect of cervical resec-
tion on sexual function. Although the research is not robust, some
women state the desire to keep their cervix for this reason. When this
option is considered, the woman needs to be made aware that she will
still be at risk of cervical carcinoma and that regular cervical smears will
continue to be necessary. However, recent research (Thakar et al 2002)
found no significant differences in outcome regarding bladder, bowel or
sexual function between total and subtotal hysterectomy.
Vaginal hysterectomy Providing that the condition of the uterus is non-malignant, a vaginal
hysterectomy may be the preferred route, particularly in cases of uterine
prolapse. It is easily combined with anterior or posterior colporrhaphy,
should this be indicated (see p. 314).
Laparoscopic assisted This procedure uses a laparoscope to inspect the pelvic cavity and to assist
vaginal hysterectomy in the vaginal removal of the uterus. The abdominal incisions are small
(LAVH) and recovery is as for vaginal hysterectomy. A study by Meikle et al (1997)
comparing TAH with LAVH found that for LAVH there were more
bladder injuries and longer operative time, but shorter hospitalisation,
Gynaecological surgery 313
OVARIAN CYSTECTOMY This is the removal of benign cysts from the ovary. The cysts are shelled
out of the ovary and the remaining ovarian tissue is repaired.
MYOMECTOMY This is the removal of one or more fibroids from the uterine wall via a
Pfannenstiel incision. The procedure may be performed for a woman
who has not completed childbearing. The fibroids are shelled out and the
resulting cavities are closed with stitches.
Simple vulvectomy Simple vulvectomy is a less common operation and much less exten-
sive than the radical version (see above). It involves removal of super-
ficial tissues and may be performed for isolated vulval lesions or vulval
irritation.
LARGE LOOP This procedure is used for suspicious lesions or very localised carcinoma
EXCISION OF THE (CIN 1 and 2) of the cervix, either as a diagnostic tool or for therapeutic
TRANSFORMATION purposes. It has largely taken the place of cone biopsy. It involves the
ZONE (LLETZ) removal, by electrocautery, of a loop of tissue from the transformation zone
of the cervix (the area between the squamous and columnar epithelium).
It is usually performed as an outpatient procedure using a colposcope.
314 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
PELVIC RADIOTHERAPY
Anterior colporrhaphy This is a primary procedure for the treatment of cystocoele or urethro-
coele (see p. 285). The repair may be reinforced by use of a mesh.
Gynaecological surgery 315
Procedure Approached via the introitus, the cervix is drawn down and
the anterior vaginal wall over the cystocoele is opened. The protrusion is
mobilised, then obliterated and supported in a more normal position
by tightening and suturing available fascia, such as the pubocervical
ligaments and fascia over the bladder. The positions of the urethra and
bladder, and the level of the bladder neck are reviewed to ensure that
continence is favoured. Finally a longitudinal or diamond-shaped strip of
the stretched vaginal wall is excised and the vagina closed. If the uterus
is tending to prolapse as well, the operation may be combined with either
a vaginal hysterectomy or a Manchester repair (see p. 316).
Postoperative condition This is as for vaginal hysterectomy (see
p. 312).
Risks and complications A short-term reduction in urinary flow rate
has been reported. There is also a risk of postoperative stress incontin-
ence (Stanton et al 1982). This latent or masked stress incontinence will
not always be a new problem but may become apparent only following
anatomical correction of the prolapse. Recurrence of the prolapse is
common; it has also been suggested that dissection of the vagina during
surgery has a detrimental effect on the innervation of the pelvic floor
(Zivkovic & Tamussino 1997). (See also posterior colporrhaphy.)
Posterior colporrhaphy This procedure is used to repair the posterior vaginal wall where a recto-
coele or enterocoele is significantly symptomatic.
Procedure For a rectocoele, the posterior wall of the vagina is opened
and the rectocoele obliterated and supported using the perirectal fascia
and by approximating and suturing the medial edges of the levator ani
muscles. A section of the stretched excess vaginal wall is excised and the
vagina is closed as for an anterior colporrhaphy.
An enterocoele is repaired in a similar way, but the peritoneal sac of
the enterocoele is excised and the uterosacral ligaments sutured together
to give support.
Perineorrhaphy is the suturing of the perineum, for example following
childbirth trauma.
Colpoperineorrhaphy is a combination of a posterior colporrhaphy and a
perineorrhaphy.
Postoperative condition This is as for vaginal hysterectomy (see
p. 312).
Risks and complications Posterior colporrhaphy is associated with a
postoperative increase in bowel and sexual dysfunctions. These symp-
toms include impaired bowel emptying (constipation, incomplete empty-
ing and the need to use rectal digitation or external support to defaecate)
and vaginal tightness or pain resulting in dyspareunia (Kahn & Stanton
1997). Long-term complications include recurrence of the prolapse, which
may require repeat surgery. Olsen et al (1997) reported a retrospective
cohort study of 395 women undergoing surgical treatment for prolapse
and incontinence. The incidence of repeat surgery in this study was 29%,
316 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
with the time intervals between repeat procedures decreasing with each
successive repair. There is also a strong association between faecal incon-
tinence and a history of more than one posterior colporrhaphy (Kahn &
Stanton 1997).
MANCHESTER REPAIR This repair may be offered to women who have uterine prolapse but who
do not wish to have a hysterectomy. The procedure involves amputation
of the cervix, which may be elongated, as well as anterior and posterior
repair and shortening of the transverse cervical and uterosacral liga-
ments. Subsequent pregnancy, whilst not recommended, is not impossi-
ble although delivery would be by caesarean section.
COLPOSUSPENSION This operation is designed to lift the bladder neck so that when the intra-
abdominal pressure is raised it will act as a compressive force around the
upper portion of the urethra. This reinforces urethral closure pressure
and counterbalances the pressure being exerted on the bladder.
Procedure Through a Pfannenstiel incision, four or five sutures are
used to attach the paravaginal and vaginal tissue on either side of the
bladder neck and upper part of the urethra to the ileopectineal ligament.
The result is elevation of the bladder neck.
Postoperative condition A suprapubic catheter is inserted which is left
in situ for 3–4 days postoperatively. The catheter is left on free drainage
initially and then clamped to allow the patient to attempt normal void-
ing. The catheter is removed once this has been re-established.
Risks and complications Voiding dysfunction, de novo detrusor instabil-
ity and genitourinary prolapse are the most commonly reported prob-
lems (Chaliha & Stanton 1999, Smith et al 2002). Patients should be
counselled preoperatively concerning possible voiding difficulties in the
immediate postoperative period. Skilled surgical judgement is required to
produce the appropriate degree of bladder neck lift, otherwise voiding
difficulty may persist, requiring long-term intermittent self-catheterisation.
Occasionally the operation fails to improve continence.
LAPAROSCOPIC Over 90 articles have been published on this procedure (Smith et al 2002),
COLPOSUSPENSION which is adapted from the open procedure already discussed. The
laparoscopic technique requires more skill than the open procedure
(Jarvis 2000). Intraoperative time is also increased although there is a
more rapid postoperative recovery. The data, however, do not appear to
support the use of this procedure and the advent of the TVT counteracts
the main advantage of a speedier recovery.
Risks and complications No significant differences in bladder function
have been observed between the open and laparoscopic procedures;
however, the laparoscopic procedure may be associated with more surgi-
cal complications (Moehrer et al 2002).
Gynaecological surgery 319
TENSION-FREE The TVT procedure is a minimal access technique performed under local,
VAGINAL TAPE (TVT) regional or general anaesthesia. The TVT device consists of a polypro-
pylene mesh (40 cm long, 1 cm wide) covered by a plastic sheath and
attached to a needle at each end.
ALTERNATIVE There are several alternatives to the above procedures. These include
PROCEDURES endoscopic bladder neck suspensions (needle suspensions, such as the
Pereyra, Raz and Stamey procedures), paravaginal repairs (Kelly), the
Marshall-Marchetti-Krantz procedure, sling procedures (Aldridge), peri-
urethral- or transurethral-bulking agents (Contigen, Macroplastique), and
320 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
PSYCHOLOGICAL The psychological effects of gynaecological surgery are many and varied.
ASPECTS OF Although some surgery is performed as an emergency, most will be elect-
GYNAECOLOGICAL ive, so the amount of preparation time may vary from a few days to many
SURGERY months.
Psychological reactions may be very complex and may involve rela-
tionships with both the partner and family or friends. The indication for
the surgery may be part of this process, although again each woman is
likely to have a different reaction. For women who are undergoing sur-
gery for symptoms affecting their quality of life, the operation may be a
relief. This could be the case for women who are having surgery to cor-
rect a prolapse, however, they may also fear that they will be ‘tied too
tight’ or that their urinary control will be affected. There are few data
regarding psychological status following surgery for stress incontinence.
Studies by Black et al (1997, 1998) suggest that a considerable number of
women report a deterioration in mental health; this may reflect the fail-
ure rate of the surgery. For women undergoing hysterectomy for DUB,
the prospect of resolving this permanently may be liberating, although it
could also be seen as a loss of femininity and of the childbearing role. If
surgery is for malignancy there will obviously be anxiety as to the even-
tual outcome, which will affect all those involved with the patient. It is
widely documented that depression may follow hysterectomy and the
use of support groups may be helpful. It has been suggested that some of
these feelings may be due to a lack of oestrogen after oophrectomy; how-
ever depression is not confined to this group of women (Hysterectomy
Association 2002). For women admitted with an ectopic pregnancy there
is the psychological effect of pregnancy loss.
All of these issues may be relevant, although the requirements to be
admitted to hospital and to undergo surgery are factors in their own right.
The woman may be anxious about being in an unfamiliar environment or
being away from home. She may have concerns about those left to cope
without her, particularly if she has carer responsibilities. Preparation and
information prior to admission all help to reduce these anxieties.
322 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
PREOPERATIVE To enable the physiotherapist to give the most effective care, at least one pre-
PHYSIOTHERAPY operative session should be arranged in a calm, unhurried environment. It
will comprise of assessment, instruction, discussion and possibly treatment.
In many hospitals, women attend a pre-admission clerking clinic and
the physiotherapist may be able to see the patient at this appointment
with other members of the team. If this is not possible, most women are
admitted the day before major surgery and the physiotherapist should
see them at this time.
In many units this preoperative session will be carried out with a group
of patients, although the women should be assessed prior to inclusion in the
group. If treatment is indicated this would be undertaken on an individual
basis. Preoperatively, patients are generally well motivated, keen to learn
and cooperative. They welcome the opportunity to ask questions and share
their fears; they also appreciate the positive use of the waiting time. If they
have already attended an outpatient clerking clinic they may recognise
some of their fellow patients; a group physiotherapy session may therefore
facilitate peer support. It is obviously more cost effective to see patients
together, although this rationale should not compromise patient care and
consent must be sought from all patients prior to the session.
Assessment The initial impression should be obtained from the medical notes. The
main reason for this is to establish the physical state of the patient and the
risk status with regard to complications. It is imperative that the pro-
posed surgery and rationale are understood by the physiotherapist. As
well as warning the physiotherapist about the possible mental state of the
patient, this also helps to prepare for questions.
The following checklist may be useful:
the waiting list or whilst awaiting admission. This may have prevented
some of these women from needing surgery. If an operation is still
favoured such women should have been given a preoperative pro-
gramme and should be adequately prepared.
If surgery is planned in advance and there are known risk factors (e.g.
chronic obstructive pulmonary disease, COPD), preoperative anaesthetic
assessment may have taken place. It may even be possible for such
patients to achieve an improvement in physical condition prior to surgery.
Instruction and Patients should have a basic understanding of the procedure, in order to
preparation appreciate the relevance of physiotherapy. They need to be aware that
it is routine for them to see a physiotherapist and that the objective is
to help them to help their own recovery. Care must be taken with use of
language, so that the physiotherapist is understood and patients are clear
as to what they need to do. It is well documented (Devine 1992) that
preoperative advice or information helps to reduce anxiety and prevent
complications. Any verbal information should be reinforced by supporting
information such as leaflets, tapes or videos (Theis & Johnson 1995). Many
units have developed their own literature but general information booklets
are also available such as the booklet by Haslett & Jennings (2003).
The main objective of the preoperative session is to give advice and
teach exercises which are appropriate for the first few postoperative
days. In many units this will be the only contact with the physiotherapist
until several days after surgery, when further advice and exercise pro-
gression for discharge and afterwards will be given. There are several
aspects that need to be covered.
Respiratory system General anaesthesia and pain can both compromise respiratory function.
The number of women experiencing respiratory complications following
major gynaecological surgery is low (Amirika & Evans 1979); however
there are a number of factors that increase the risk of postoperative
respiratory complications. These include pre-existing lung disease (COPD,
asthma), smoking, reduced mobility and prolonged anaesthesia (Berek &
Hacker 2000). The existence of any of these risks should be determined
from the records. In order to reduce the risk it is advisable to educate the
patient with regards to both respiratory function and early ambulation.
Patients also need to be aware of the need to accept good pain control,
although this in itself can compromise respiratory and bowel function.
Upper abdominal surgery is known to cause severe and prolonged
alterations in pulmonary mechanics (Richardson & Sabanathan 1997).
Although there is little research in relation to gynaecological procedures,
it is recognised that opiates and sedatives can affect the natural ‘sigh’
mechanism. This mechanism maintains the patency of the smaller air-
ways, reducing the functional residual capacity.
A preoperative advice session allows the physiotherapist to identify
patients at risk of respiratory complications as well as to teach appropri-
ate techniques to optimise respiratory function. These techniques include
the active cycle of breathing technique (ACBT), with the use of a sniff at
324 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
the end of inspiration to increase lung volume for at-risk patients. The
use of forced expiratory technique (huffing) and supported coughing is
advised for use only if retained secretions are present postoperatively.
Coughing is likely to cause less pain if the patient supports the perineum
or abdomen, depending on the surgical approach.
Smoking should be discussed, although there is little evidence that
stopping or reducing smoking immediately prior to surgery is of benefit.
Some women will be keen to stop and see their admission to hospital as
the right time to do so. In the UK, smoking cessation is the target of a
national campaign (DoH 1998). Many Trusts employ or have access to
smoking cessation advisors. Some hospital staff may also have been
through a programme to give them skills to help patients in this situ-
ation. Physiotherapists need to be familiar with their local services.
Circulatory system There is a postoperative risk of deep vein thrombosis (DVT) and possibly
pulmonary embolus. This is due to intraoperative pressure and trauma to
the pelvic vasculature, as well as enhancement of the normal clotting
mechanism caused by surgery and bleeding. Risk assessment, which is
usually completed at the preadmission clerking clinic, will direct appro-
priate prophylactic measures. These may include antiembolitic stockings
and antithrombolytic drugs (e.g. Fragmin).
Early ambulation helps to reduce these risks, although full-range
plantar- and dorsiflexion of the ankle will also increase venous return in
the calves. Stiffness and soreness of the legs and buttocks can be reduced
by active hip and knee flexion and extension and by weight transference
and pressure relief. Women will usually be encouraged to sit in a chair for
a short while on the first postoperative day and will start to mobilise
more fully on the second.
Pelvic floor muscle These exercises are important regardless of the surgical route used. For
exercises women undergoing vaginal hysterectomy or repair, the pelvic floor muscles
(PFMs) are directly affected by surgery and need to be strengthened to
provide maximal functional support. The role of the PFMs in the treatment
of stress incontinence is well documented (Berghmans et al 1998). For
women who are having anti-stress-incontinence procedures, exercises
should be encouraged, to strengthen and support. It is well documented
that hysterectomy may affect bladder and bowel function (see p. 312).
Therefore pelvic floor muscle exercises (PFME) are also recommended
following abdominal hysterectomy.
It is easier to learn PFM contractions prior to surgery. It is known that
brief verbal instruction is not adequate for many women to achieve cor-
rect pelvic floor action (Bø et al 1988, Bump et al 1991). It is not usually
appropriate for women to undergo vaginal assessment of their PFM
function at this preoperative session. The physiotherapist must therefore
use diagrams or models and provide sufficient detail when explaining
the anatomy, function and contraction of the muscles. A combination of
fast (phasic), slow maximal and submaximal (tonic) contractions should
be encouraged, as well as the use of an anticipatory PFM contraction (‘the
knack’) for activities causing any increase in intra-abdominal pressure
(Miller et al 1996, Naylor 2002).
Abdominal muscle Whilst it is assumed that the abdominal muscles are directly affected by
exercises abdominal surgery, there is currently no evidence to support this.
Following the clinical-reasoning process with regard to pain causing
muscle inhibition, it seems appropriate for women to work these muscles
in order to restore normal function following abdominal surgery.
Transversus abdominus contractions (submaximal) are believed to
facilitate pelvic floor muscle activity and enhance core stability (Sapsford
et al 2001). These exercises, which can be difficult to teach, should be
taught in a position appropriate for the postoperative period (e.g. crook
lying or standing). Pelvic tilting taught in crook lying works the oblique
abdominal muscles but may also help to reduce wind pain. The same
appears to be true of gentle trunk rotations, although, as yet, there is no
research evidence to support this.
Gentle abdominal muscle exercises also help to facilitate trunk move-
ment and early mobilisation, by reducing the fear of movement. Whilst it
may be possible to teach these exercises in a group setting, they will need
to be performed on a hospital bed and checked individually.
Posture and back care Decreased mobility, poor positioning and lack of lumbar support may
cause backache in the postoperative period. As well as the above abdom-
inal muscle exercises and early mobilisation, patients should be advised
to adopt supported positions, using appropriately placed pillows or
lumbar rolls. This may also help to reduce neck pain and headaches.
326 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Wind pain This can be caused by stationary air in the gut due to reduced peristalsis
following general anaesthetic. It is also thought to be caused by air in the
peritoneal cavity, and this takes time to be absorbed. The resulting pain
can be acute, within the abdomen or referred to the right shoulder, or
both. Early ambulation, gentle abdominal muscle exercises and abdom-
inal massage have all, anecdotally, been reported as helping to reduce
this pain.
Patient discussion Having discussed all of the above areas, the patient may still have con-
cerns. It is important that anxiety levels are reduced as far as possible so,
given sufficient time, the rapport built between the specialist physiother-
apist and the patient should make raising of concerns easier. The matter
can then be discussed and referral to another team member arranged if
thought appropriate.
Early treatment The immediate objectives are to achieve good respiratory and vascular
function and early mobilisation. For most patients who have received a
thorough preoperative preparation, these issues will not be a problem
and no intervention will be required for the first day or two following
surgery. Nursing staff should be familiar with the need for patients to
perform breathing and circulatory exercises. They should also be able to
facilitate appropriate transfers and mobilisation.
If no preoperative preparation has taken place, however, early assist-
ance may be required. This can be a slow and time-consuming process, as
patients may be affected by either anaesthetic or postoperative analgesia.
They may not be receptive to an unfamiliar person or understand the
rationale behind the new advice they are given.
For patients with known risk factors or early respiratory complica-
tions, assessment and appropriate treatment must be commenced as soon
as possible.
Further progression Ideally these will have been learnt preoperatively. PFME should be
encouraged as soon as possible after surgery. Pain will cause muscle inhib-
Pelvic floor muscle ition and so encouragement to take adequate analgesia, along with a
exercises delay in commencing exercises, is important if pain is a problem. Many
physiotherapists believe that PFME should be delayed if a catheter is
present in the urethra, although there is no evidence to prove any harmful
Gynaecological surgery 327
effects (Haslam & Pomfret 2002). The PFME may be started if a supra-
pubic catheter is in place, although abdominal discomfort around the
catheter during cocontraction of the tranversus abdominus may again
cause a delay in starting these exercises.
A combination of fast (phasic), slow maximal and submaximal (tonic)
exercises are appropriate, with varying emphasis depending on the type
of and rationale for surgery (Naylor 2002). If surgery has been performed
for prolapse, submaximal contractions held for several seconds may help
to increase the resting tone of the PFM and increase postural support.
Following abdominal surgery, the exercises are used to enhance the func-
tion of the trunk stabilisers, by cocontraction of the transversus abdomi-
nus, and to reduce the possibility of urinary incontinence. Again, slow
recruitment, submaximal holds are more important (Sapsford et al 2001).
The use of PFM ‘bracing’, known as ‘the knack’ (Miller et al 1996), is
important following all gynaecological surgery. This contraction counter-
acts the increase in intra-abdominal pressure and both fast and slow max-
imal contractions are needed for this to be effective. This is particularly
important for women after continence procedures.
Abdominal muscle Ideally these will have been taught preoperatively. The preoperative
exercises section gives information about the rationale for abdominal muscle exer-
cises (see p. 325). The importance of pain causing muscle inhibition
cannot be understated (see PFME, p. 326).
Transversus abdominus, pelvic-tilting and knee-rolling exercises in
crook lying will help to reduce backache, stiffness and wind pain. They
may be commenced as soon as pain allows, usually within the first few
days. Care, however, must be taken when recommending any progres-
sion of abdominal muscle exercise as any increase in intra-abdominal
pressure could put a strain on healing tissues.
The most important reason for performing abdominal muscle exer-
cises is to improve the support provided by these muscles. In order to do
this the local and global stabilisers need to be functioning well before
further progression occurs.
Posture and back care There is a tendency to adopt protective flexed postures following surgery.
Abnormal postures require correction. The patient must be made aware
of the problem and be encouraged to sit, stand and walk ‘tall’, using the
transversus abdominus, the PFMs and lumbar support where appropri-
ate. It is important that the woman understands how to take care of her
back and this must be discussed prior to discharge.
Stairs are not usually a problem for women after gynaecological sur-
gery. However, if there is concern about the woman’s ability to climb the
stairs at home following discharge, or if indicated for other reasons, then
the physiotherapist can assess and advise.
Rest This is as important as mobilisation. Too much activity will cause tired-
ness, which can delay recovery. Sleep and relaxation can be difficult to
achieve on a busy ward; but adopting comfortable resting positions and
discussing anxieties will help. For some patients, the teaching of relax-
ation techniques or a recommendation that they move to a quieter part of
the ward may be beneficial.
Immediate postoperative The patient will be given antibiotics. ACBT, huffing and supported
complications coughing are recommended. Humidification and positioning, as well as
ambulation, may help to improve expectoration.
Chest infection
DVT Prophylactic care has been discussed in the preoperative section (see
p. 324). Should a DVT occur then anticoagulant therapy will commence
with instructions on mobility status.
Wound infection As for chest infection, the patient will be given antibiotics. Any wound
infection may reduce the exercise level, which will have a knock-on effect
on recovery rate.
Voiding dysfunction Routine postoperative nursing observations should pick up any prob-
lems with voiding, such as retention, urgency and frequency, although it
is the responsibility of all members of the multidisciplinary team to moni-
tor and act on any problems. Straining to void must be discouraged as
this will increase the pressure on both the PFM and other healing struc-
tures. Infection of the urinary tract or bladder will be treated with antibi-
otics. The patient may report symptoms of urinary incontinence directly
to the physiotherapist, particularly if the patient is aware of the role of
physiotherapy from preoperative contact.
PREPARING TO LEAVE Patients should be adequately prepared for discharge home. The infor-
HOSPITAL mation they have been given verbally must be reinforced in written or
audio format. This will allow them to refer to the advice once at home but
it also allows the advice to be accessible to carers and other members of
the family. Any carer demands on patients themselves should have been
resolved whilst in hospital, if not before.
If patients have been seen preoperatively then some of the discharge
advice may have been given at that stage. This would be appropriate
if concerns regarding discharge are causing anxiety before surgery. All
women must be seen at least once following their operation for advice
on progression to their normal activity level and to prevent long-term
complications or, in some cases, recurrence of the initial problem.
Gynaecological surgery 329
Discharge advice • The first 1–2 weeks should be a continuation of hospital care. This
following uncomplicated means a combination of gentle mobilisation and rest, with someone to
major gynaecological prepare meals and perform other household tasks.
surgery • It is crucial that constipation is avoided. Straining at defaecation will
increase the pressure on the PFM as well as other healing structures.
Advice should be given regarding fibre and fluid intake as well as
short-term laxative use if required. All women will benefit from being
given advice on appropriate positioning and defaecation technique
(Markwell & Sapsford 1995). (See p. 387.)
• After a few days, short walks outside can be introduced with a gradual
progression in distance and speed as recovery occurs.
• After 1–2 weeks light household activity can be recommenced, but
prolonged standing should be avoided. Activity levels can gradually
be increased so that slightly heavier jobs (e.g. light shopping and
ironing) are undertaken by 4 weeks.
• Lifting more than 1 kg must be avoided for 4 weeks; after that a
gradual increase is recommended but it will take at least 3 months to
return to heavy lifting. It must be emphasised that the transversus
abdominus and PFM should be braced during any lifting. If, despite
this, breath holding or abdominal straining occur, the load is too
heavy. It may be recommended that some women never return to their
usual preoperative lifting level.
• Driving may be recommenced at about 4–6 weeks; however, women
should be advised to check their insurance cover. The main concerns are
the ability to perform an emergency stop (and the effect this would have
on healing tissues), general movement in the car and heavy steering.
Women are well advised to try an emergency stop before driving on
public roads; if they are hesitant to do so they should not drive.
• Encouragement should be given to continue the exercise programme
with gradual progression.
• By 6 weeks, household activities such as vacuuming and laundry tasks
may be recommenced.
• Most units will arrange an outpatient review with a member of the
consultant team at about 6 weeks. This is the earliest at which women
are advised to return to work – the more active the job, the longer
is required off work, with some women returning to work as long as
3 months after their operation.
• Some physiotherapists provide a postoperative class about 6 weeks
after surgery. This can be used to reinforce information about PFME,
defaecation technique, moving and handling, general back care and
return to fitness.
• Sexual activity is recommenced when comfortable, but most women
wait until after their 6-week review appointment. Dyspareunia can be
a complication of vaginal surgery, owing to physical or psychological
problems, or both (see p. 296)
• General exercise is not recommended until at least 6 weeks. Ballistic
activities and those causing large increases in intra-abdominal pressure
are to be avoided initially and for some patients permanently. The
progression of walking, swimming or water-based exercise is
particularly beneficial.
330 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
LIFELONG ADVICE The importance of maintaining good PFM function cannot be empha-
sised enough and women need to be aware that PFME should be as much
of a habit as cleaning their teeth!
Although the recovery rate and routine are similar regardless of the
surgical route, the rationale is different. For women with poor quality
connective tissue who have undergone surgery for prolapse, the contri-
buting lifestyle factors must be discussed so that they are able to reduce
recurrence. This means the avoidance of constipation, heavy lifting,
weight-bearing exercise and management of any aggravating respiratory
conditions. It may also mean weight reduction, for which they may need
advice and support. The body will be getting older over time and women
need to be aware of the adverse role these factors can play, although this
may require huge lifestyle changes. By educating patients, physiother-
apists are able to empower patients to help themselves.
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of Obstetrics and Gynaecology 109:566–569. Publications, Beaconsfield.
Brown J S, Sawaya G, Thom D H et al 2000 Hysterectomy Hidlebaugh D A 2000 Cost and quality-of-life issues
and urinary incontinence. Lancet 356:535–539. associated with different surgical therapies for the
Bump R C, Hurt W G, Fantl J A et al 1991 Assessment of treatment of abnormal uterine bleeding. Obstetrics and
Kegel pelvic muscle exercise performance after brief Gynecology Clinics of North America 27(2):451–465.
verbal instruction. American Journal of Obstetrics and Hutchings A, Black N A 2001 Surgery for stress incontinence:
Gynecology 165(2):322–329. a non-randomised trial of colposuspension, needle
Gynaecological surgery 331
suspension and anterior colporrhaphy. European Olsen A L, Smith V J, Bergstrom J O et al 1997 Epidemiology
Urology 9(4):375–382. of surgically managed pelvic organ prolapse and urinary
Hutchings A, Griffiths J, Black N A 1998 Surgery for stress incontinence. Obstetrics and Gynecology 89(4):501–506.
incontinence: factors associated with a successful RCP (Royal College of Physicians) 1995 Incontinence: causes,
outcome. British Journal of Urology 82(5):634–641. management and provision of services. RCP, London, p 1–5.
Hysterectomy Association 2002 Online. Available: Richardson J, Sabanathan S 1997 Prevention of respiratory
http://www.hysterectomy-association.org.uk. complications after abdominal surgery. Thorax
Jarvis G J 2000 Surgery for urinary incontinence. Ballière’s 52(suppl 3):S35–S40.
Clinical Obstetrics and Gynaecology 14(2):315–334. Rufford J, Cardozo L 2001 The role of TVT in genuine stress
Kahn M A, Stanton S L 1997 Posterior colporrhaphy: its incontinence. Reviews in Gynaecological Practice
effects on bowel and sexual function. British Journal of 1(1):7–11.
Obstetrics and Gynaecology 104(1):82–86. Sapsford R, Hodges P, Richardson C et al 2001 Co-activation
Laycock J, Standley A, Crothers E et al 2001 Clinical of the abdominal and pelvic floor muscles during
guidelines for the physiotherapy management of females voluntary exercises. Neurourology and Urodynamics
aged 16–65 with stress urinary incontinence. Chartered 20:31–42.
Society of Physiotherapy, London, p 12–14. Smith T, Daneshgari F, Dmochowski R et al 2002 Surgical
Markwell S J, Sapsford R R 1995 Physiotherapy management treatments of incontinence in women. In: Abrams P,
of obstructed defaecation. Australian Journal of Cardozo L, Khoury S et al (eds) Incontinence, Ch. 11.
Physiotherapy 41:279–283. Health Publications, Plymouth, p 825–863.
Meikle S F, Nugent E W, Orleans M 1997 Complications and Stanton S L, Hilton P, Norton C et al 1982 Clinical and
recovery from laparoscopy-assisted vaginal hysterectomy urodynamic effects of anterior colporrhaphy and vaginal
compared with abdominal and vaginal hysterectomy. hysterectomy for prolapse with and without
Obstetrics and Gynecology 89(2):304–311. incontinence. British Journal of Obstetrics and
Miller J M, Ashton-Miller J, DeLancey J O L 1996 The Knack: Gynaecology 89(6):459–463.
use of precisely timed pelvic muscle contraction can Thakar R, Ayers S, Clarkson P et al 2002 Outcomes after total
reduce leakage in stress urinary incontinence. versus subtotal hysterectomy. New England Journal of
Neurourology and Urodynamics 15:392–393. Medicine 347(17):1318–1325.
Milsom I, Ekelund P, Molander U et al 1993 The influence of Theis S L, Johnson J H 1995 Strategies for teaching
age, parity, oral contraception, hysterectomy and patients: a meta-analysis. Clinical Nurse Specialist
menopause on the prevalence of urinary incontinence in 9(2):100–105.
women. Journal of Urology 149(6):1459–1462. Thomson A J, Sproston A R, Farquharson R G 1998
Moehrer B, Ellis G, Carey M et al 2002 Laparoscopic Ultrasound detection of vault haematoma following
colposuspension for urinary incontinence in women. vaginal hysterectomy. British Journal of Obstetrics and
Cochrane Database of Systematic Reviews. Update Gynaecology 105(2):211–215.
Software, Oxford. Online. Available: http://www. van der Vaart C H, van der Bom J G, de Leeuw J R J et al 2002
cochrane.org/cochrane/revabstr/ab002239.htm The contribution of hysterectomy to the occurrence of
Naylor D 2002 Which is the best way to exercise pelvic floor urge and stress urinary incontinence symptoms. British
muscles? Journal of the Association of Chartered Journal of Obstetrics and Gynaecology 109:149–154.
Physiotherapists in Women’s Health 91:23–28. Ward K, Hilton P 2002 Prospective multicentre randomised
Neale E J 2002 Abdominal hysterectomy after insertion of trial of tension-free vaginal tape and colposuspension as
tension-free vaginal tape. British Journal of Obstetrics primary treatment for stress incontinence. British
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Further reading
Cardozo L, Staskin D (eds) 2002 Textbook of female urology Cardozo L, Khoury S et al (eds) Incontinence, Ch. 11.
and urogynaecology. Isis Medical Media, London. Health Publications, Plymouth, p 825–863.
Smith T, Daneshgari F, Dmochowski R et al 2002 Surgical
treatments of incontinence in women. In: Abrams P,
Useful addresses
Hysterectomy Association
Tel 0871 7811141
Website: www.hysterectomy-association.org.uk
333
Chapter 11
CHAPTER CONTENTS
Introduction 333 Urodynamic, radiological and electromyographical
Normal lower urinary tract function 336 assessment 361
Lower urinary tract dysfunction 342 Understanding urinary dysfunction 364
Incontinence of urine 343 Physiotherapy treatment 364
Voiding difficulties 348 Management of persistent urinary
Physiotherapy assessment methods 349 incontinence 379
The terminology used in this chapter largely complies with the ICS
Standardisation of terminology of lower urinary function (Abrams et al
2002a), which is published in full in Appendix 1 on p. 427. However, to
assist readers in consulting literature published earlier than 2002, the
1988 version (Abrams et al 1988) is also included as Appendix 2 on p. 449.
INTRODUCTION
mental – of the whole person, but also the environment. This includes
privacy and cleanliness.
In addition, 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 faeces into clothing, in a bed or chair, on to the ground or into a recep-
tacle not designated for the purpose the person is likely to be labelled as
‘incontinent’.
‘Incontinence’ has been defined as the involuntary or inappropriate
passing of urine or faeces, or both, that has an impact on social function-
ing or hygiene (DoH 2000). This definition applies only after early child-
hood. Incontinence of urine or faeces is a symptom or a sign with a cause,
not a condition or a specific disease. It may be a temporary state associ-
ated 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). Incontinence
is not life threatening, but it is humiliating, distressing, degrading and
expensive (Hu 1990) for the sufferer. Where it persists, it can lead to isol-
ation, depression, loss of self-esteem, and ill health, for example infec-
tions (Wyman et al 1990). The odour and damage to property it causes
militate against proper social integration (Grimley et al 1993) and, espe-
cially for children and the elderly, can even result in the person being
ostracised, abused and receiving insufficient care from unsympathetic or
poorly informed carers. It has been suggested that incontinence is a major
factor in sufferers and carers reaching crisis point with consequent refer-
ral to residential care (Continence Foundation 2000).
There is considerable individual variation in what each person classes
as a ‘continence problem’. Furthermore there are many sufferers who do
not seek help because they are too embarrassed to consult their general
practitioners or anyone else, and others who consider their state to be
inevitable (Hampel et al 1997). Sufferers naturally oppose the ‘inconti-
nent’ label – ‘I’m not incontinent, I just leak sometimes!’ Researchers have
used a variety of parameters regarding amount lost and frequency of
loss in their definitions of incontinence, which makes firm statements
on prevalence unwise. However, the Royal College of Physicians (RCP
1995) produced a useful synthesis of the literature and the Continence
Foundation (2000) expanded on this to produce a model to enable read-
ers to produce an estimate of prevalence in their particular area, which is
certainly a useful starting point when appraising services for sufferers in
a locality. It is safe to say that in the UK, incontinence, both urinary and
faecal, is more common in women than men and that it increases with
parity and age (RCP 1995, Thomas et al 1980, 1984). Faecal incontinence
is probably less common than urinary incontinence but there is no doubt
that faecal incontinence is underreported for obvious reasons. Faecal
incontinence is more often accompanied by urinary incontinence (double
incontinence) than occurring alone. It is also safe to say that most
Urinary function and dysfunction 335
Prevention of Prevention has always been much better than cure – assuming that
continence problems cure is even possible once a health problem has started. Continence is
priceless and an unappreciated gift until it is lost. Much suffering could
be avoided if individuals had in-depth understanding of how to promote
their own continence. Repetitive coughing, smoking, frequent constipa-
tion, 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 (Hannestad et al 2003). A simple
understanding of the workings of the tracts concerned, what is and is not
normal, what to avoid and where to go for speedy advice would make a
start in continence promotion. Following childbirth, it is important to
regain prepregnancy 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 contrac-
tions (Wall & Davidson 1992), and it is never too late to start!
Physiotherapists interact with large numbers of people in a wide range
of contexts. Physiotherapists are good communicators and also have
the knowledge and skills to make a substantial impact in this field of
prevention. Continence status and continence promotion should be con-
sidered routinely for all patients, clients and carers. This imperative is
not limited to physiotherapists working in obstetrics and gynaecology,
although obstetrics in particular offers unique opportunities in preven-
tion. For example, patients with hay fever, asthma, chronic chest condi-
tions, 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
dysfunctions.
336 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
The basic anatomy of the lower urinary tract was described in Chapter 1
(see p. 18). Urine is produced continuously by the kidneys. It passes, via
the ureters by means of peristalsis, from kidneys to the bladder in vary-
ing amounts – more during the day and less at night owing to the diurnal
rhythm of antidiuretic hormone secretion. The bladder acts alternately as
a storage organ and then as a pump to void urine in a cyclic fashion. The
act of voiding urine is called micturition – hence the use of the term – ‘the
micturition cycle’.
THE MICTURITION The micturition cycle (Fig. 11.1) consists of two phases: bladder filling
CYCLE and 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 post-
poned 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 detru-
sor 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 incom-
ing 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
60 Decision to void
Detrusor
contraction
Bladder emptying
Detrusor pressure cm H2O
45
Bladder relaxation
30
First desire to void
Postponement
15
ling
Bladder fil
Volume change
Compliance volume ⫽ .
Change in detrusor pressure
• the elastic connective tissue, including muscle fibres in the neck of the
bladder and urethral wall, placed obliquely and longitudinally, closing
the lumen of the urethra
• the turgidity of the cells of the walls and the blood supply
• the adhesive force of contact of the moist epithelial lining of the
urethral walls
• the length of the urethra – 3–5 cm in women
• the steady contraction of the type 1 striated muscle of the external
urethral sphincter (see p. 20)
• the support, occlusive compression and lift applied by the type 1
fibres and, when necessary, the type 2 fibres of the levator ani
muscles
• the intra-abdominal pressure applied to the proximal portion of the
urethra above the pelvic floor.
Eventually, 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.
Average
flow rate
Voided volume
Time (s)
Maximum flow rate
bladder base returns to its higher position. Some women develop the
habit of bearing down or contracting the abdominal muscles, or both, at
the end of micturition in an attempt to squeeze out a final drop. Women
in a hurry may bear down during voiding to try to increase the flow rate.
Conversely many women are able to slow or even stop urine flow mid-
stream by voluntarily contracting their PFMs strongly and then relaxing
to restart the flow, for example to collect a midstream urine specimen.
Voluntary contractions of the PFMs may also be used to encourage detru-
sor relaxation in order to defer micturition for short periods or overcome
urgency, or both, utilising the perineodetrusor reflex (Mahony et al 1977).
Several authors (Bø et al 1989, Bump et al 1991, Kegel 1948, Shepherd
1990) have claimed that about 30% of parous women have no innate
ability to consciously contract their PFMs voluntarily; however, expert
opinion suggests that most can be taught the skill.
Storage The bladder wall is richly supplied with stretch receptors whose dis-
charge 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. This is
probably the mechanism brought into play intuitively if the point of
extreme bladder filling has been reached and a suitable site has yet to be
found, and it can be complemented to advantage by conscious pelvic
floor contraction (Hilton 1988). It is also the mechanism that makes it
difficult to micturate in stressful circumstances.
Mahony et al (1977) described a series of storage and voiding reflexes.
One of these, the perineodetrusor inhibitory reflex, is of particular
340 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Decision to
void taken
Postpone
voiding
Preparatory
actions
Nerve Nerve g
g in
in fill
roots fill roots
T11–L3 m T11–L3 from
fro ng
ng i
hi t ch
tc re ct
re St tra
A desire St ax Bladder A desire n Bladder
to void R el to void Co
Nerve Nerve
roots Con roots Rela
S2–4 tract S2–4 x
Co External Re External
ntr lax
act sphincter sphincter
Inhibit voiding
x
la
A desire Re
to void Bladder
Co
nt
Nerve
ra
c
roots Con
t
tract
S2–4
Co External
ntr
act sphincter
Levator ani
(c) muscles
Figure 11.3 A simplified diagrammatic representation of the neurological control of urinary continence: (a) a mild
desire to void; (b) decision to void; (c) desire to void but environment not conducive.
Urinary function and dysfunction 341
A SUMMARY OF • The bladder and urethra are structurally sound and healthy; damage
FACTORS WHICH or pathology, such as infection, will affect function.
FAVOUR NORMAL • The nerve supply to the bladder, urethra, external sphincter and PFM
URINARY is intact; conditions such as multiple sclerosis and diabetes, or
FUNCTIONING childbearing, can cause disruption.
• The bladder is positioned and tethered 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; child-
bearing 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, and should result in continence being relatively
unaffected by intra-abdominal pressure changes.
• 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’.
342 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
• The woman does not suffer from faecal impaction, for this can cause
urinary incontinence. 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 11⁄2 litres per day, and avoidance of
excess alcohol or caffeine (e.g. coffee, tea, cola, chocolate, Lucozade).
Though the maintenance of urinary continence is multifactorial, experi-
ence indicates that considerable damage or deterioration in these factors,
or both, can occur without inevitable loss of continence.
INCONTINENCE OF URINE
COMMON TYPES OF Loss of urine through channels other than the urethra is called extra-
URINARY urethral incontinence. This may be due to congenital abnormality (e.g. an
INCONTINENCE aberrant ureter draining into the vault of the vagina). Fistulae between
the bladder or urethra and the vagina are most commonly the result
Extraurethral of trauma at pelvic surgery such as hysterectomy, particularly where the
incontinence pelvic anatomy has been distorted by disease such as endometriosis,
infection or carcinoma. In the Developing World, childbirth is still a major
cause of trauma resulting in fistulae (Wall 1999) (see pp. 88 and 94) and it is
not yet unknown in the West. Management usually requires reconstruc-
tive surgery (Hilton 2001, 2002, Shah & Vakalopoulos 2002).
Changing terminology The ICS (Abrams et al 2002a) has recommended that the terms ‘motor
and sensory urgency motor urge incontinence’ and ‘reflex incontinence’
should no longer be used; also that ‘detrusor instability’ and ‘detrusor
hyperreflexia’ respectively should be subsumed into the detrusor over-
activity idiopathic and neurogenic categories respectively.
The urgency and possible incontinence resulting from detrusor over-
activity has a variety of causes. It is naturally associated with frequency;
it is the second most common cause of urinary incontinence in women
in their middle years (McGrother et al 2001) and the most common cause
in the elderly. The precise aetiology is not fully understood, but usu-
ally the unwanted detrusor activity can be demonstrated by means of
cystometry.
Local pathology such as infections, malignancies, interstitial cystitis or
stones leads to hypersensitivity of the receptors in the bladder wall, and
sometimes the urethra. Thus, as the bladder fills, early and unwanted
detrusor contractions are either produced spontaneously or provoked by
activity. Cystitis is the most common example of this manifestation. The
patient responds by voiding frequently in an effort to reduce leakage
episodes, and this behaviour may even continue after the cause has been
removed.
Neurogenic detrusor overactivity presents in a variety of forms. For
example, there may be detrusor contraction and urethral relaxation in the
absence of any perceived sensory desire to void, owing to neurological
impairment. This condition is outside the scope of this book, but is essen-
tially the result of an uninhibited sacral micturition centre and associated
reflex arc. It is seen in paraplegics, and the bladder empties incompletely
and without proper conscious control.
In patients experiencing urgency, with or without leakage, there may
be apparently spontaneous detrusor contractions or contractions pro-
voked by such common activities as walking or coughing. In the latter
case any resulting leakage is sometimes confused with urodynamic stress
incontinence until urodynamic assessment is made. Such contractions
may indicate a neurological disorder such as multiple sclerosis. However,
it is known that they may occur in the apparent absence of neuro-
pathology, and may even be asymptomatic, in which case they are con-
sidered significant only if the patient complains of them. Where there is
no known cause, a diagnosis of idiopathic detrusor overactivity would be
appropriate.
Management is crucial, particularly in the elderly where urgency and
detrusor overactivity incontinence predisposes to falls and fractures as
people try to rush to the toilet (Brown et al 2000). It consists of removing
the cause whenever possible and explaining the problem to the patient.
This should be followed by pharmacotherapy to reduce detrusor activity,
exercises to strengthen the PFM if necessary, and then teaching defer-
ment techniques using repeated voluntary PFM contraction (VPFMC),
Urinary function and dysfunction 345
Urodynamic stress The phrase ‘stress incontinence’ may be used to denote a symptom, a
incontinence sign and a condition.
1. 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). This may be due to urodynamic stress
incontinence, but could be entirely or partly due to detrusor contrac-
tions provoked by these activities – that is, detrusor overactivity.
2. 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 con-
ducted standing up, rather than lying down. The patient may also be
able to demonstrate how a particular activity such as jumping pro-
duces a leak.
3. The condition. Urodynamic stress incontinence (USI) is the name
coined to denote the condition in which there is involuntary loss of
urine when, 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. Urodynamic assessment is the only reliable way
of diagnosing this, and indeed urethral sphincter incompetence and
detrusor overactivity frequently coexist.
Mixed urinary incontinence is the complaint of involuntary leakage asso-
ciated with urgency and also with exertion, effort, sneezing or coughing.
USI is often associated with urgency and frequency. This may be due
to a heightened awareness of any desire to void for fear of leakage. The
woman will try to keep her bladder as empty as possible by repeated
voiding, and it is possible that this might remove the normal healthy
challenge to the muscular elements of the closure mechanism, possibly
predisposing to atrophy and producing a vicious circle.
How the various factors comprising the urethra closure mechanism
interact, and in what proportion, is not fully understood, nor is it known
to what degree each may be compromised before USI occurs. Prolapse of
the bladder and urethra, due to damage to supporting structures or asso-
ciated with uterine descent, may be a cause, possibly due to loss of the
pinchcock effect of the intra-abdominal pressure. Conversely prolapse,
particularly if it substantially involves the anterior wall of the vagina, may
favour continence by causing a kink in the urethra. Atrophy associated
346 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
with reduced oestrogen and ageing presumably attacks the elastic and
adhesive factors of the urethral wall. However, weakness and sagging of
the pelvic floor are the factors on which physiotherapists have concen-
trated their attention. This weakness may result from any of the following:
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 affects 15–20% of 5-year-old chil-
dren and up to 2% of young adults (Glazener & Evans 2003). 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. The vast majority of children who suffer from nocturnal
enuresis are dry by puberty but the condition causes great psychological
Urinary function and dysfunction 347
suffering and social deprivation. The child has difficulties staying over-
night with friends or going on school trips; it can cause stress between
parents and the child, and even abuse (Warzak 1993). The condition
requires specialist care and this is usually given by the continence advisor.
Parents and sufferers should also be encouraged to seek help and advised
to contact the Enuresis Resource and Information Centre (ERIC).
Management begins with a full assessment, possibly with cystometry
to detect detrusor overactivity. The young patient and carer must under-
stand the problem. It may be necessary to change diet to reduce caffeine
intake, such as cola drinks and chocolate. Reward charts and scheduled
awakening may be tried. Where it is thought that the child sleeps too
deeply to be aware of the desire to void, various alarm systems can be
used. 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 Girls in particular go through a giggling phase around puberty, if not
before. A few find this results in embarrassing leakage of urine. There is
often a positive family history of this problem. It is thought that giggle
incontinence is caused by detrusor overactivity induced by laughter
(Chandra et al 2002).
Following careful assessment and elimination of pathology, treatment
is as for detrusor overactivity; in severe cases this may include pharmo-
cotherapy. 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 con-
tracting these muscles before and while giggling. Continence-promoting
advice should include fluid intake and bowel habits (see p. 368).
Incontinence associated The urethra and bladder lie in close proximity to the vagina; thus sexual
with sexual activity activity can cause urinary symptoms and lower urinary tract dysfunc-
tion, and this in term may give rise to sexual problems. ‘Honeymoon cyst-
itis’ or postcoital dysuria, with and without infection, is common in
young women, and dysuria, urgency and urinary tract infections are
noted by postmenopausal women following intercourse. Many women
also have the urge to void urine during or immediately following coitus,
and some experience actual leakage during intercourse on penetration or
orgasm. Leakage on penetration is more commonly associated with USI,
urgency, whereas detrusor overactivity as well as USI may be implicated
with leakage at orgasm (see p. 294). Women who experience this distress-
ing condition may be comforted by the realisation that they are not alone;
Hilton (1988) found 24% of 324 sexually active women referred to a gynae-
cological clinic experienced incontinence – two-thirds on penetration and
one-third on orgasm.
The women’s health physiotherapist is often the first person in whom
the patient confides the presence of this embarrassing problem, and, in
348 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Functional This section includes all cases where there is involuntary loss of urine
incontinence resulting from a deficit in ability to perform toileting functions secondary
to physical or mental limitations. This is a very important group for phys-
iotherapists and highlights the need for all physiotherapists to consider
the continence status of all patients and to have its promotion as an
implicit objective in all rehabilitation across all specialties. Being depend-
ent on others for toiletting is a recipe for disaster. It may well be that it is
the women’s health physiotherapist on whom rests the responsibility to
raise the awareness of colleagues.
Only careful assessment will reveal the crux of the problem; physio-
therapists, in collaboration with occupational therapists, will look first
for evidence of insufficient mobility in strength and range of movement,
and balance difficulties – in which case the solution will lie in improving
these where possible, or arranging for the toilet to be more easily access-
ible (e.g. moving the toilet nearer, or the seat higher, or adding grab rails).
Other types of obstacles include heavy difficult doors, insufficient turn-
ing space, complicated clothing and fear of falling. Each of these requires
an individualised solution in collaboration with the continence advisor
and the occupational therapist. Physiotherapists are particularly skilled
at assisting carers to plan transfers and lifts.
In hospitals and care homes, it is crucial that toilets are clearly marked
to overcome problems associated with poor sight and confusion. New
patients/residents should be actually shown where the toilets are – several
times if necessary. It is important that there are sufficient toilets to avoid
queuing and that they are kept scrupulously clean. Many women dislike
using toilets away from their own home and deferring voiding and
defaecation will inevitably lead to accidents. More difficult is trying to
facilitate, as far as possible, independent voiding for the confused and
demented. Studying the relevant key mannerisms and natural habits of
these individuals can lead to an individualised programme of prompted
voiding. Alternatively timed voiding, for example being taken to the
toilet every 2 hours or so, may be successful in some cases (see p. 377).
VOIDING DIFFICULTIES
volume of urine, caused by the urethra being obstructed, that it cannot con-
tract effectively. Urethral dyssynergia, which occurs often with multiple
sclerosis, is a condition in which the urethral musculature does not relax
when the detrusor contracts for voiding. The result may be chronic uri-
nary retention. Eventually the pressure in the bladder rises and over-
comes the urethra closure pressure, and urine is passed in small amounts
as a dribble or spurt, often on movement or effort, until the pressure in the
bladder and the urethral closure pressure equate. This leaves a significant
volume of residual urine, and the pressure then quickly builds up again.
This situation can arise from neurological damage affecting the pelvic
innervation, for example diabetic neuropathy; some damage may result
in detrusor atonia, for example spinal shock, or cauda equina lesions.
Urethral obstruction in women may be caused by faecal impaction or
acute infection in the urethra, or can result from fibrosis following, for
example, bladder neck surgery or pelvic irradiation for carcinoma.
Assessment should first be by uroflowmetry to assess the flow rate,
if any, and a bladder scan will give an indication of the volume of urine
in the bladder following voiding. Management consists of removing the
cause where possible. Faecal impaction can be relieved and followed by
attention to diet and bowel training. Urethral obstruction due to urethral
fibrosis may be improved by laser treatment or urethral stretching. Weak
detrusor activity may sometimes be enhanced by drugs such as bethan-
echol chloride. In intractable neurological cases, clean intermittent self-
catheterisation may be taught, or a suprapubic catheter implanted.
Parity Duration
Year Type delivery Wt 1st 2nd 3rd Tear/Epis PN exs?
1.
2.
Figure 11.4 Physiotherapy 3.
4.
assessment form.
Urinary function and dysfunction 351
MEDICAL HISTORY
Other conditions (e.g. back pain problems, allergies, hayfever, asthma, chronic cough,
diabetes, high BP, depression)……………………………………………………………….
…………………………………………………………………………………………………..
Obesity
Smoking
Bowels – B/O per week………………………………….
Leakage wind/fluid/solid………………………………………………………………………
SURGICAL HISTORY
*
*
*
CURRENT MEDICATION
…………………………………………………………………………………………………..
………………………………………………………………………………………………
DIGITAL EXAMINATION
Vagina ………………………………………………………………………………………….
…………………………………………………………………………………………………..
Sensation/pain…………………………………………………………………………………
Anterior wall/grade………………………………………………………….
Posterior wall/grade………………………………………………………...
Grade L R
Hold time
Repetitions
Fast repetitions
Reflex to cough
Co-contract with TA
Signature Date
Figure 11.4 (Contd).
HISTORY OF THE The initial priority is to gain insight into the problem as the patient
PATIENT’S CONDITION perceives and experiences it, and the specific ways in which the condition
AND DETAIL OF is affecting her life. It is also important to note aspects of the person’s life,
PRESENT STATE past and present, which may have a bearing on the current situation (e.g.
occupation, childbearing, or back problems). Where the patient has been
352 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
URINALYSIS Urinalysis uses reagent strips and is a simple cost-effective way of detect-
ing a number of substances in urine such as sugar, blood, leucocytes, pro-
teins, nitrites and ketones. The patient is asked for a specimen of urine
and within 1 hour a reagent strip is dipped into it as per the instruction on
the reagent strip container. Sections of the strip change colour according
to abnormal content of the urine. The strip can then be read against the
normal coding key on the strip container. If the result is positive a mid-
stream urine sample should be sent for full laboratory testing.
Physiotherapists are strongly advised to seek official training in the
reading of these strips and in judging smell, colour and degree of cloudi-
ness of the urine (see Addison 2002).
FREQUENCY/VOLUME This is an invaluable tool in assessment. The patient is asked to note the
CHART (BLADDER time of day and to measure the volume of urine voided each time she
DIARY) goes to the toilet. This is recorded on a special chart over a period of days
decided with the patient or her carers, or both jointly (Fig. 11.5). Most
conveniently the patient voids into a large measuring jug, which may
have to be supplied to her. However, some people find this stressful.
Patients are recommended, where possible, to place the jug between their
thighs and sit on the toilet. Crouching over the lavatory, rather than sit-
ting relaxed on the seat, can result in an abnormal, interrupted or incom-
plete micturition sequence (Moore et al 1991). Patients may prefer to
place a small washing-up bowl into the toilet, micturate into it and then
pour the urine into the jug. This collecting process can be very demanding;
Date: I woke up at: I went to sleep at:
Time Record drinks taken Record ( ) each Tick when you Each time you leak urine, circle
(type and amount) time you use the changed a whether you were:
toilet to pass urine pad/pantyliner
353
Figure 11.5 A 1-day frequency/volume chart for assessment. (Courtesy of Leicestershire MRC Incontinence Study.)
354 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
it may be too difficult to carry out in the workplace because of the need
to have the measuring jug available. It requires agility and some dexter-
ity, and consequently it is not suitable for all patients. However, it is a test
physiotherapists can use and, for those patients who can cope, it is help-
ful to keep a record for several days, according to the exact information
required. It is often helpful if this includes weekdays and a weekend, or
days of paid employment and ‘home’ days. Where incontinence is asso-
ciated with a particular part of the menstrual cycle, recording over a
longer period may be necessary. In addition, on the same chart it is pos-
sible to record urinary accidents and the time, type and amount of drinks
taken.
From the chart it is possible to determine:
PAD TEST The test approved by the ICS (Abrams et al 1988 see Appendix 2) takes
1 hour and comprises the following sequence:
1. The test is started without the patient voiding.
2. A preweighed absorbent perineal pad is put on and the timing begins.
The patient is asked not to void until the end of the test.
3. The patient drinks 500 mL of sodium-free liquid (e.g. distilled water)
within 15 minutes, then sits or rests to the end of the first half hour.
4. In the following half hour the patient walks around, climbs up and
down one flight of stairs, and performs the following exercises: stand-
ing up from sitting (⫻10); coughing vigorously (⫻10); running on the
spot for 1 minute; bending down to pick up a small object (⫻5); wash-
ing the hands under cold running water for 1 minute.
At the end of the hour the pad is removed and weighed; any difference
from the starting pad weight constitutes fluid loss, and this is recorded.
If the pad becomes saturated during the test then a second pad may be
used. In this assessment, an increase of up to 1 g is considered normal to
allow for possible sweating and vaginal discharge.
The critics of this test highlight its stressfulness and artificiality. Versi
et al (1988) showed it to be unsatisfactory as a screening test; it gave a
Urinary function and dysfunction 355
PAPER TOWEL TEST This test is derived from a test used in research by Miller et al (1998).
In standing, the patient holds a coloured paper towel against the peri-
neum and coughs strongly three times. Any leakage is absorbed by the
paper towel, which, where damp, changes colour. Alternatively, having
removed lower underwear the patient stands astride the paper towel and
coughs three times; any leakage falls on to the towel. Assessment of the
amount of leakage can be measured by weighing or measuring the area
of the dampness. This test has been criticised as being undignified for the
patient. However, for those who do not leak whilst lying down, it can be
a satisfying vindication of their complaint.
PERINEAL AND The Royal College of Obstetricians and Gynaecologists (RCOG) has pub-
VAGINAL ASSESSMENT lished guidelines for intimate examinations (RCOG 2002). The Association
for Continence Advice (ACA) has produced comprehensive guidelines
entitled Examination and Assessment of the Female Pelvic Floor (ACA 2003)
which describe how to perform such an examination. The CSP informa-
tion paper no. PA 19 entitled Pelvic Floor and Vaginal Assessment (CSP
1996) sets out the range of options for acquiring the skill, and the CSP
information paper no. 19B entitled Association of Chartered Physiotherapists
in Women’s Health (ACPWH) Guidelines for Tutors Teaching Pelvic Floor and
Vaginal Assessment (CSP 1998) offers advice to tutors. Physiotherapists are
strongly advised to study all these guidelines and undertake specialist
practical training in this intimate examination, from an expert. ACPWH
356 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
The procedure in brief The whole procedure must adhere to the locally agreed infection
control policy. An explanation of the examination procedure and its
purposes is given to the woman; this is first, to enable the physiotherapist
to have an accurate knowledge of the condition of the perineum and
vaginal and, second, to establish the condition and strength of the PFMs.
It is important to check whether the patient has a known allergy to latex
and it may be helpful to use a simple diagram or model of the pelvis and
its contents to aid the patient’s understanding of the procedure. The
patient must be given the option of having a chaperone present during
the examination, whether the person is brought by the patient or pro-
vided by the physiotherapist. Furthermore, the patient must be informed
that she can opt out at any stage. If at any point in the procedure
the physiotherapist becomes aware of even the slightest sign of emo-
tional or physical discomfiture, the examination should be discontinued
immediately.
The woman’s informed consent to the examination must be obtained
and documented (DoH 2001). She is then given privacy (and help if
needed) to remove underwear and prepare herself on a couch in crook
lying. The couch should have been covered with disposable paper with
two pillows at the head. The patient is covered with a disposable paper
sheet, and an absorbent pad may be placed under the buttocks. The phys-
iotherapist talks through the examination, explaining what she is doing
and simply reporting what she is finding. The perineum is observed first
for skin condition, signs of infection, vaginal discharge, haemorrhoids,
prolapse and evidence of episiotomy or previous surgery. The patient is
asked to cough and strain; evidence of prolapse, ballooning of the peri-
neum or any leakage of urine or faeces is noted.
Wearing gloves and using a lubricant, the physiotherapist then sep-
arates the labia; after further observation the index finger of the dominant
hand is gently inserted into the vagina. The texture of the walls, evidence
of prolapse, quality of sensation and any pain caused are noted. The
physiotherapist curls her finger over the levator ani muscles and the
woman is asked to contract the pelvic floor muscles as if to stop leakage
or stop passing wind, or to grip the therapist’s finger and prevent its
withdrawal. The ability to contract or not is recorded, and where volun-
tary contraction is possible it is graded. With training and experience,
judgements can be made concerning the texture and integrity of the
muscle, scarring, the width between the two medial edges of the PFM,
and degrees of prolapse. The presence of reflex contraction to cough, and
coactivation of the PFMs by contraction of the transversus abdominis
muscle, are tested. The sensation over the perineum and of the anal
sphincter to touch, and the anal reflex may also be checked. The patient
is assisted to get off the couch and replace clothing. The patient is
then given a clear description of the findings and their implications for
treatment.
Urinary function and dysfunction 357
Manual grading of The method of grading most commonly used in the UK was proposed by
the strength of a Laycock & Chiarelli in 1989. It is a six-point scale (0 ⫽ nil contraction,
PFM contraction 1 ⫽ flicker, 2 ⫽ weak, 3 ⫽ moderate, 4 ⫽ good, 5 ⫽ strong) modelled on
the Oxford scale. Laycock & Jerwood (2001) built on this by developing
and validating the ‘PERFECT’ scheme whereby:
P ⫽ power – which is more correctly the ‘strength’ of the PFM deter-
mined on the six-point scale; both the left and right sides of the
levator ani muscles are graded
E ⫽ endurance – i.e. the time measured in seconds (up to 10) that a max-
imum voluntary contraction (MVC) can be held before fatigue sets in
R ⫽ repetitions – i.e. the number of MVCs which can be performed (up to
10) interspersed with rests of 4 seconds
F ⫽ fast – i.e. the number of 1-second contractions (up to 10) performed,
contracting/relaxing as quickly as possible, up to 10 or until fatigue
sets in
ECT – i.e. ‘every contraction timed’ – to complete the acronym.
An intertester reliability test of digital vaginal assessment of the PFM
(Jeyaseelan et al 2001) found that intertester reliability could not be
assumed but, where physiotherapists had received adequate specialist
training, it was good.
The perineometer Perineometers record changes in activity in the region of the vagina.
There are two types, one recording pressure changes, the other monitor-
ing electromyographic activity (EMG). The most commonly used simple
perineometer in the UK is the Peritron (Fig. 11.6). It is designed to record
the changes in pressure produced by voluntary contraction of the PFMs.
This is achieved by means of a vaginal pressure probe, which is usually
covered for use with a condom; if necessary a little lubricant jelly is
applied. Patients should be asked if they wish to introduce the probe
themselves, and every care should be taken to maintain their dignity. The
whole procedure must also adhere to the locally agreed infection control
policy. The visual display is motivating for the patient providing she can
produce a voluntary contraction, but if not, it is depressing to see nil
being recorded. Great care must be taken if the results of use are to be
treated as a monitor and compared over time. If physiotherapists try the
equipment out on themselves they will appreciate how many confound-
ing factors can effect the reading, such as the position of the probe, time
of day, day of month, load in bowel, breath holding, position on couch,
whether the head is supported or not, etc.
The Educator Neen Healthcare UK has developed a simple device called the ‘Educator’
(Fig. 11.7), which is inserted into the vagina with the patient in crook half-
lying. A voluntary contraction of the PFM will cause the indicator to
Urinary function and dysfunction 359
QUALITY OF LIFE AND In the last decade there has been an increasing awareness of the affect on
SYMPTOMS quality of life of continence problems, and an explosion of questionnaires
QUESTIONNAIRES to try to measure this. There are two main groups of questionnaire:
generic and disease specific, and these are well documented by Donovan
et al (2002). It is important to use validated questionnaires. The King’s
Health Questionnaire is commonly used; it is specific for urinary incon-
tinence and can be scored (Donovan et al 2002, Kelleher et al 1997). It has
been thoroughly tried and tested, and is now translated into several
languages. However, it takes a patient about 30 minutes to complete and
10 minutes to score. In contrast, the new International Consultation on
Incontinence Questionnaire (ICIQ), in its short form (ICIQSF), has been
rigorously pruned down to just 6 questions and will take a patient only
a few minutes, and is scored in moments! It will be found in full in
Appendix 2 in the second edition of the documentation of the second Con-
sultation of Incontinence (Abrams et al 2002b) This has been validated
and the short completion time is an obvious plus point for physiother-
apists. Work is in progress toward producing a modular ICIQ – modules of
which may well be useful to physiotherapists in certain circumstances.
IMAGING – Many obstetric units now own a small portable ultrasound scanner
ULTRASOUND designed to scan the bladder and calculate the volume of urine in the
SCANNING OF THE bladder. This has obvious use postnatally where there is concern of acute
BLADDER retention. It can also be helpful to the physiotherapist with a patient who
reports a feeling of incomplete emptying postmicturition. A postvoid
residual of ⬍100 mL may be considered within normal limits for symptom-
free women.
It is possible to use ultrasonography to visualise the lower urinary
and intestinal tracts including the bladder, urethra, external urethra
Urinary function and dysfunction 361
sphincter, rectum and anus, PFMs and associated connective tissues (see
reviews by Artibani et al 2002; Khullar 2001, 2002). Contraction of the PFM
can be seen by the operator and the patient, and the amount it lifts cephal-
ically can be observed. Damage to muscle and connective tissue is some-
times discernible. It has been used transvaginally with a vaginal probe,
and transperineally or translabially with the probe held against the peri-
neum or between the labia. The transvaginal approach has been largely
discontinued because the probe distorts structures around the vagina.
So far the use of ultrasonography in this way has been chiefly confined
to research and diagnostics. However, it is probable that as equipment
becomes cheaper that it will become more widely available. This is a
modality that will appeal to physiotherapists and one that, with appro-
priate training, could be useful in assessment and treatment. It can also
be used to image the transversus abdominis muscles.
CYSTOMETRY This test (see reviews by Garnett & Abrams 2002; Hughes & Abrams
2001) determines the relationship between the volume of fluid and the
pressure in the bladder, during both filling and voiding. Accurate tech-
nique is essential and the ICS Report on good urodynamic practice
(Schafer et al 2002) is to be found at www.ics.org.uk.
Two catheters are introduced into the bladder, one to fill it, the other
to record pressure – a combination of the intra-abdominal pressure and
detrusor pressure. A third catheter is introduced into the rectum to record
rectal pressure, which is generally the same as intra-abdominal pressure
although muscle contraction of the rectal wall will be evident. This infor-
mation is interpreted electronically and is available as two continuous
graphic traces or on a VDU. The rectal or intra-abdominal pressure is
automatically subtracted from the total bladder pressure, and the result,
the intrinsic detrusor pressure, is available as a third trace. It is therefore
possible to watch and have a permanent record of the detrusor pressure
as the bladder is filled with warmed normal saline (or contrast medium
362 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
URETHRAL PRESSURE The pressure in the urethra may be measured in both the storage and
PROFILOMETRY voiding phases by means of a microtransducer mounted on the tip of a
fine catheter (Garnett & Abrams 2002, Lose 2001, Versi 1990), or by a
fluid-filled or gas-filled catheter attached to an external transducer. The
catheter is drawn down the urethra from the bladder neck to the external
meatus during the storage phase, with or without provocative stress
(coughs), and the urethral closure pressure is measured at several points
to give a urethral pressure profile (UPP). A trace is produced.
The procedure may be carried out during voiding (VUPP) to detect
obstruction; in such cases it is necessary to measure the bladder pressure
simultaneously.
UROFLOWMETRY This is quite a reliable indicator of normal detrusor contraction and ureth-
ral relaxation. The patient is asked to void, in private, into a toilet in
Urinary function and dysfunction 363
which a flow meter has been fitted. It is important that the patient sits to
void. This device measures the quantity of fluid passed per unit of time.
The necessary equipment can be easily transportable and could be avail-
able to physiotherapists.
DISTAL URETHRAL The accurate detection of leakage of urine is obtained by inserting a short
ELECTRIC probe with two ring electrodes into the distal part of the urethra until the
CONDUCTANCE distal ring is 1.5 cm from the external urethral meatus. Passage of urine
past the electrodes increases conductivity between them, and this can be
recorded electronically (Peattie et al 1989).
ELECTROPHYSIO- For some time it has been possible to record the electrical activity associ-
LOGICAL TESTS ated with resting and contracting muscles (see reviews by Fowler &
Vodusek 2001, Fowler et al 2002, and Vodusek & Fowler 2001). Consider-
able research effort has been channelled into electrophysiological studies
of the levator ani muscle – particularly the puborectalis and the external
anal sphincter. This was because it became evident that childbirth could
cause not only direct division of the anal sphincter (Sultan 2002) and
stretching of the PFM, but also injury to the innervation (Snooks et al
1984). Single fibre density (FD) and pudendal nerve and perineal nerve
terminal motor latencies (PNTML, PerNTML) have been measured
(Snooks et al 1984, Swash 1985).
Electromyography Single needle EMG has been used to examine the puborectalis and exter-
nal anal sphincter. A fine EMG needle is inserted and the motor unit
action potentials in the immediate vicinity of the needle can be recorded
at rest and on contraction on an oscilloscope. In both these muscles, activ-
ity will be expected at rest as well as on contraction. Duration, ampli-
tude and the number of phases of the action potentials of individual
motor units can be measured. Normal muscle has a typical pattern of
measurements (Swash 1985).
Single fibre density A motor unit is comprised of an anterior horn cell and its myelinated
axon, which divides into a number of terminal branches, each of which
serves a single muscle fibre. When the axon or any of its branches are
damaged, reinnervation of the bereft muscle fibres may occur by regener-
ation of the axon or by collateral sprouting of neighbouring healthy motor
nerve axons. In the latter case the number of muscle fibres supplied
by that motor unit is greater, and the FD is said to be increased. In addi-
tion, the motor unit activity recorded is of greater length and amplitude,
and is polyphasic. The normal FD in the puborectalis and anal sphincter
muscles is 1.5. It is calculated by taking 20 recordings during mild
contraction in various parts of a muscle, counting the components making
up the 20 individual motor unit action potentials, and taking the mean
(Swash 1985).
364 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Motor conduction tests If a nerve is stimulated electrically, there is a delay before the muscle
responds. The latency of response can be measured and is increased
Pudendal nerve terminal where a nerve passes through areas of localised injury or disease, for
motor latency example the median nerve at the wrist in carpal tunnel syndrome, or
where there is actual neuropathy. An intrarectal stimulating and record-
ing device is introduced into the anus to stimulate the pudendal nerve
and record the response of the external anal sphincter muscle. The
latency of the response is measured and recorded on a graphic printout
(Fowler & Vodusek 2001, Snooks et al 1984).
Perineal nerve terminal This is a similar test using a catheter-mounted recording electrode in the
motor latency urethra (Swash 1985).
Cystourethroscopy or This is an endoscopic investigation of the bladder and urethra to look for
cystoscopy pathological lesions which could explain the signs and symptoms.
Following collation of the full history and the results of appropriate tests,
the physiotherapist must seek to understand the patient’s condition and
how the signs and symptoms are being produced (Table 11.1). Only then
can the best treatment be selected.
PHYSIOTHERAPY TREATMENT
For patients with Assuming VPFMC is possible, patients should be taught deferment tech-
urgency or urge niques such as ‘the knack’, series of repeated strong PFM contractions,
incontinence, or both distraction, or perineal pressure, and encouraged to desist from going ‘to
the loo just in case’, to increase the period between voids. In addition,
patients will probably be receiving pharmocotherapy. Some patients find
the side-effects of medication too unpleasant to continue; others seem not
to benefit at all. For these patients, it may be appropriate to offer a trial
of electrical stimulation from a home stimulator. This should be set to
deliver a current of 5–10 Hz in continuous mode with a 500 s pulse
duration. The objective of this is to try to inhibit the detrusor muscle and
normalise reflex activity. The suggested treatment regimen would be
once or twice a day for 20–30 minutes.
CONTINENCE- An adult should drink 1000–1500 mL per day, but consideration should be
PROMOTING ADVICE taken of diet because some people take in more fluid with their food than
others (e.g. as soups, stews, citrus fruit, etc.). It has been suggested that a
urine output of about 1500 mL is a better guide. Suffice to say that some
people drink unnecessarily large volumes and others do not drink
enough. Concentrated urine may irritate the bladder; drinking large vol-
umes will cause frequency. Patients are generally advised to restrict their
caffeine and alcohol intake, as both are diuretics and tend to heighten the
activity of the detrusor muscle and reduced tension in the external urethral
sphincter. Caffeine should be reduce gradually to avoid withdrawal
symptoms such as headache. Although there is some controversy over the
adverse effects of caffeine, the effect of limiting this produces a marked
improvement for some patients. Hannestad et al (2003) reported a strong
correlation between smoking, even when it had been discontinued, tea
drinking and obesity and incontinence. Women should sit, not crouch to
void and defaecate. Every effort should be made to avoid regular strain-
ing at stool and to use an optimal sitting position (see p. 388).
Responsibilities (for children, the elderly, or disabled) and occupations
that involve heavy lifting and leisure activities that result in ballistic
movements (e.g. netball, aerobics or weight training) need to be reviewed.
Advice, equipment and training may be needed for carers straining daily
to lift and handle family members in the home. As a general principle, if
an activity causes leakage the patient should discontinue it and maybe
with treatment it can be resumed later. Medication being taken for other
health problems can also cause leakage, particularly diuretics and those
for high blood pressure. Physiotherapists are advised to consult the
British National Formulary. A change in the time of administration and
use of alternative medication are worth considering.
TEACHING PFM The teaching of PFM contractions is one of the most difficult tasks
CONTRACTIONS required of the physiotherapist, probably because the muscles are not
directly visible to either patient or therapist, and demonstration cannot
Urinary function and dysfunction 369
Teaching points A large, simple diagram or a model (or both) of the pelvis, pelvic organs
and the levator ani muscles is helpful to show the three openings, and the
Visualisation lifting and gripping effect of the muscle action.
Language Throughout the teaching session the language must be chosen specif-
ically for each individual patient, employing words and images that are
likely to be familiar and easily understood, for example asking the
patient to simulate:
Example of instruction Are you comfortable on that chair? Now can you sit like this, knees and
to a patient feet apart? Lean forwards a little and support yourself with forearms on
thighs. Can you feel your back passage near the chair seat? Think about
the back passage, imagine you want to pass wind or empty your bowels;
close shut your back passage as tightly as you can and try and pull it up
toward your waist. Now let go. Try twice more. What can your feel? Try
not to clench your buttocks at the same time or hold your breath! Now
let’s imagine you have a full bladder but there are no toilets available and
you must wait! Squeeze shut your front passage tight and try to lift it
away from the chair. Now let go. Try twice more. What do you feel? Be
sure not to clench your buttocks, hold your breath or pull your tummy
in strongly. (NB Noticeable cocontraction of the transversus abdominis
muscles may occur with VPFMC.) Now think about your vagina/birth
canal; pretend you have a tampon slipping out and are trying to grip it.
What can you feel? Try twice more, then have a rest.
‘Now let’s try tightening, closing and lifting back passage, front pas-
sage and the vagina, all three together. What can you feel? Now let go.
Try again and let go. Can you feel any lift?
370 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Now try a cough; what happens to your pelvic floor? Yes, it goes
down. Now pull up your pelvic floor ‘up and in’; hold it tight and give
another cough. Did it still go down against the chair seat? Tightening like
that would be a good way of trying to stay dry when you cough or
sneeze, or of helping you ‘hold on’ when you get the urge to pee.
Now try tightening and letting go quite quickly and count. See how
many tightenings you can do before you feel the muscles getting tired.
Well done! How many was that? Have a rest. Now tighten as strongly as
you can and hold, and see how long you can hold before you feel the
muscle just letting go despite you trying to keep holding. Have a rest and
we’ll try again and I’ll time you to see how many seconds you can hold.
Well done, that was X seconds. Have a rest and we will do that again, etc.
Duration and repetition of The patient is asked to perform long, strong contractions one after the
contractions other with a rest of about 4 seconds between, each held for as long as pos-
sible, to see how many contractions can be performed before serious
fatigue sets in. The length of the hold and the number of repetitions are
recorded. The patient is also asked to try repeating short, sharp quick
contractions until fatigued and the preceived number is recorded.
Patients should be warned that there may be a little variation from day
to day in performance, according to the time of day, and even the time of
the month if they are premenopausal; but that overall, in the coming
weeks, an increase in duration and in the number of contractions pos-
sible is the objective and is the expected reward for practising regularly.
They can be reassured that the research evidence supports this form of
treatment (Hay-Smith et al 2001, Wall & Davidson 1992, Wilson et al
2002). However, it will take time!
Changing the starting The patient will probably find that PFM contractions performed in other
positions positions (e.g. supine lying, crook lying and standing) will each ‘feel’ dif-
ferent. It is a useful exercise, having started in sitting, to experiment
in the initial teaching session by going on to try contracting in other
positions. Sometimes the patient reports more sensation or better quality
contraction, or both. This illustrates the fact that contractions can be
performed in virtually any position. It also gives a further opportunity
for checking for contraction in the gluteal, hip adductor and abdominal
muscles, and for whether the patient is holding her breath or bearing
down. The patient should also understand that it is possible to exercise
the PFM in a variety of situations: while queuing, telephoning, on the bus
or train, watching television or waiting for the kettle to boil.
General advice The patient is advised to contract her PFM before and during any of the
events, which, for her, normally trigger leakage, for example when
coughing, sneezing, laughing, nose blowing, lifting, running or jumping,
or with a strong desire to void. This technique is called ‘the knack’ (Miller
et al 1998a, b) or counter-bracing.
Number and content of In discussion with the patient, possibly at the second attendance, a plan
practice sessions of daily practice sessions is made. This must be realistic and attainable as
well as being agreeable to the patient. Some people are best able to exer-
cise ‘a little and often’ (hourly or half-hourly); others practise more reli-
ably using two or three intensive sessions per day. The fact that the more
exercise that is done the sooner results will be noticeable, and that even
then it will take time, must be impressed on the patient. Olympic gold
medals are not won by people who train occasionally! Some patients are
helped to comply by keeping an exercise diary (Bø 1990).
The most advantageous programme of exercises to strengthen and
improve the endurance of the PFM is not known and probably will vary
from patient to patient. Women should be encouraged to do both sub-
maximal holding contractions and fast, short maximal contractions. Bo
et al (1989) showed improvement in patients with stress incontinence using
8–12 groups of contractions, each of which consisted of one contraction
held for as long as possible followed by three or four short ones. This regi-
men was repeated three times each day and contractions were carried out
in a variety of positions. The greatest improvement was found in those
patients who also attended the clinic for practice sessions which included
general exercise.
Further sessions, Each time the patient attends for treatment a verbal reassessment should
reassessment and be made. If good progress seems to be being made, a repeat digital exam-
progression ination is not usually necessary on each visit. If there is no improvement
or if the patient is doubtful as to whether the right muscles are being
used, a repeat examination should be offered. However if clinic-based
biofeedback equipment is available, its use may serve two purposes –
remotivating the patient and enabling the physiotherapist to reappraise
the exercise programme.
As with all re-education, the patient needs regular encouragement to
increase the length, intensity and number of repeat PFM contractions. A
variety of positions should be used, working toward those in which leak-
age used to occur; PFM contractions will be more difficult in some posi-
tions (e.g. squatting). Once a satisfactory routine of simple daily PFM
contractions has been established, it may be appropriate to teach trans-
versus abdominis muscle contractions in four-point kneeling, sitting and
standing to try to encourage coactivation with the pelvic floor (Jones et al
2002, Sapsford 2001). It is a contraction that lends itself to combination
with activities of daily living (e.g. walking).
If the patient has evidence of back pain or core instability, or both, this
should be addressed. As the woman regains reliable continence, other
activities designed to develop physical fitness should be suggested, such
372 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Attendance for It has been suspected for many years by physiotherapists that most
treatment patients start with great enthusiasm and complete the assigned number
of contractions for the first few days; but if they are left to follow the pro-
gramme uncoached or monitored the daily number of contractions drops
in most cases rather than increases. Research by Thow (1990/1) seems to
support this, and others (Bø et al 1989, Wilson et al 1987) have shown that
patients who are sent away to practise at home on their own, experience
less improvement than those who attend the physiotherapy department
regularly. In response to an open question in a survey concerning phys-
iotherapeutic services for stress incontinence (Mantle & Versi 1989),
physiotherapists strongly indicated that they considered the patient’s
motivation to be critical to outcome; yet it is difficult to maintain motiv-
ation alone. Could it be that the apparent benefit sometimes seen from the
addition of regular clinic-based biofeedback or electrical muscle stimula-
tion (or both) to the treatment regimen has more to do with the rechar-
ging of the patient’s determination to persevere with the exercises than
anything else?
To derive the maximum improvement possible from a programme of
PFM exercises, it will need to be continued for 3 to 6 months. The woman
should be seen by the physiotherapist after no more than a week for a
thorough check and further instruction if necessary. Initially appoint-
ments should be frequent to provide regular reinforcement and encour-
agement. Thereafter they can be more widely spaced in order to develop
the woman’s independence and responsibility for her own therapy.
Group treatment sessions can be very cost effective for the therapist as
well as therapeutic and pleasant for women. A friendly telephone call
periodically can be very supportive and is a valuable method of main-
taining contact with women who are unable to make regular visits to
their physiotherapist.
BIOFEEDBACK Biofeedback equipment is of two types: for clinic use and home use.
Biofeedback may be used in assessment (see p. 357), in treatment as a
challenge and motivator and, with great care, as an audit tool (see also
Haslam 2002). It is time consuming so in treatment a judgement needs to
be made by the physiotherapist and the patient as to its cost benefits,
and this may vary through an episode of treatment. A systematic review
(Berghmans et al 1998) could find no added benefit from biofeedback
over PFM exercises alone. However, a further meta-analysis (Weatherall
1999) disputed this, and many physiotherapists claim to find it highly
motivating for some patients.
Manometry Manometric devices are used with a vaginal pressure probe and give
biofeedback by means of a manometer or a visual display. Where units of
measurement of pressure change are given, centimetres of water (cm H2O)
Urinary function and dysfunction 373
are usually used, but because there are so many possible variables the
results are not transferable from one piece of equipment to another, or
from one patient to another. Even with the same patient and with the
same equipment, every effort must be made to control the variables (see
also p. 358).
Computerised manometric The display from such equipment is shown on a VDU screen and in
equipment preparing the patient it is essential for both physiotherapist and patient
to see it. The patient is usually positioned initially in well-supported half-
lying with the head supported. If measurements are going to be used
comparatively, then detail must be recorded of the exact position of back-
rest and pillows. A vaginal probe is used in accordance with local infec-
tion control policies. The deflated probe is introduced into the vagina to
a predetermined depth and then pressures are normalised to the base-
line. Using a blank screen, the patient is then asked to perform a VPFMC
and the result is visualised. It may be wise to allow the patient practice
(warm-up) time before recording the reading. The patient is then asked to
perform a suitable series of held contractions and a series of fast, short
contractions appropriate to her ability. This may be repeated or screens
can be changed and templates used to add further degrees of difficulty –
mental as well as physical. Records may be kept for future comparison.
Handheld devices Manometric handheld devices have been produced for home use but
there are cost implications for either the NHS or the patient. It is impor-
tant to be sure of benefit before suggesting use. Such gadgets tend to be
seven-day wonders!
Other In the rehabilitation of muscle, resistance in the form of weights has long
been used to increase strength and endurance. Attempts to find a means
Vaginal cones of applying graded resistance to the PFM led to the development and
marketing of vaginal cones in 1988. The theory underpinning cone usage
is that there is increased reflex activity of the PFM to support and retain
the cone against gravity, and to counteract downward slippage. Over the
years companies have manufactured these in sets of five to nine small,
progressively weighted cylinders, ranging from 10 to 100 g or as a set of
weights which fit into a single cone. Each cone is about the size and shape
of a tampon and has a nylon string attached to one slightly tapered end
to facilitate removal from the vagina. Some sets supply cones in two
different diameters to accommodate the range in vaginal diameter. To
overcome potential problems with infection control, cones should be
single user. Cones can be purchased over the counter in the UK. They are
supplied with instructions but ideally the patient should receive instruc-
tion from a specialist physiotherapist.
Selecting the appropriate cone The lightest cone is inserted into the
vagina while in the semisquatting or half-lying position, or standing with
one foot up on a chair. The cone is inserted with the pointed end and
string downwards and must be placed far enough into the vagina to lie
just above the level of the pelvic floor. The patient then stands and walks
around. If the cone can be retained for 1 minute, the patient progresses on
to the next cone, which is slightly heavier, and so on until a cone slips out
in under 1 minute. The heaviest cone that can be retained for 1 minute is
used for exercise.
Treatment sessions It is usually suggested that twice a day the patient
inserts a cone and walks around for up to 15 minutes. If the cone slips
down it is pushed back up. Once the cone can be retained for 15 minutes
without slipping, progress is made to the next cone. Over time, coughing,
stairs and other activities of daily living may be introduced as a progres-
sion. Furthermore, Bø (2002) suggests teaching a patient to resist traction
applied to the cone string while standing. A course of at least 1 month is
recommended.
A Cochrane review (Herbison et al 2002) of research using cones con-
cluded that there is some evidence that cones are better than no active
treatment in the treatment of stress incontinence, but noted that there was
a considerable dropout of patients in some of the studies examined, for
example that of Cammu & Van Nylen (1998). Research has shown that
some older women dislike putting ‘things into their vagina’ (Prashar et al
2000). Bø (1995, 2002) has also questioned their use from an exercise sci-
ence perspective. She suggests that retention for as long as 15–20 minutes
Urinary function and dysfunction 375
• It is often the case that greater weight can be retained in the morning
than the evening.
• If the width between the medial edges of the levator ani muscles is
very wide, congenitally or as a result of trauma at deliveries, retention
may be impossible.
• If the innervation to part of the pelvic floor has been permanently
damaged the potential for improvement may be very small.
• Vaginal secretions vary through the menstrual cycle and will be
greatest in mid-cycle. Moisture will be increased by sexual intercourse,
spermicides or lubricant jelly. Cone retention may thus be adversely
effected.
• A full rectum may make retention easier.
• Traction on the cord can be used to give an additional challenge to
the PFM.
ELECTRICAL The research evidence for using electrical stimulation for patients with
STIMULATION urinary dysfunction is limited and it is generally unpopular with
patients. For an authoritative review of its use see Fall & Lindstrom
(1991). It can be used for two purposes. One is to produce muscle con-
traction and this can be used to attempt to assist patients who seem
unable to produce a VPFMC or have very weak PFM, particularly if they
have urodynamic stress incontinence. Once a patient is able voluntarily
to contract the PFM reliably then intensive active exercise is probably the
best treatment. The other use of electrical stimulation is to utilise the
sensory stimulation it causes to inhibit detrusor overactivity and nomalise
reflex activity, so this is useful for some patients who experience urgency
and urge incontinence (see also Laycock & Vodusek 2002).
Low-frequency muscle There are two main types of equipment used to apply electrical stimula-
stimulation tion in the treatment of urinary incontinence: computerised clinic-based
machines and small battery-operated devices for home use. It is usual to
use a vaginal electrode and commonly this is the Periform (see p. 373),
provided that it is comfortable for the patient. It is supplied with an indi-
cator, which, if attached, can be used to confirm whether or not a PFM
contraction is being obtained by the electrical stimulation. There are nar-
rower vaginal electrodes if these are needed; alternatively flat adhesive
electrodes can be used externally.
Computerised clinic-based Some equipment can be used for both EMG and electrical stimulation
electrical stimulation either separately or in combination. The patient should be comfortably
equipment positioned and well supported in half-lying such that both patient and
physiotherapist can see the screen. The equipment allows for seemingly
infinite permutations, but for stimulating PFM contractions it is usual to
use a 250 s pulse duration and a frequency of 35–40 Hz. The duty cycle
is chosen with great care. In that stimulation is often used for very weak
muscles or where the patient is unable to produce a VPFMC, it is wise to
select rest periods of double the stimulation period, and a stimulation
period which matches, in seconds, the ability of the patient to hold a
contraction – if this is possible. The patient is encouraged to join in and,
with equipment with EMG facilities, they can compare their efforts to
those of the stimulation. Where a patient cannot contract, a starting duty
cycle of 2 seconds on and 4 off would be appropriate, for 5 minutes in the
first instance and with the patient trying to join in. Intensity needs to
be such that a good contraction is produced. Progress will match the
patient’s ability to hold contractions, need less rest and tolerate longer
treatment sessions up to 30 minutes.
It is sometimes claimed that stimulation of this kind strengthens
muscles. Stimulation for several hours a day is required to strengthen
muscles significantly. Complex clinic-based equipment is less well suited
to treating urgency and urge incontinence because the patient is best
served with daily sessions of 20–30 minutes.
Battery-operated Ideally these are sturdy and simple to operate, and have facilities for set-
electrical stimulation ting the pulse width, frequency and duty cycle to those most appropriate
devices for clinic-based or for each patient; it is helpful if the machine records how often and for how
home electrical long the device is used as a check on compliance. These are particularly
stimulation well suited to treating urgency and urge incontinence, enabling the patient
to be treated daily cost effectively. A vaginal electrode is used. The patient
with urgency symptoms must be very carefully instructed, receive an
instruction sheet and have a telephone contact number should difficulties
arise. A pulse width of about 500 s, a frequency of 5–10 Hz and the maxi-
mum tolerable intensity are used. Daily treatment sessions start at about 5
minutes but quickly rise to 20–30 minutes if all is well.
Electrical stimulation of the PFM can also be carried out using a battery-
operated device in the clinic or at home, or both locations, using the
appropriate settings given in the previous section. See also page 367
concerning loaning and maintenance of loaned equipment.
Urinary function and dysfunction 377
BLADDER RETRAINING Bladder retraining or drill was first described by Jeffcoate & Francis
(1966) and was called ‘bladder discipline’. It was used in the manage-
ment of frequency, urgency without leakage and urge incontinence
(bladder overactivity) (Frewen 1979, Jarvis & Millar 1980, Jeffcoate &
Francis, 1966) and then was extended to the treatment of genuine (uro-
dynamic) stress incontinence (Fantl et al 1991, Wyman et al 1998). Originally
some patients were admitted to hospital to assist adherence to the
strict regimen. The objective is to help patients who are ‘ruled by their
bladders’ and ‘tied to the toilet’.
The main aims are to:
TIMED AND PROMPTED Where patients are unable to toilet independently or are confused, or
VOIDING both, timed voiding may be helpful to avoid ‘accidents’. The patient’s
need for the toilet is observed and charted over several days, a routine of
toileting times is then set – ideally this is individualised. Commonly in
residential and nursing homes this is set at 2-hourly intervals and the
patient is taken to the toilet or sat on a commode whether or not they
378 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
express a desire to void. Where the patient can go to the toilet independ-
ently, a prompt to void with some guidance may be sufficient.
The concept of timed voiding is also useful for patients who have lost
sensation of bladder fullness, and for those women whose life is so pres-
sured and intense that they ‘forget’ or fail to take the opportunity to void
until it is really too late. Furthermore, employers who try to place restric-
tions on when or how often employees are allowed to go to the toilet
should be challenged. People need to realise that anyone will ‘have an
accident’ if they ‘wait’ long enough.
FUNCTIONAL ACTIVITY In assessing the patient referred with incontinence, it is important for the
physiotherapist to determine to what extent poor balance, joint stiffness or
lack of strength and endurance in muscles other than the pelvic floor may
be actually contributing to the incontinence or aggravating it. Con-
sideration should also be given as to how far general lack of fitness is
responsible for weakness of the pelvic floor musculature. An example
of joint stiffness as a contributory factor to incontinence would be osteo-
arthritic knees, which make standing up from sitting a very painful,
‘breathholding’ struggle, resulting in leakage either because the raised
intra-abdominal pressure provokes detrusor contractions or because it
overwhelms the urethral closure mechanisms. In addition (or alterna-
tively), such a disability could result in the woman taking so long to reach
the toilet that accidents occur. In such a case, one solution would be specific
treatment to relieve pain, mobilise joints and strengthen the leg muscles,
whereas another would be to change the environment (Muir Gray 1986).
Another possibility is that the inactivity and social withdrawal caused
by the incontinence leads to generalised muscular weakness including
the perineal muscles. The pelvic floor musculature is active in its urethral
closure role and its supportive role to a variable extent round the clock,
the degree of muscle activity being related to what the woman is doing. A
gradient of activity might be represented by lying, sitting, standing, walk-
ing, bending and lifting. Such activities as talking, laughing and shouting
interact with these. The amount of work done by the pelvic floor in a day
is governed by what a woman does. Reduced activity, if she is sitting at
home a great deal, will reduce the daily work of the pelvic floor and lead
in time to many muscles (including the PFM) becoming less strong.
Gordon & Logue (1985), writing of postpartum women, reported that any
form of muscular exercise improved perineal muscle function. They went
on to comment that pure perineal exercises were not extensively practised
either because women were not convinced of the benefit or because they
found them tedious, and that perhaps more emphasis should be placed on
exercise that women find interesting and fulfilling.
Functional activities should be part of an integrated treatment pro-
gramme. Activities that are known to cause leakage should be excluded
at the start of such a programme; and being able once again to achieve
them without leakage could be used as an objective test of improvement.
Bø et al (1989) used this approach, which also included group general
exercise sessions. The physiotherapist is the only professional who is able
Urinary function and dysfunction 379
to assess the patient in this holistic way and decide, first, whether specific
exercises or more general exercises are required, and if so, to plan and
implement the right programme for the individual.
DEVICES Small intravaginal and intraurethral devices have been produced. Some
promote continence by supporting the bladder neck and others are
designed to stop urine loss by blocking the urethra. The reader is referred
to Anders (2002).
Where, despite exhaustive and repeated assessment and the best of team
care, a patient is still left with some degree of incontinence of urine or fae-
ces, efforts should be directed towards management. The continence
advisor can give invaluable help to all concerned in finding the best care
solutions for each individual case which will maintain dignity and allow
social integration, while reducing the workload and keeping down costs.
The physiotherapist may be able to contribute toward these goals with
treatment that produces just a little more strength or range of movement.
This may enable a patient to become independent by coping with
manoeuvres such as ISC or pad changing for themselves, or make it
possible for the patient, in spite of all the problems, to get out and about
and enjoy life. Incontinence, immobility, social deprivation and depression
are a lethal cocktail.
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Swash M 1985 Anorectal incontinence: electrophysiological Wall L L, Davidson T G 1992 The role of muscular re-education
tests. British Journal of Surgery 72(suppl):S14–S20. by physical therapy in the treatment of genuine stress
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urinary incontinence. British Medical Journal Survey 47(5):322–331.
281:1243–1245. Warzak W J 1993 Psychological implications of nocturnal
Thomas T M, Egan M, Walgrove A et al 1984 The prevalence enuresis. Clinical Pediatrics (Phila) Spec No:38–40.
of faecal and double incontinence. Community Medicine Weatherall M 1999 Biofeedback or pelvic floor exercises for
6:216–220. female genuine stress incontinence: a meta-analysis of
Thow M 1990/1 Compliance with a programme of pelvic trial identified in a systematic review. British Journal of
floor exercise. Journal of the Association of Chartered Urology International 83(9):1015–1016.
Physiotherapists in Obstetrics and Gynaecology 68:10–12. Wilson P D, al Samarrai T, Deakin M et al 1987 An objective
Versi E 1990 Relevance of urethral pressure profilometry to assessment of physiotherapy for female genuine stress
date. Ch 6 in: Drife J O, Hilton P, Stanton S L (eds) incontinence. British Journal of Obstetrics and
Micturition. Springer Verlag, London, p 81–110. Gynaecology 94:575–582.
Versi E, Cardozo L, Anand D 1988 The use of pad tests in the Wilson P D, Bo K, Hay-Smith J et al 2002 Conservative
investigation of female urinary incontinence. British treatment in women. Ch 12 in: Abrams P, Cardozo L,
Journal of Obstetrics and Gynaecology 8:270–273. Khoury A et al (eds) Incontinence. Health Publications/
Versi E, Orrego G, Hardy E et al 1996 Evaluation of the home Plymbridge Distributors, Plymouth, p 573–624.
pad test in the investigation of female urinary Wyman J F, Harkins S W, Fantl J A 1990 Psychological
incontinence. British Journal of Obstetrics and impact of urinary incontinence in the community-
Gynaecology 103(7):720. dwelling population. Journal of the American Geriatrics
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Cardozo L, Staskin D (eds) Textbook of female urology and Wyman J F, Fantl J A, McClish D K et al 1998 Comparitive
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Wall L L 1999 Birth trauma and the pelvic floor: lessons from of female urinary incontinence. American Journal of
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8(2):149–155.
Further reading
Abrams A, Wein A 1998 The overactive bladder. Pharmacia MacLean A B, Cardozo L (eds) 2002 Incontinence in women.
Upjohn, Milton Keynes. RCOG Press, London.
Cardozo L, Staskin D (eds) 2002 Textbook of female urology Sapsford R, Bullock-Saxton J, Markwell S (eds) 1998
and urogynecology. Isis Medical Media, London. Women’s health. W B Saunders, London.
Laycock J, Haslam J (eds) 2002 Therapeutic management of
incontinence and pelvic pain. Springer, London.
Useful addresses
Association of Chartered Physiotherapists in Women’s 34 Old School House, Britannia Rd, Kingswood, Bristol
Health BS15 8DB
c/o Chartered Society of Physiotherapy, 14 Bedford Row, Email eneuresisompuserve.com
London WC1R 4ED Website: www.eric.org.uk
Website: www.womensphysio.com
InconTact
Association for Continence Advice Email [email protected]
Astra House, Arklow Road, New Cross, London SE14 6EB Website: www.incontact.org
Email [email protected]
Website: www.aca.uk.com International Continence Society
Chartered Society of Physiotherapy ICS Office, Southmead Hospital, Bristol BS10 SNB
14 Bedford Row, London WC1R 4ED Email [email protected]
Website: www.csp.org.uk Website: www.icsoffice.org
Continence Foundation NEEN Healthcare
307 Hatton Square, 16 Baldwins Gardens, London EC1N 7RJ Old Pharmacy Yard, Church Street, East Dereham,
Email [email protected] Norfolk NR19 1DJ
Website: www.continence-foundation.org.uk Tel 0362 698966; Fax 0362 698967
Enuresis Resource and Information Centre (ERIC) Email [email protected]
Website: www.neenhealth.com
383
Chapter 12
CHAPTER CONTENTS
Introduction 383 Physiotherapy assessment of faecal incontinence
Normal bowel function 384 and bowel dysfunction 402
Bowel and anorectal dysfunction 388 Treatment for bowel and anorectal dysfunction 410
INTRODUCTION
PREVENTION As ever, prevention is better than cure and, in this field, it begins with an
appreciation of the wide range in normal function between individuals
and even in the same individual over time. The traditional view that
‘the bowels should be opened once a day’ is not the case for many
people, and many ordinary aspects of day-to-day living can affect an indi-
vidual’s normal habit (e.g. a change in the level of activity, a change in
location, spicy foods, the menstrual cycle, the workplace). The education
of parents would enable good childhood habits to be established and this
aspect of a child’s life to be facilitated and unobtrusively monitored with-
out overemphasis. However, at any age, regular meals, a healthy diet, an
unhurried environment that enables a person to obey a ‘call to stool’ and
the availability of a private place to defaecate, which allows the person to
adopt an individually suitable defaecation position, are all important.
The possibility of the side-effects of medication, resulting in bowel
dysfunction, should always be considered by the prescriber. Where there
is a possibility of problems arising, the patient should be warned and
encouraged to report the fact if the effects become unacceptable. Some
drugs are constipating (e.g. anticholinergics, opiates, iron supplements,
non-steroidal anti-inflammatory drugs (NSAIDs)) and other medications
cause diarrhoea (e.g. antibiotics). There is much health education needed
in this area and health professionals would assist in this by routinely
‘giving permission’ to raise the matter by including appropriate ques-
tions in history taking. Bowel and anorectal dysfunction may occur in
association with many pathologies such as stroke, Parkinson’s disease
and inflammatory bowel disease; but, in the absence of serious pathol-
ogy, even quite minor and temporary reductions in mobility, or dexterity
or both may adversely affect functional aspects of independent toileting,
causing preventable problems.
Figure 12.1 Bristol stool chart. (Reproduced by kind permission of Dr K W Heaton, Reader in Medicine at the
University of Bristol; © 2000 Norgine Ltd.)
386 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Rectum Sacrum
Intra-abdominal
pressure
Pubis
DEFAECATION The act of emptying the rectum is called defaecation or ‘opening the
bowels’. The normal frequency of defaecation varies substantially
between individuals from three times a day to three times a week for 94%
of the population (Drossman et al 1982). It has also been shown that women
defaecate less often and less regularly than men (Heaton et al 1992). For
most people the colon is quiet at night but the activity of getting up in the
morning and having breakfast stimulates mass peristaltic movements
propelling material, which may be solid, liquid or flatus, into the rectum.
This may be accompanied by quite urgent sensations that the individual
recognises as a ‘call to stool’. The presence of material in the rectum
causes the upper portion of the IAS to relax allowing ‘sampling’ to take
place. If evacuation is inconvenient or impractical, defaecation can be
deferred by repeated strong voluntary squeezes of the external anal
sphincter, which has the effect of reversing peristalsis, returning faecal
material to the rectum and colon, and facilitating a resumption of con-
traction of the IAS. The rectum and colon then relax and the sensation of
needing to empty wears off. Defaecation can be delayed, but normally
there will be reminders as the colon and rectum contract periodically. It
must be appreciated that the longer material stays in the colon and rec-
tum the more water is removed and the harder the stools become.
Once the decision to defaecate is taken, an acceptable site is found and
clothing arranged; a sitting or squatting position is usually intuitively
adopted, which widens the anorectal angle. Expert opinion recommends
the position shown in Figure 12.3. The knees should be apart and higher
than the hip joints; this may require the feet to be on a support such as a
stool, telephone directories or upturned washing bowl. The trunk should
be flexed forward at the hips supported on the forearms, and with the neu-
tral spinal curves maintained. Where possible the heels should be raised.
Physiotherapists will immediately appreciate the possible negative effect
on defaecation of providing patients with raised toilet seats! Those
providing raised toilet seats must assess this crucial aspect and where nec-
essary seek solutions to avoid possible iatrogenic difficulties in evacuation.
388 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Where raised support for the feet is required, there is the obvious danger
of the person falling over it when leaving the toilet.
If the call to stool has been urgent and considerable pressure generated
by the mass movements of the gut, the IAS will have relaxed. Once the
individual is in position, the pelvic floor musculature relaxes such that
the floor descends 1–2 cm to the plane of the ischial tuberosities. This fur-
ther increases the anorectal angle and the anal canal widens and shortens
to become a funnel. If all is favourable, the EAS and puborectalis muscles
will then release. Either evacuation will then occur without further effort
as a result of peristalsis or it will be necessary for the person to produce a
rise in intra-abdominal pressure (i.e. ‘strain’). Sometimes a short rise in
pressure ‘to get things started’ is all that is needed and peristalsis then
takes over; at other times sustained, intense and repeated straining is
required, particularly when the stool is hard and dry.
The raised intra-abdominal pressure utilised to assist defaecation is
achieved by a complex coordination of trunk muscles, sometimes called
‘brace and bulge’ (Chiarelli & Markwell 1992); this combines breath hold-
ing, descent of the diaphragm, lateral widening of the waist with bulging
of the lower abdomen, descent of the pelvic floor, and isometric activity in
the pubo-, ilio- and ischiococcygeus muscles to give support to the rectum.
A full description of the importance of coordination between the
abdominals, the pelvic floor musculature, diaphragm and multifidus can
be found in Sapsford (2001) (see also p. 414).
Once emptying is complete, a closure reflex restores the involved
structures to their storage mode and position.
Dysfunctions of the bowel, rectum or anus generally fall into two main
groupings: one in difficulty in evacuating faecal material, the other in an
Bowel and anorectal function and dysfunction 389
SOME USEFUL • Anal incontinence is the term used to describe the involuntary loss of
DEFINITIONS flatus, liquid or solid per anus that is a social or hygienic problem.
• Anismus is the term used to describe incoordinate activity of anal
sphincters and the levator ani muscles such that they fail to relax when
defaecation is attempted.
• Constipation was generally defined as defaecating twice or less a week
and was usually subjective because it relied on self-reporting.
However, it became evident that the public frequently use the term
to describe the need to strain to evacuate stool. The most recent defini-
tion (the Rome 11 criteria) has the support of an international con-
sensus (Thompson et al 1999) and relies on self-reporting of more
specific bowel-related symptoms. Functional (non-pathological)
constipation is defined as including two or more of the following
symptoms for at least 12 weeks in the last 12 months (not necessarily
consecutive):
䊊 straining in ⬎1/4 defaecations
NB Loose stools are not present, and there are insufficient criteria for IBS.
• Proctalgia fugax is the name given to sudden severe pain affecting the
rectum lasting anything from minutes to hours. Attacks may occur
days or month apart. The pain is probably caused by muscle spasm
and there appears to be no structural disease.
PREVALENCE As there has been a wide range of differences in the definition of consti-
pation, it is difficult to define absolutely the prevalence of the condition.
Prevalence of However, Thompson et al (1999) stated that constipation is persistent,
constipation difficult, infrequent or incomplete defecation, occurring in up to 20% of
the population. They also stated that it is more common in women than
men and increases with age. This was also shown in a large study of
Australian women by Chiarelli et al (2000), who found a prevalence rate
of 14.1% in women aged 18–23 years, 26.6% in women aged 45–50 years
and 27% in women aged 70–75 years.
Prevalence of anal or The prevalence of anal or faecal incontinence is equally difficult to quan-
faecal incontinence tify because of the reluctance of sufferers to admit (Khullar et al 1998) to
the problem or to report it to a doctor or researcher. There is also the wide
variation in frequency and severity of episodes. The picture is further
clouded by the fact that much of the research into prevalence has been
conducted using samples of persons over the age of 60. Norton et al
(2002a), in an analysis for the 2nd International Consultation on
Incontinence, considered the available evidence to be level 2 and sum-
marised the prevalence of anal continence thus: it increases with age but
is present in all age groups and both genders, varying from 1.5% in chil-
dren to 50% in nursing home residents.
In a USA community-based study (Roberts et al 1999), using a ran-
domised sample of 762 women aged 50 or more, faecal incontinence was
reported by 13.2% of those in their 50s and 20.7% of those of 80 or more.
Severity and frequency of faecal incontinence is rarely mentioned in the
literature, but in a study by Talley et al (1992) of 328 men and women
aged 65–93 living at home, faecal incontinence more than once a week
was reported by 3.7%. In addition Roberts et al (1999) found that, of
those women with faecal incontinence, 59.6% also experienced urinary
incontinence.
Abuse It is difficult to assess fully the frequency of abuse in the general popula-
tion as it is often unreported and only few pursue their abusers to the
courts. Women often suffer long-term effects of their abuse, which can be
triggered into their conscious when attending for bladder or bowel dys-
function therapy. It is thought that an abnormal learned response may
occur after sexual assault or abuse (Leroi et al 1995). This may show itself
as anismus, paradoxical puborectalis contraction and pelvic floor
dyssynergia on attempted defaecation as the pelvic floor muscles fail to
release, although the initial examination may appear normal (Bruce &
Sletten 2002). It is therefore essential to take a comprehensive history of
the patient’s condition and important to establish with every patient that
they are giving full informed consent before performing any physical
examination in the vaginal or anorectal area. However, many patients
may not initially relate their previous abuse and therefore it is essential
that an examination should be discontinued if there are any signs of men-
tal or physical discomfort during any assessment. Expert opinion consid-
ers that if a person has suffered any sexual abuse then it is inappropriate
for a physiotherapist to carry out any invasive examination or treatment.
Women’s health physiotherapists must be aware of the possibility of
abuse and know to whom to refer the patient if there is any apparent
need. They should not attempt to carry out any psychosexual counselling
themselves unless they have had the appropriate specialist training.
392 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Eating disorders Many patients with eating disorders complain of constipation, often con-
sidering it their most incapacitating symptom (Mehler 1997). Anorectal
abnormalities have been shown in patients with anorexia nervosa com-
plaining of constipation (Chiarioni et al 2000). It was thought that the
delayed colonic transit time was probably due to their abnormal eating
habits. Chun et al (1997) showed that once anorexic patients consumed
food and had a balanced weight gain or weight maintenance diet for at
least 3 weeks, colonic transit returned to normal in the majority of patients.
Dykes et al (2001) showed that, in a group of 28 consecutive patients
referred for biofeedback treatment for constipation, 60% had evidence of
current affective disorder and 66% previous affective disorder; with 33%
reporting a distorted attitude to food. The authors suggested that any
patients presenting to surgical departments with chronic intractable con-
stipation should be referred for a psychological assessment.
Binge eaters have also been studied and it was shown that obesity
was associated with more frequent constipation, diarrhoea, straining and
flatus whether or not the subjects reported binge eating (Crowell et al
1994).
Laxative abuse/overuse/dependence is also common in those with
eating disorders suffering with constipation (Bruce & Sletten 2002). This
group of patients, with a current eating disorder or history of a former
eating disorder, or both, have often had a previous inpatient psychiatric
episode of care and very low bodyweight.
Food and drink Insufficient fluid intake has been suggested as a possible contributory
cause to constipation. In one study, eight young men had, in randomised
order, 1 week of 2500 mL of beverages per day, a week with less than
500 mL per day with a 1-week washout in between; the week of fluid
deprivation (⬍500 mL) decreased stool frequency and weight (Klauser
et al 1990). In older adults a low fluid intake has been associated with
constipation (Robson et al 2000). It has also been shown by Brown et al
(1990) that coffee (both caffeinated and decaffeinated) affects gut motility
in some normal people; hot water had no effect.
Low calorie intake rather than low fibre consumption has been shown
to be related to constipation in the elderly (Towers et al 1994). Muller-
Lissner (1988) evaluated 20 papers on the effect of wheat bran on large
bowel function. He found that bran increased the stool weight and
decreased the transit time in healthy controls and in those with IBS, diver-
ticula and constipation. However, those with constipation had lower stool
output and slower transit regardless of whether they had taken bran and
responded less well to bran treatment than controls. In the elderly it has
been shown that a higher intake of bran was associated with greater fae-
cal loading and no decrease in constipation symptoms (Donald et al 1985).
Anti et al (1998) looked at the effects of a high-fibre diet and fluid sup-
plementation in patients with functional constipation with an age range of
18–50 years (n ⫽ 117). They found that a daily fibre intake of 25 g could
increase stool frequency in those with chronic functional constipation; this
could be significantly improved by a fluid intake of 1.5–2 litres per day.
Bowel and anorectal function and dysfunction 393
Ignoring the call to Polite society still considers it inappropriate to discuss bowel activity in
stool/workplace general conversation. Therefore members of the general population have
constipation little or no awareness as to what may be considered normal bowel activ-
ity and even less understanding of how they can potentially harm them-
selves. If individuals continuously ignore the call to stool and delay
defaecation over long periods of time they are inadvertently making con-
stipation more likely. Physical activity levels have further decreased with
the use of advancing technology, and many people are computer based
using technology such as teleconferencing; a lack of physical activity is
known to cause constipation.
Shift working can further affect the normal ‘body clock’ and normal
habits become more difficult to retain. This can affect the nursing profes-
sion, the emergency services and all those who work alternate day and
night shifts, from factory workers to air travel personnel. Many people
can associate with this problem having suffered from ‘holiday constipa-
tion’ when change in time zones and dietary habits affect bowel activity.
Another possible workplace problem can be that of a lack of sufficient
pleasant toilet facilities. Small cubicles that may be difficult for pregnant
women or large people, irregular cleaning, poor ventilation, and lack of
toilet paper, soap and towels all contribute to people putting off emptying
their bowels during the working day. This can also apply to schoolchil-
dren. Those people working ‘on the move’ such as district nurses, commu-
nity midwives and salesmen are also at the mercy of whatever facilities
are available. It has been shown that, in women attending a gynaecology
clinic, 85% crouch over (rather than sit on) public toilet seats and 37% even
crouch over the toilet seat in a friend’s bathroom (Moore et al 1992); this is
hardly conducive to bowel emptying when away from home.
There have also been changes in eating habits in recent years: long
hours, fast foods, irregular eating, high levels of caffeine intake and
highly processed foods – these can all compound the problem.
Irritable bowel Irritable bowel syndrome (IBS) affects 10% of people, with a female pre-
syndrome dominance (Talley & Spiller 2002), and is the commonest functional gas-
trointestinal disorder. People with IBS can be divided into those who
present with spastic constipation having abdominal pain related to
bowel spasm, and those with painless diarrhoea complaining of stool fre-
quency without abdominal pain. Most patients seem to report functional
abdominal pain, which can be just as severe and disabling as organic pain
(Moriarty 1999). The pain of IBS is most commonly felt in either the right
or left iliac fossa or right hypochondrium, whereas pain of functional ori-
gin tends to be diffuse and may be anywhere in the abdomen or even out-
side it. Clinically patients report abdominal distension, pain relief with
394 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Menstruation There have been several studies to investigate the often-reported increase
of bowel symptoms premenstrually. Kane et al (1998) studied women
with ulcerative colitis (n ⫽ 49), Crohn’s disease (n ⫽ 49) and IBS (n ⫽ 46)
and 90 healthy community controls. Premenstrual symptoms were
reported by 93% of the total of women (most often in those with Crohn’s
disease). All disease groups had a more cyclical pattern to their bowel
habits (diarrhoea, abdominal pain and constipation) than the controls.
Moore et al (1998) concluded, in their systematic review, that one-third of
otherwise asymptomatic women may experience gastrointestinal symp-
toms at the time of menstruation; whilst 50% of women with IBS report a
perimenstrual increase in symptoms.
Gender has also been investigated, as more women are likely to suffer
with IBS than men. Menstrual cycle symptoms were investigated and
reported by Lee et al (2001). In this study of 700 people, three groups, all
with IBS, were compared: 54 postmenopausal women, 61 premenopausal
women and 54 age-matched men. Menstrual-cycle-related worsening of
symptoms was reported by 40% of the women, but as there were few dif-
ferences between pre- and postmenopausal women it was determined
that the gender differences were unlikely to be attributable to the men-
strual cycle.
Neurological conditions Constipation can arise in many different neurological conditions. These
include Parkinson’s disease, multiple sclerosis and spinal cord injury.
Any alteration to the normal somatic or autonomic control of the colorec-
tal tract is going to have some effect on normal bowel activity. This can
be an additional burden to those already suffering with a neurological
condition and can cause them an increasing sense of helplessness. The
women’s health physiotherapist should have a holistic approach to treat-
ment to optimise healthy function.
Pain associated with An anal fissure is a split or tear in the lining of the lowest part of the anal
anal fissure canal and may be caused by severe constipation or childbirth. Even
though the fissure may be comparatively short in length (often less than
5 mm) it can be extremely painful and make life miserable. Each time the
person attempts to open their bowels the fissure is stretched provoking
acute pain and therefore causing great anxiety each time the person feels
the call to stool. If the fissure heals itself it is said to have been an acute
fissure; however, if the fissure becomes permanent it is said to be a
chronic fissure, sometimes with the formation of a slightly swollen skin
tag at the outer margin of the fissure.
Treatment of the chronic fissure is often by the use of glycerol trinitrate
(GTN) cream, applied to the lower anal canal and anal margin to facilitate
relaxation of the internal sphincter. However, sometimes the pain and
396 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Pregnancy and Constipation and a feeling of bloating are common complaints of preg-
postpartum nancy. It has been reported as being present in 42% of multiparous
women and 26% of primiparous women (Marshall et al 1998). This is due
mainly to decreasing colonic peristalsis owing to the effect of proges-
terone on the smooth muscle of the gut. It has also been suggested that
there is an increase in water absorption due to increased levels of aldos-
terone and angiotensin (Hytten 1990). In early pregnancy excessive nau-
sea and vomiting are common and may result in a decrease of fluids
passing through the digestive tract. As the pregnancy progresses the
decrease in physical activity can affect colonic activity, as can the pre-
scription of iron supplements. Diet may be adversely affected by food
cravings in pregnancy and care must be taken to ensure that there is a
healthy balanced diet with adequate dietary fibre. Dietary fibre supple-
mentation has been studied by Anderson & Whichelow (1985). After
2 weeks’ baseline observation, the two intervention groups were asked to
take 10 g of dietary fibre supplement (corn-based biscuit or wheat bran)
daily; the third group had no intervention. After 2 weeks of the interven-
tion the number of bowel movements were increased with softer stool
consistency in both intervention groups; there were no changes in the
non-intervention group.
As the pregnancy develops the enlarging uterus and pelvic floor
remodelling may also be contributory factors to defaecatory straining
(Brubaker 1996). After delivery the common practice of giving codeine-
based analgesia may exacerbate any existing problems with constipation.
Pregnant women should be given relevant advice concerning a healthy
diet during pregnancy. They should also be taught appropriate defaeca-
tion techniques and pelvic floor muscle exercise; this should then be
reinforced postnatally.
Prolapse A rectocoele is a herniation of the anterior rectal wall and the posterior
vaginal wall into the vagina. This tear in the rectovaginal septum most
commonly occurs above the attachment to the perineal body (Richardson
1993). According to its severity it may protrude through the vaginal introi-
tus and may be associated with anterior vaginal wall defects or entero-
coele, or both. Constipation and straining at stool has been thought to be
a contributory factor to the formation of a rectocoele (Siproudis et al 1993).
Bowel and anorectal function and dysfunction 397
Psychiatric disorders It has been found that 27% of patients with major depression report the
onset or worsening of constipation with the onset of the depression
(Garvey et al 1990). Even higher rates have been found in other studies
(Bruce & Sletten 2002). It must be remembered that anticholinergic medi-
cation to treat the depression can slow the transit time in the gut and
exacerbate any pre-existing constipation. It may therefore be advisable to
have selective seretonin reuptake inhibitors (SSRI) prescribed for depres-
sion if appropriate, as they do not affect bowel activity.
Anxiety disorders are also prevalent in those with constipation. These
include defaecation rituals, bowel obsessions, obsessive–compulsive
disorder, panic disorders and generalised anxiety disorder (Bruce &
Sletten 2002). They may result in severe restrictions on food, prolonged
time on the toilet, avoidance of social situations and a refusal to leave
home until the bowels are opened; this can impose severe restrictions on
everyday life.
The elderly With increasing age there may be a decrease in mental function and mobil-
ity and an increase in anxiety and confusion. This, together with frailty
and a decreased ability to chew food adequately, can lead to a change in
dietary habits. A study of elderly ambulatory outpatients showed that
those who ate fewer meals and had a lower calorie intake were more
likely to suffer with constipation. Calorie intake seemed of greater import-
ance than the consumption of dietary fibre (Towers et al 1994).
398 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
CONSEQUENCES OF The failure to recognise or take action on the call to stool can result in
CONSTIPATION other physiological problems. Many authors have reported problems
with constipation; these include Koch et al (1997) reporting prolonged
and excessive straining, also a need to use digital help to defecate.
Camilleri & Szarka (2002) reported that constipation can lead to a feeling
of incomplete emptying, abdominal cramping and pain, bloating, peri-
neal pain and nausea. Further symptoms mentioned by Pemberton
(2002) include anal pain, perineal descent causing additional problems
with emptying, needing to use finger pressure on the perineum or poster-
ior vaginal wall to empty the bowels and rectal prolapse. Constipation
and faecal incontinence have also been implicated as contributors to urin-
ary urge incontinence (Ouslander & Schnelle 1995). It is believed that the
full rectum exerts pressure on the bladder, which can then trigger sensory
urgency, urinary frequency and urge incontinence.
Other symptoms mentioned by constipated patients may include dis-
comfort and pain in emptying the bowels, headache, skin problems and
general malaise. It is also known that over a long period of time hard
stools can irritate the bowel walls causing them to produce more fluid
and mucus that can bypass the hard stool and then leak out. Also haem-
orrhoids are often associated with constipation and straining.
Constipation associated with delay in the call to stool, discomfort,
pain and straining, once established, can severely affect quality of life.
Bowel and anorectal function and dysfunction 399
Psychological problems These can also result from constipation. It has been long been known that
stress affects bowel function (Drossman et al 1982) and that depression
and eating disorders can also be related to constipation. It has been
shown that the general well-being of people with constipation is lower
than that of the general population (Glia & Lindberg 1997). Therefore
stress in the workplace can be part of the downward spiral from an occa-
sional problem to one of chronic constipation and all the other possible
problems associated with it. The vicious circle of bad food habits and bad
toileting habits may lead to increased anxiety. It may result in a mis-
guided person refraining from eating and drinking on the day of an
important meeting owing to fear of needing the toilet, which will only
make matters worse. Asbury & White (2001) state that increasing stress
can cause many other symptoms. These include:
FACTORS Any lack of control of flatus or stool, however temporary or minor, is very
CONTRIBUTING TO unnerving and stressful. At its least severe, there may be loss of flatus in
ANAL INCONTINENCE company with the risk of telltale sounds and smell; at its most devastating
there is uncontrolled complete emptying of the bowel with little or no warn-
ing and in an inappropriate place. The chief adverse factors to continence
are those that may contribute to the likelihood of the anal sphincters being
overwhelmed (e.g. age, anal sphincter damage, liquid stool). However, the
picture is sometimes complicated by the patient’s ability to adapt and find
ways of compensating for deficits in specific physiological mechanisms by
using other biological and behavioural means to maintain continence.
Age Research shows that resting anal closure pressure and maximum squeeze
pressure decline with age and there is an age-dependent increase (partic-
ularly in women) in the pressure needed to produce an initial sensation
of rectal filling and to trigger the RAIR (Akervall et al 1990). There is also
an age-related increase in perineal descent at rest, which would increase
the anorectal angle, and a slowed pudendal nerve conduction rate
(Jameson et al 1994). This means that the elderly will be more at risk of
incontinence of flatus and stool regardless of other factors.
Anal sphincter There is clear evidence that physical disruption of the integrity of either
dysfunction or both of the anal sphincters or the immediate adjacent tissues may
jeopardise continence (Kalantar et al 2002). This may occur as a result
400 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Childbirth At vaginal delivery, physical damage may occur to the external or internal
anal sphincter, or both, as a result of a perineal tear or an episiotomy which
extends from vagina to the anus. If the sphincter is involved in any way, the
lesion should be classified as a ‘third degree tear’. Sultan (1999) has recom-
mended three subdivisions of third degree tears and these have been
incorporated into the Royal College of Obstetricians and Gynaecologists
guideline no. 29 (RCOG 2001). However, it is now known that occult dis-
ruption of one or other sphincter may occur without visible damage, and
this is thought to be due to shearing of tissue during labour. Sphincter
injuries are more common in primipara, and other associated risk factors
include a large baby, forceps delivery, prolonged second stage and occipi-
toposterior presentation (Sultan et al 1994). Specialist training is required
for obstetricians and midwives with respect to examination to detect
sphincter disruption, and postpartum repair should be undertaken by an
expert in an operating theatre where the light is good (MacLean & Cardozo
2002). Endoanal ultrasound has proved invaluable in detecting and assess-
ing anal sphincter disruption (see p. 409).
Surgery There has been considerable concern regarding possible iatrogenic dam-
age to the sphincters that can occur as a result of anal surgery (Nelson
1999), for example anal stretch, sphincterotomy or haemorrhoidectomy.
Kelly et al (1998) reported a substantial decrease in maximum squeeze
pressure following hysterectomy in those who also had multiple vaginal
deliveries. Deterioration in bowel function posthysterectomy was also
shown by van Dam et al (1997). Of the women in the study (n ⫽ 531), 59%
indicated normal defaecation prior to the hysterectomy; after surgery
31% reported severe deterioration and 11% mentioned a moderate
change. The most common symptom of which women complained was
severe straining.
Accidents Damage can also result from accidents (e.g. road traffic accidents), and
from abusive or unwanted (rape) penetrative sexual activity. In the latter
case, a small study (n ⫽ 7) by Engel et al (1995) showed that all had IAS
damage and three had additional EAS disruption.
Trauma Trauma to the nerve supply to the anal sphincters or the perineum, or
both, as a result of tears, episiotomy or traction on the pudendal nerve
during childbirth, may reduce anal sphincter function in the short or long
term. Jameson et al (1994) showed that increased parity correlates with
decreased squeeze pressure.
Bowel and anorectal function and dysfunction 401
Habitual chronic straining This may permanently stretch the perineal connective and muscle tissue
at the stool resulting in descending perineal syndrome. This stretching may damage
the nerve supply to the sphincters or the pelvic floor muscles, or both;
straining predisposes to haemorrhoids, which may reduce the efficiency
of the sealing capability of the closure mechanism, and can even result in
rectal prolapse. The stretched perineum cannot give the normal support
to the rectum and anus and the lower position of the perineum allows an
increase in the anorectal angle. An association between excessive perineal
descent and hysterectomy has been reported (Karasick & Spettell 1997).
All these possibilities are able to compromise continence.
Liquid stool Diarrhoea is the term used to describe very frequent bowel evacuation or
the passage of very loose watery, poorly formed stools, or both. However,
research suggests (Talley et al 1994) that patients use the term variously
so it should be interpreted very cautiously. Liquid stool is associated with
faecal incontinence (Kalantar et al 2002). The commonest cause is an
infection, viral or bacterial, which is usually contracted from infected food
or water. The use of laxatives, which stimulate the activity of the gut, can
result in material being propelled so quickly through the intestines that
there is insufficient time for absorption of water or for stool formation. A
number of drugs cause diarrhoea in some people as a side-effect (e.g.
some drugs for gastric and duodenal ulcers, hypertension, antibiotics
and iron preparations). Women’s health physiotherapists should refer to
the British National Formulary if concerned.
Patients with certain subtypes of IBS (see p. 393) experience diarrhoea
as a result of abnormal contractions of the intestinal musculature and
heightened sensitivity to stretching or distension. The cause is as yet
unknown and there is no detectable structural disease. The condition is
exacerbated by stress and anxiety, and may follow intestinal infection.
Sufferers of any condition which results in inflammation and ulceration
of segments of the intestinal tract (e.g. Crohn’s disease, ulcerative colitis,
tumours or radiation enteritis) may experience episodes of diarrhoea.
Patients with faecal impaction (see p. 398) may well present with leak-
age of stool and apparent diarrhoea but in fact it is due to the impacted
material in the rectum stimulating the RAIR, which allows the softer
more liquid material from higher up the intestinal tract to leak round and
past the impacted material in the rectum, and out through the anus.
Functional faecal This term covers all faecal incontinence resulting from failure to reach an
incontinence appropriate place to defaecate in time, in the absence of any of the factors
discussed above. Leaders at children’s camps sometimes find children
who have ‘messed’ themselves because they were afraid to go out to the
toilets in the dark or could not open the door, etc. Accident and emer-
gency health professionals would do well to consider this aspect of care
for patients waiting for hours for diagnoses and treatment for even quite
simple traumas like Colles fracture or sprained ankle.
The women’s health physiotherapist must ensure that the faecal incon-
tinence is not arising from an inability to achieve toilet transfers, from a
402 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
lack of adequate mobility and balance, that patients are able to manage
their own clothing, especially underclothing, and have adequate manual
dexterity to be able to cleanse themselves. The environmental factors to
be taken into consideration include: toilet and bed heights, toilet location,
clear and unambiguous gender signposting, lighting and flooring, acces-
sibility and adequate manoeuvring space, the bed and the bedding,
clothing and footwear, medication and fluids taken, eyesight and hear-
ing, orientation and any help available if needed.
Occupational therapists are members of the multiprofessional team
concerned with the functional care of patients; they are experts on
matters of functional incontinence. It may be appropriate to refer a
patient to occupational therapy for a functional home assessment; this
may then result in the provision of appropriate toileting aids, appliances
and clothing adaptations.
Please complete the form and bring it with you to your appointment on …………………
Time of bowel Consistency: Did you reach Did you soil Any blood or Other
movement/s e.g. pellets, soft, the toilet in your underwear/ mucus? comments
hard, pencil thin, time? pad? Yes/no
diarrhoea etc. Yes/no Yes/no
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
• Can they control flatus and can they discriminate between flatus, solid
and liquid?
• Do they ever have difficulty emptying their bowels; do they strain, use
perineal pressure, vaginal pressure or need to empty their bowels
manually?
• Do they wear any pads or appliances and how much help are they?
• Do they have/have they had haemorrhoids?
• Do they ever feel a heaviness or anything protruding from the anus or
vagina?
• Do they ever strain to empty their bowels?
• In what position do they empty their bowels?
• Do they feel that they completely empty?
• Do they ever experience any abdominal bloating?
• Do they use a lot of toilet paper to cleanse the anal area?
• Do they ever have any skin soreness or other skin problems in the anal
region?
FOOD DIARY
Name: . . . . . . . . . . . . . . . . . Hospital number: . . . . . . . . . . . . . . . . . . .
Please complete during a normal week all that you eat and drink over a period of 7 days. Note the times of the food and drink
and indicate any bowel problems that you experienced on that day
Breakfast Lunch Evening meal Fluids (type Other snacks Bowel problems on
and volume) the day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Colonic transit studies Radiological transit studies can be a useful tool in the evaluation of
severely constipated patients. They can be carried out by the ingestion of
radio-opaque different-shaped and different-sized markers on different
days, followed by abdominal X-rays on several days afterwards to track
the markers’ progression. The studies cannot be carried out if a woman is
pregnant or if there is bowel obstruction. A full description of the method
can be found in Metcalf (1995).
It has been reported that the rectal tone after a meal is absent or
blunted in patients having obstructed defecation with prolonged transit
times (Gosselink & Schouten 2001a).
Bowel and anorectal function and dysfunction 409
Endoanal EAUS enables clinicians to visualise and detect accurately defects of both
ultrasonography (EAUS) the IAS and EAS. It is a simple procedure using an anal probe that
patients generally find acceptable. The 360° rotating ultrasound trans-
ducer is placed in the anal canal and is used to gain an image of the
subepithelium and both the IAS and EAS. It can detect any damage to
the sphincters so that an accurate diagnosis and treatment may be carried
out. As experience accumulates it is giving valuable assistance in the
selection of patients, particularly postpartum, who may benefit from
prompt sphincter repair, either sphincteroplasty (i.e. overlapping of the
two ends) or apposition of the two sides. Sadly results of surgery are
rarely perfect, many patients have residual symptoms and some may
develop new evacuation disorders (Malouf et al 2000a). Further details of
transrectal ultrasound imaging of the pelvic floor can be found in Khullar
(2002).
Magnetic resonance MRI provides high-resolution images in multiple planes and may be
imaging (MRI) used to evaluate the pelvic floor. However, it is expensive, limited to
static studies and mainly considered a research tool. A study by Malouf
et al (2000b) compared the use of MRI and anal endosonography in
patients with faecal incontinence. They determined that the methods are
equivalent in diagnosing EAS injury but MRI is inferior in diagnosing
IAS injury.
Pudendal nerve A special device is placed intra-rectally with its tip directed to the
terminal motor latency pudendal nerve where it travels around the ischial spine on one side or
(PNTML) the other. There are two electrodes on the device, one at its tip and one
at the level of the anal sphincter. Current is passed through the tip
electrode and a measurement taken at the other electrode where it
detects activity in the anal sphincter. The test is repeated on both sides.
The time that it takes for the pulses to pass down the nerve and make
the muscle contract is known as the nerve latency. Less than 2.2 ms is
considered normal; longer than 2.2 ms indicates some nerve damage.
The test is not carried out during pregnancy or if a cardiac pacemaker is
in situ.
410 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Strength duration The assessment of the neural innervation of skeletal muscles by the use of
curves strength duration curves was previously common practice for physio-
therapists. In more recent times Monk et al (1998) have investigated and
proposed the use of the strength duration curve for assessment of the
EAS in conjunction with anal manometry for the investigation of faecal
incontinence. Further work has been reported (Mills et al 2002) in which
the strength duration curve was compared with other methods of diag-
nostic anorectal testing (manometry, rectal sensation, EMG, PNTML and
endoanal ultrasound). It was shown that the strength duration curve of
the EAS significantly correlates with established methods of EAS func-
tion and its innervation. Therefore the strength duration curve of the EAS
can be a simple measure to show EAS denervation.
DIET Prior to any therapy it is essential to determine the type (see Fig. 12.1) and
frequency of the stool. In the case of infective diarrhoea, rectal bleeding,
blood or mucus in the stools or a recent change in bowel habit, medical
advice must be immediately sought.
If none of these is present, it may be that appropriate dietary modifica-
tion is all that is necessary. Appropriate soluble and insoluble fibre should
be part of a well-balanced diet including five pieces of fruit or portions of
vegetables per day. It is believed that prebiotics, which are non-digestible
carbohydrates that stimulate the growth of desirable bacteria in the gut,
and probiotics, which are supplements of ‘friendly’ bacteria, help the
colonic bacteria to maintain normal digestion. There is no clear evidence
to support their use, but they appear to be without side-effects and work
well in some patients. Good food sources of prebiotics are bananas,
asparagus, garlic, wheat, tomatoes, onions, chicory and Jerusalem arti-
chokes. Probiotics are usually bought as live bacteria added to foods,
drinks and yoghurts (e.g. Actimel, Yakult, Bio yoghurts).
It should always be checked that any patient suffering with any bowel or
anorectal dysfunction is consuming appropriate types and volumes of flu-
ids. It is generally recommended that approximately 1.5 litres (3 pints) of
fluid a day are appropriate. This may increase according to the patient’s level
of activity; it is best assessed by looking at the patient’s fluid output (ideally
about 1.5 litres). Alcohol can affect people’s bowels in different ways, there-
fore a food and drink diary is of some importance in ascertaining any effect.
Bowel and anorectal function and dysfunction 411
BOWEL RETRAINING A regular habit of bowel emptying is often helpful. This can be retrained
by a regular healthy diet and toileting 20–30 minutes after a meal or
warm drink, especially breakfast, to utilise the gastrocolic response. If it
becomes apparent that the call to stool takes place in a particular part of
the day then appropriate planning can be made.
Bowel retraining may be necessary for those suffering with bowel
frequency and urgency. St Mark’s Hospital advocates a four-stage ‘holding
on’ programme (full details obtainable on the internet at www.bowelcon-
trol.org.uk) in which patients are given the following instructions:
• Sit on the toilet and hold on for as long as you can. Whatever you can
manage double it and double it again aiming for 5 minutes.
• When you have mastered this, try holding on for 10 minutes (some-
thing to read may be helpful).
• When able, try to hold on for 5 minutes whilst in the bathroom but not
sat on the toilet.
• When able to hold on for 10 minutes away from the toilet, move fur-
ther away from the bathroom.
However, sitting on the toilet may excite the reflexes associated with
bowel emptying and people may find they spend the longest time on
achieving stage one.
MEDICATION It may be that the drugs that a person is taking for other conditions are
causing a problem of constipation. These drugs include anticholinergics,
diuretics, oral iron supplements, sympathomimetics, antacids, antihy-
pertensives and NSAIDs (Emmanuel 2002). It is therefore always worth-
while to ask the GP to review the medication being taken in those suffering
with constipation.
However, it may be necessary for a patient to take some form of medi-
cation to assist in manipulating the stool consistency to one that is easier
both to contain and to expel, also perhaps to stimulate increased peristal-
sis. The expenditure on laxatives in the UK was reported as being £43 bil-
lion by Petticrew et al (1999). It is therefore of great importance that,
when it is necessary, the appropriate laxative is used. However, it was
also stated in the same study (Petticrew et al 1999) that the reviewed
laxative trials have serious methodological shortcomings.
412 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
• lactulose
• polyethylene glycol (PEG) – Movicol.
These agents reduce the absorption of water from the bowel; this
water retention in the stool softens it, increases its bulk and stimulates
peristalsis. Adverse effects can include abdominal pain and flatulence.
Osmotics may be used when stimulants and bulking agents have failed.
A study by Attar et al (1999) showed that PEG (Movicol) was more effect-
ive than lactulose, and better tolerated. There was less flatus reported
with a higher mean frequency and less straining at stool in the PEG
group.
Bowel and anorectal function and dysfunction 413
• arachis oil (NB not to be used with anyone with any peanut allergy)
• docusate sodium – Docusate, Docusol, Dioctyl.
These preparations aim to lubricate and soften the stool. They can be
given as a retention enema but should be used with caution in case of any
intestinal obstruction.
Faecal incontinence Faecal incontinence can be influenced by the stool consistency. It may be
necessary to take appropriate medication to thicken the stool.
• loperamide (Imodium)
• codeine phosphate.
These drugs reduce peristalsis and gastrointestinal motility by stimulat-
ing the opioid receptors in the bowel. They can have the adverse effect of
constipation. Loperamide has the additional advantage of having a direct
effect on the anal sphincter causing an increase in anal sphincter pressure
(Read et al 1982).
Absorbents These include agents such as kaolin. They absorb water without increas-
ing stool bulk, making the stool firmer and smaller.
Topical agents It has been reported that application of 10% phenylephrine gel to the
anus produces a significant rise in the resting anal pressure in healthy
human volunteers (Carapeti et al 1999).
Defaecation technique Effective defaecation is that in which patients have sufficient warning,
can delay if necessary, get to the toilet easily, sit comfortably and evacu-
ate with minimal effort and without harm to themselves. This involves
coordinated activity between the somatic and autonomic nervous
414 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
• sitting on a chair
• feet supported on a footstool of approximately 15 cm with heels
raised
• hips flexed to more than 90°
• the weight of the upper trunk supported on the forearms, resting on
the abducted thighs
• neutral spinal curves.
• lateral bracing with brief 1–2 second holds and sustained 10–20-seconds
holds
• anal release facilitated by lower abdominal bulging
• practice of the combination of bracing and bulging.
Markwell & Sapsford (1998) further describe how the forward-lean
sitting position results in the anterior shift of the abdominal contents.
The lowering diaphragm pushes the abdomen out and lengthens the rec-
tus abdominis with an isometric hold in its outer range such that pub-
orectalis is then able to release and anal shortening and widening result.
It is also believed that diaphragmatic breathing with the breath held with
the diaphragm low will assist the defaecation pattern (Chiarelli 2002).
Bowel and anorectal function and dysfunction 415
Anal sphincter exercise The EAS and puborectalis are both under somatic control and contribute
to the faecal continence control mechanism. Appropriate exercise can
therefore improve faecal continence status. However, exercise must be
associated with appropriate lifestyle changes where necessary. This
includes attention to stool consistency, diet and general exercise, and
defaecation training to prevent straining at the stool.
It is first necessary to ensure that the appropriate action is taking place;
this is best done by an anorectal examination (see p. 406) but if this is not
possible the external signs of puckering and inwards drawing of the anus
can be used to assess an appropriate sphincter exercise programme.
Initially it may be an advantage to instruct the patient to sit resting back
in the chair (for proprioception of the posterior pelvic floor) with knees
slightly apart. The instructions are those of squeezing as though to stop
passing wind or stool, and lifting the sphincter off the chair, whilst con-
tinuing with normal breathing. There may be further activation by giving
the instruction to try the same whilst reducing foot pressure on the floor
(but not attempting to lift the feet completely off the floor). Once the per-
son has localised the anal sphincter muscles they should then be trained
in the same way that other pelvic floor muscles are trained (see Ch. 11).
This will include strong holds of maximal length, longer contractions of
approximately half the maximum hold for endurance and finally fast con-
tractions. There must always be adequate rest periods depending on the
muscle grade and ability. As the patient becomes able, the length and
number of contractions are increased and the rest periods shortened.
Chiarioni et al (1993) showed that a squeeze of at least 20 seconds is nec-
essary to control faecal urgency when there is more liquid stool.
Instructions to the patient for self-checking can include using a mirror
for observation, or feeling a lift of the anal sphincter away from an exam-
ining finger.
It is generally found that exercising three times a day is both possible
and sufficient to achieve muscle improvement. Concentrated effort is
necessary initially, but sphincter exercises must then be incorporated into
416 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Faecal incontinence Norton & Kamm (2001a) systematically reviewed 46 studies published in
English that used biofeedback to treat adults complaining of faecal incon-
tinence. It was difficult to evaluate the results as the studies had many
variables concerning type of biofeedback and exercise. However, they
concluded that the results suggest that biofeedback and exercises help
the majority of patients with faecal incontinence.
Norton et al (2002b) further investigated four groups of patients
reporting faecal incontinence. Group A received standard medical
and nursing care advice, group B advice plus instructions on anal sphinc-
ter exercises, group C additional hospital-based computer-assisted
Bowel and anorectal function and dysfunction 417
Massage for It has been suggested that abdominal wall massage may be a therapeutic
constipation effective treatment for those with chronic constipation. It has been sug-
gested that abdominal massage may: encourage peristalsis, release
spasm, relieve flatulence, precipitate bowel opening, may be used in
retraining bowel function, is safe, non-invasive and can be performed as
self-massage or by a carer (Richards 1998). There has been description in
the literature of its use with 32 institutionalised adults having severe dis-
ability (Emly et al 1998); it was found to be as effective as laxatives within
that environment. Richards (1998) further describes abdominal massage
being used to good effect in a mixed group of 10 patients (ages 4–63) with
a variety of conditions from IBS to multiple sclerosis. Each participant in
the study received at least 35 massage treatments over a 7-week period.
It was suggested that such treatment reduces the use of laxatives and is
therefore both beneficial to the patient’s well-being and cost effective.
However Klauser et al (1992) studied nine constipated patients (aged
63–73 years) and seven healthy volunteer subjects (aged 26–28 years)
with a 3-week treatment phase (with nine sessions) and a control phase.
They found that the healthy volunteers and patients did not differ signi-
ficantly during the control and massage periods.
The lack of scientific evidence from large studies in the general consti-
pated population means that at present the practitioner cannot necessar-
ily anticipate successful outcomes from abdominal massage. However, it
is easily learnt and is both generally safe and non-invasive, provided that
the contraindications to abdominal massage, such as cancer of the bowel,
any abdominal herniation or recent abdominal surgery or scarring, are all
heeded (Richards 1998).
Massage technique Before any massage takes place the environment must be conducive to
relaxation and the patient positioned in a comfortable position.
Emly (1993) describes a five-part technique taking about 15–20
minutes that she used for a 21-year-old cerebral palsy patient, with olive
418 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
oil as a couplant:
1. stroking from the stomach to the groin to encourage initial relaxation
2. when relaxation is felt, effleurage along the colon starting in the right
iliac fossa and then travelling along the ascending, transverse and
descending sections of colon
3. following the effleurage strokes by circular kneeding along the line of
the colon in the same direction as previously
4. more effleurage as previously
5. side-to-side stroking across the abdominal wall.
Massage should never be a therapy employed in isolation, but rather be
part of a general management plan for the underlying constipation. As
recent abdominal surgery is a contraindication to massage of the abdomen,
appropriate abdominal exercise postsurgery may be utilised. Other mas-
sage ‘equipment’ has also been reported as being used in spinal units, such
as a tennis ball being abdominally rolled along the length of the colon for
self-massage (Richards 1998).
Neuromuscular Electrical stimulation has been used for many years as a method of
stimulation re-education of muscle by raising cortical awareness, normalising reflex
activity and having a direct affect on the muscle stimulated. However, a
Cochrane review by Hosker et al (2003) concluded that at present there is
insufficient evidence to draw reliable conclusions on the effect of electrical
stimulation for the treatment of faecal incontinence. They reported that
there is a suggestion that stimulation may have a therapeutic effect but
that this is not certain.
If a patient is assessed to have a low voluntary anal squeeze on exam-
ination and exercise does not seem to be leading to any improvement, it
may be appropriate to consider a course of stimulation by a home treat-
ment unit preferably for daily use or attendance for clinic-based therapy.
It is proposed that an anal electrode should be used to ensure that max-
imal stimulation can take place, but care must be taken as the anal mucosa
is often more sensitive than the vaginal mucosa (Laycock 2002). As it is
generally the EAS and posterior pelvic floor compartment that is under-
going treatment, it is appropriate to use a frequency of 35–40 Hz with a
pulse duration of 250 s with a non-fatiguing duty cycle (depending on
the patient’s ability).
Rectal sensitivity If there is a problem with reduced sensation to rectal filling, sensitivity
training training is used to re-educate the contraction of the EAS in response to
rectal distension. This can be achieved by using a simple device: a rectal
balloon attached to a plastic tube with a three-way tap to enable air to be
introduced by a syringe. A condom covers the balloon and proximal tube
to ensure good infection control and assist in the removal of the device.
The patient is in side lying whilst the balloon is introduced into the
rectum, then air or water is introduced via the syringe until the patient
reports the threshold sensation. The air/water is then removed and the
patient instructed to contract the anal sphincter strongly as soon as a
Bowel and anorectal function and dysfunction 419
Anal plugs Disposable anal plugs and tampons have been designed to help control
intractable faecal incontinence by obstructing the anal canal; they are
inserted into the upper part of the anal canal and removed to allow
420 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Anal cones Specially designed cones for anal incontinence are available via the inter-
net. However, there is no research literature to back up their efficacy.
Skin care and Sore skin in the anal region is a common problem for those suffering from
body odours anal incontinence owing to the effects of faeces on the skin in the area. Some
people have problems with properly wiping the area and leaving a residue
behind; others can have faecal seepage, especially of liquid stool. Immo-
bility and inactivity make the problem worse. Advice will comprise of using
soft toilet paper or moist wipes (avoiding any with an alcohol base) or moist
cotton wool, always wiping from front to back, and washing after a bowel
movement whenever possible (portable bidets are available, or a jug
with warm water or plant spray can all be useful), then gently patting dry.
Strongly perfumed soaps, bath foams, disinfectants or antiseptics, talcum
powder or deodorants should be avoided. It is also desirable to wear cotton
underwear and avoid tights (unless crotchless). Synthetic fibre, tight cloth-
ing and biological detergents are also best avoided and great care should be
taken in rinsing underwear thoroughly after washing. It is also advisable to
avoid creams unless specifically advised to use them; the stoma nurse or
continence advisor will often be the person to advise on appropriate
creams, skin barriers or barrier wipes. If a continence pad is used, it must be
changed at the first sign of soiling. If the anal area does become sore it is
sensible to have some time each day when air can circulate in the area. If
there is skin irritation it is essential that the patient is instructed to resist the
urge to scratch.
There are useful suggestions from St Mark’s hospital to be found on
the internet at the site www.bowelcontrol.org.uk/tips. These include:
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Further reading
Books Pettigrew M, Watt I, Sheldon T 1997 Systematic review of the
Norton C, Kamm M 1999 Bowel control: information effectiveness of laxatives in the elderly. Health Technology
and practical advice. Beaconsfield Publishers, Assessment 1(13):i–iv, 1–52.
Beaconsfield. Potter J, Norton C, Cottenden A (eds) 2002 Bowel care in older
Pemberton J H, Swash M, Henry M M 2002 The pelvic floor. people: research and practice. Clinical Effectiveness Unit,
Its function and disorders. W B Saunders, London. Royal College of Physicians, London.
Bowel and anorectal function and dysfunction 425
Leaflets Kyle G, Oliver H, Prynn P 2003 The procedure for the digital
ACA (Association for Continence Advice) 2003 ACA removal of faeces, guidelines 2003. Collaborative venture
continence resource pack for care homes. ACA, London. between NHS, Thames Valley University and Norgine.
Addison R, Davies C, Haslam D et al 2001 Managing Potter J, Norton C, Cottenden A (eds) 2003 Bowel care in older
constipation in adults and older people. An interim guide people: concise guide. Clinical Effectiveness Unit, Royal
for healthcare professionals. Funded by Norgine and College of Physicians, London.
produced by Professional Medical Communications.
Useful addresses
British Digestive Foundation National Association for Colitis and Crohn’s Disease,
3 St Andrew’s Place, London NW1 4LB PO Box 205, St Albans, Herts AL1 1AB
Website: www.bdf.org.uk Website: www.nacc.org.uk
Continence Foundation Royal College of Physicians
307 Hatton Square, 16 Baldwin Gardens, London EC1N 7RJ 11 St Andrews Place, London NW1 4LE
Website: www.continence-foundation.org.uk Website: www.rcplondon.ac.uk
IBS Network
Northern General Hospital, Sheffield S5 7AU
Website: www.ibsys.com
427
Appendix 1
Standardisation of terminology of
lower urinary tract function
Report from the standardisation sub-committee of the International Continence Society. Reproduced with
permission of the International Continence Society Committee on Standardisation of Terminology.
First published in Neurology and Urodynamics 21:167–178 (2002)
Members: Paul Abrams, Linda Cardozo, Magnus Fall, Derek Griffiths, Peter Rosier, Ulf Ulmsten,
Philip van Kerrebroeck, Arne Victor, and Alan Wein
LOWER URINARY Symptoms are the subjective indicator of a disease or change in condition
TRACT SYMPTOMS as perceived by the patient, carer or partner and may lead him/her to
(LUTS) seek help from health care professionals. (NEW)
Symptoms may either be volunteered or described during the patient
interview. They are usually qualitative. In general, Lower Urinary Tract
Symptoms cannot be used to make a definitive diagnosis. Lower Urinary
Tract Symptoms can also indicate pathologies other than lower urinary
tract dysfunction, such as urinary infection.
SIGNS SUGGESTIVE Signs are observed by the physician including simple means, to verify
OF LOWER URINARY symptoms and quantify them. (NEW)
TRACT DYSFUNCTION For example, a classical sign is the observation of leakage on coughing.
(LUTD) Observations from frequency volume charts, pad tests and validated
symptom and quality of life questionnaires are examples of other instru-
ments that can be used to verify and quantify symptoms.
TREATMENT Treatment for lower urinary tract dysfunction: these definitions are from
the 7th ICS report on Lower Urinary Tract Rehabilitation Techniques
(Andersen et al 1992).
Appendix 1: ICS standardisation of terminology 2002 429
Lower urinary tract symptoms are defined from the individual’s per-
spective, who is usually, but not necessarily a patient within the health-
care system. Symptoms are either volunteered by, or elicited from, the
individual or may be described by the individual’s caregiver.
Lower urinary tract symptoms are divided into three groups, storage,
voiding, and post micturition symptoms.
1.1 STORAGE Storage symptoms are experienced during the storage phase of the blad-
SYMPTOMS der, and include daytime frequency and nocturia. (NEW)
1
The term night time frequency differs from that for nocturia, as it includes voids that
occur after the individual has gone to bed, but before he/she has gone to sleep; and
voids which occur in the early morning which prevent the individual from getting back
to sleep as he/she wishes. These voids before and after sleep may need to be considered
in research studies, for example, in nocturnal polyuria. If this definition were used then
an adapted definition of daytime frequency would need to be used with it.
2
In infants and small children the definition of Urinary Incontinence is not applicable.
In scientific communications the definition of incontinence in children would need
further explanation.
3
The original ICS definition of incontinence, ‘Urinary incontinence is the involuntary
loss of urine that is a social or hygienic problem’, relates the complaint to quality of life
(QoL) issues. Some QoL instruments have been, and are being, developed in order to
assess the impact of both incontinence and other LUTS on QoL.
4
The committee considers the term ‘stress incontinence’ to be unsatisfactory in the
English language because of its mental connotations. The Swedish, French and Italian
expression ‘effort incontinence’ is preferable, however, words such as ‘effort’ or
‘exertion’ still do not capture some of the common precipitating factors for stress
incontinence such as coughing or sneezing. For this reason the term is left unchanged.
430 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
1.2 VOIDING Voiding symptoms are experienced during the voiding phase. (NEW)
SYMPTOMS
• Slow stream is reported by the individual as his or her perception of
reduced urine flow, usually compared to previous performance or in
comparison to others. (NEW)
• Splitting or spraying of the urine stream may be reported. (NEW)
• Intermittent stream (Intermittency) is the term used when the
individual describes urine flow, which stops and starts, on one or more
occasions, during micturition. (NEW)
• Hesitancy is the term used when an individual describes difficulty in
initiating micturition resulting in a delay in the onset of voiding after
the individual is ready to pass urine. (NEW)
5
Urge incontinence can present in different symptomatic forms, for example, as
frequent small losses between micturitions, or as a catastrophic leak with complete
bladder emptying.
6
These non-specific symptoms are most frequently seen in neurological patients,
particularly those with spinal cord trauma and in children and adults with
malformations of the spinal cord.
Appendix 1: ICS standardisation of terminology 2002 431
1.3 POST MICTURITION Post micturition symptoms are experienced immediately after micturi-
SYMPTOMS tion. (NEW)
1.4 SYMPTOMS Dyspareunia, vaginal dryness and incontinence are amongst the symp-
ASSOCIATED WITH toms women may describe during or after intercourse. These symptoms
SEXUAL INTERCOURSE should be described as fully as possible. It is helpful to define urine leak-
age as: during penetration, during intercourse, or at orgasm.
1.5 SYMPTOMS The feeling of a lump (‘something coming down’), low backache, heavi-
ASSOCIATED WITH ness, dragging sensation, or the need to digitally replace the prolapse in
PELVIC ORGAN order to defaecate or micturate, are amongst the symptoms women may
PROLAPSE describe who have a prolapse.
1.6 GENITAL AND Pain, discomfort and pressure are part of a spectrum of abnormal sensa-
LOWER URINARY tions felt by the individual. Pain produces the greatest impact on the
TRACT PAIN 8 patient and may be related to bladder filling or voiding, may be felt after
micturition, or be continuous. Pain should also be characterised by type,
frequency, duration, precipitating and relieving factors and by location as
defined below:
7
Suprapubic pressure may be used to initiate or maintain urine flow. The Crede3
manoeuvre is used by some spinal cord injury patients, and girls with detrusor
underactivity sometimes press suprapubically to help empty the bladder.
8
The terms ‘strangury’, ‘bladder spasm’, and ‘dysuria’ are difficult to define and of
uncertain meaning and should not be used in relation to lower urinary tract dysfunction,
unless a precise meaning is stated. Dysuria literally means ‘abnormal urination’, and
is used correctly in some European countries however, it is often used to describe the
stinging/burning sensation characteristic of urinary infection. It is suggested that these
descriptive words should not be used in future.
432 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
1.7.1 Genito-urinary Genito-urinary pain syndromes are all chronic in their nature. Pain is the
pain syndromes major complaint but concomitant complaints are of lower urinary tract,
bowel, sexual or gynaecological nature.
9
The ICS believes this to be a preferable term to ‘interstitial cystitis’. Interstitial cystitis
is a specific diagnosis and requires confirmation by typical cystoscopic and histological
features. In the investigation of bladder pain it may be necessary to exclude conditions
such as carcinoma in situ and endometriosis.
10
The ICS suggests that the term vulvodynia (vulva – pain) should not be used, as it
leads to confusion between single symptom and a syndrome.
Appendix 1: ICS standardisation of terminology 2002 433
In clinical practice, empirical diagnoses are often used as the basis for ini-
tial management after assessing the individual’s lower urinary tract
1.7.2 Symptom symptoms, physical findings and the results of urinalysis and other indi-
syndromes suggestive cated investigations.
of lower urinary tract
dysfunction • Urgency, with or without urge incontinence, usually with frequency
and nocturia, can be described as the overactive bladder syndrome, urge
syndrome or urgency-frequency syndrome. (NEW)
2.1 MEASURING THE Asking the patient to record micturitions and symptoms13 for a period of
FREQUENCY, SEVERITY days provides invaluable information. The recording of micturition
AND IMPACT OF events can be in three main forms:
LOWER URINARY
TRACT SYMPTOMS • Micturition time chart: this records only the times of micturitions, day
and night, for at least 24 hours. (NEW)
11
The ICS suggests that in men, the term prostatodynia (prostate-pain) should not be
used as it leads to confusion between a single symptom and a syndrome.
12
In women voiding symptoms are usually thought to suggest detrusor underactivity
rather than bladder outlet obstruction.
13
Validated questionnaires are useful for recording symptoms, their frequency, severity
and bother, and the impact of LUTS on QoL. The instrument used should be specified.
434 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
This is usually commenced after the first void produced after rising in
the morning, and is completed by including the first void on rising the
following morning.
14
It is useful to ask the individual to make an estimate of liquid intake. This may be done
precisely by measuring the volume of each drink or crudely by asking how many drinks
are taken in a 24-hour period. If the individual eats significant quantities of water
containing foods (vegetables, fruit, salads) then an appreciable effect on urine production
will result. The time that diuretic therapy is taken should be marked on a chart or diary.
15
The causes of polyuria are various and reviewed elsewhere but include habitual
excess fluid intake. The figure of 2.8 is based on a 70 kg person voiding ⬎40 ml/kg.
16
The normal range of nocturnal urine production differs with age and the normal
ranges remain to be defined. Therefore, nocturnal polyuria is present when greater than
20% (young adults) to 33% (over 65 years) is produced at night. Hence the precise
definition is dependant on age.
Appendix 1: ICS standardisation of terminology 2002 435
2.2 PHYSICAL Physical examination is essential in the assessment of all patients with
EXAMINATION lower urinary tract dysfunction. It should include abdominal, pelvic,
perineal and a focussed neurological examination. For patients with
possible neurogenic lower urinary tract dysfunction, a more extensive
neurological examination is needed.
2.2.2 Perineal/genital Perineal/genital inspection allows the description of the skin, for exam-
inspection ple the presence of atrophy or excoriation, any abnormal anatomical
features and the observation of incontinence.
2.2.3 Vaginal Vaginal examination allows the description of observed and palpable
examination anatomical abnormalities and the assessment of pelvic floor muscle
function, as described in the ICS report on Pelvic Organ Prolapse. The
17
The term ‘functional bladder capacity’ is no longer recommended as ‘voided volume’
is a clearer and less confusing term, particular if qualified e.g. ‘maximum voided
volume’. If the term bladder capacity is used, in any situation, it implies that this has
been measured in some way, if only by abdominal ultrasound In adults, voided
volumes vary considerably. In children, the ‘expected volume’ may be calculated from
the formula (30 ⫹ (age in years ⫻ 30) in ml). Assuming no residual urine this will be
equal to the ‘expected bladder capacity’.
18
Coughing may induce a detrusor contraction, hence the sign of stress incontinence is
only a reliable indication of urodynamic stress incontinence when leakage occurs
synchronously with the first proper cough and stops at the end of that cough.
436 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
• Pelvic organ prolapse is defined as the descent of one or more of: the
anterior vaginal wall, the posterior vaginal wall, and the apex of the
vagina (cervix/uterus) or vault (cuff) after hysterectomy. Absence of
prolapse is defined as stage 0 support; prolapse can be staged from
stage I to stage IV. (NEW)
Pelvic organ prolapse can occur in association with urinary incontin-
ence and other lower urinary tract dysfunction and may on occasion
mask incontinence.
2.2.4 Pelvic floor Pelvic floor muscle function can be qualitatively defined by the tone at
muscle function rest and the strength of a voluntary or reflex contraction as strong, weak
or absent or by a validated grading system (e.g. Oxford 1–5). A pelvic
muscle contraction may be assessed by visual inspection, by palpation,
electromyography or perineometry. Factors to be assessed include
strength, duration, displacement, and repeatability.
2.2.5 Rectal Rectal examination allows the description of observed and palpable
examination anatomical abnormalities and is the easiest method of assessing pelvic floor
muscle function in children and men. In addition, rectal examination is
essential in children with urinary incontinence to rule out faecal inpaction.
2.3 PAD TESTING Pad testing may be used to quantify the amount of urine lost during
incontinence episodes, and methods range from a short provocative test
to a 24-hour pad test.
3.2 FILLING The word ‘cystometry’ is commonly used to describe the urodynamic
CYSTOMETRY investigation of the filling phase of the micturition cycle. To eliminate
confusion the following definitions are proposed:
The filling phase starts when filling commences and ends when the
patient and urodynamicist decide that ‘permission to void’ has been
given.20
Bladder and urethral function, during filling, need to be defined
separately.
The rate at which the bladder is filled is divided into:
19
The term Ambulatory Urodynamics is used to indicate that monitoring usually takes
place outside the urodynamic laboratory, rather than the subject’s mobility using natural
filling.
20
The ICS no longer wishes to divide filling rates into slow, medium and fast. In practice
almost all investigations are performed using medium filling rates which have a wide
range. It maybe more important during investigations to consider whether or not the
filling rate used during conventional urodynamic studies can be considered physiological.
438 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
3.2.1 Bladder sensation • Normal bladder sensation can be judged by three defined points noted
during filling cystometry during filling cystometry and evaluated in relation to the bladder
volume at that moment and in relation to the patient’s symptomatic
complaints.
䊊 First sensation of bladder filling is the feeling the patient has,
try, that would lead the patient to pass urine at the next convenient
moment, but voiding can be delayed if necessary. (CHANGED)
䊊 Strong desire to void this is defined, during filling cystometry,
3.2.2 Detrusor function In everyday life the individual attempts to inhibit detrusor activity
during filling cystometry until he or she is in a position to void. Therefore, when the aims of the
filling study have been achieved, and when the patient has a desire to
void, normally the ‘permission to void’ is given (see Filling Cystometry).
That moment is indicated on the urodynamic trace and all detrusor activ-
ity before this ‘permission’ is defined as ‘involuntary detrusor activity’.
21
Whilst bladder sensation is assessed during filling cystometry the assumption that it is
sensation from the bladder alone, without urethral or pelvic components may be false.
22
The assessment of the subject’s bladder sensation is subjective and it is not, for example,
possible to quantify ‘low bladder volume’ in the definition of ‘increased bladder sensation’.
23
The ICS no longer recommends the terms ‘motor urgency’ and ‘sensory urgency’.
These terms are often misused and have little intuitive meaning. Furthermore, it may be
simplistic to relate urgency just to the presence or absence of detrusor overactivity when
there is usually a concomitant fall in urethral pressure.
Appendix 1: ICS standardisation of terminology 2002 439
24
There is no lower limit for the amplitude of an involuntary detrusor contraction but
confident interpretation of low pressure waves (amplitude smaller than 5 cm H2O)
depends on ‘high quality’ urodynamic technique. The phrase ‘which the patient cannot
completely suppress’ has been deleted from the old definition.
25
Phasic detrusor contractions are not always accompanied by any sensation, or may be
interpreted as a first sensation of bladder filling, or as a normal desire to void.
26
’Terminal detrusor overactivity’ is a new ICS term: it is typically associated with
reduced bladder sensation, for example in the elderly stroke patient when urgency may
be felt as the voiding contraction occurs. However, in complete spinal cord injury
patients there may be no sensation whatsoever.
27
ICS recommends that the terms ‘motor urge incontinence’ and ‘reflex incontinence’,
should no longer be used as they have no intuitive meaning and are often misused.
28
The terms ‘detrusor instability’ and ‘detrusor hyperreflexia’ were both used as generic
terms, in the English speaking world and Scandinavia, prior to the first ICS report in
1976. As a compromise they were allocated to idiopathic and neurogenic overactivity
respectively. As there is no real logic or intuitive meaning to the terms, the ICS believes
they should be abandoned.
440 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
3.2.4 Bladder capacity: • Cystometric capacity is the bladder volume at the end of the filling
during filling cystometry cystometrogram, when ‘permission to void’ is usually given. The end
point should be specified, for example, if filling is stopped when the
patient has a normal desire to void. The cystometric capacity is the
volume voided together with any residual urine. (CHANGED)30
• Maximum cystometric capacity, in patients with normal sensation, is
the volume at which the patient feels he/she can no longer delay
micturition (has a strong desire to void). (ORIGINAL)
• Maximum anaesthetic bladder capacity is the volume to which the
bladder can be filled under deep general or spinal anaesthetic and
should be qualified according to the type of anaesthesia used, the speed
29
The observation of reduced bladder compliance during conventional filling
cystometry is often related to relatively fast bladder filling: the incidence of reduced
compliance is markedly lower if the bladder is filled at physiological rates, as in
ambulatory urodynamics.
30
In certain types of dysfunction, the cystometric capacity cannot be defined in the same
terms. In the absence of sensation the cystometric capacity is the volume at which the
clinician decides to terminate filling. The reason (s) for terminating filling should be
defined, e.g. high detrusor filling pressure, large infused volume or pain. If there is
uncontrollable voiding, it is the volume at which this begins. In the presence of
sphincter incompetence the cystometric capacity may be significantly increased by
occlusion of the urethra e.g. by Foley catheter.
Appendix 1: ICS standardisation of terminology 2002 441
of filling, the length of time of filling, and the pressure at which the
bladder is filled. (CHANGED)
3.2.5 Urethral function The urethral closure mechanism during storage may be competent or
during filling incompetent.
cystometry
• Normal urethral closure mechanism maintains a positive urethral
closure pressure during bladder filling even in the presence of increased
abdominal pressure, although it may be overcome by detrusor
overactivity. (CHANGED)
• Incompetent urethral closure mechanism is defined as one which
allows leakage of urine in the absence of a detrusor contraction.
(ORIGINAL)
• Urethral relaxation incontinence is defined as leakage due to urethral
relaxation in the absence of raised abdominal pressure or detrusor
overactivity. (NEW)31
• Urodynamic stress incontinence is noted during filling cystometry, and is
defined as the involuntary leakage of urine during increased abdominal
pressure, in the absence of a detrusor contraction. (CHANGED)
Urodynamic stress incontinence is now the preferred term to ‘genuine
stress incontinence’.32
31
Fluctuations in urethral pressure have been defined as the ‘unstable urethra’.
However, the significance of the fluctuations and the term itself lack clarity and the
term is not recommended by the ICS. If symptoms are seen in association with a
decrease in urethral pressure a full description should be given.
32
In patients with stress incontinence, there is a spectrum of urethral characteristics
ranging from a highly mobile urethra with good intrinsic function to an immobile
urethra with poor intrinsic function. Any delineation into categories such as ‘urethral
hypermobility’ and ‘intrinsic sphincter deficiency’ may be simplistic and arbitrary, and
requires further research.
442 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
3.3 PRESSURE FLOW Voiding is described in terms of detrusor and urethral function and
STUDIES assessed by measuring urine flow rate and voiding pressures.
3.3.1 Measurement of Urine flow is defined either as continuous, that is with out interruption, or
urine flow as intermittent, when an individual states that the flow stops and starts
during a single visit to the bathroom in order to void. The continuous flow
curve is defined as a smooth arc shaped curve or fluctuating when there
are multiple peaks during a period of continuous urine flow.35
• Flow rate is defined as the volume of fluid expelled via the urethra per
unit time. It is expressed in mL/s. (ORIGINAL)
• Voided volume is the total volume expelled via the urethra. (ORIGINAL)
• Maximum flow rate is the maximum measured value of the flow rate
after correction for artefacts. (CHANGED)
• Voiding time is total duration of micturition, i.e. includes interrup-
tions. When voiding is completed with out interruption, voiding time
is equal to flow time. (ORIGINAL)
• Flow time is the time over which measurable flow actually occurs.
(ORIGINAL)
• Average flow rate is voided volume divided by flow time. The average
flow should be interpreted with caution if flow is interrupted or there
is a terminal dribble. (CHANGED)
33
The leak pressure point should be qualified according to the site of pressure
measurement (rectal, vaginal or intravesical) and the method by which pressure is
generated (cough or valsalva). Leak point pressures may be calculated in three ways
from the three different baseline values which are in common use: zero (the true zero of
intravesical pressure), the value of pves measured at zero bladder volume, or the value
of pves immediately before the cough or valsalva (usually at 200 or 300 ml bladder
capacity). The baseline used and the baseline pressure, should be specified.
34
Detrusor leak point pressure has been used most frequently to predict upper tract
problems in neurological patients with reduced bladder compliance. ICS has defined it
‘in the absence of a detrusor contraction’ although others will measure DLPP during
involuntary detrusor contractions.
35
The precise shape of the flow curve is decided by detrusor contractility, the presence
of any abdominal straining and by the bladder outlet. (11)
Appendix 1: ICS standardisation of terminology 2002 443
• Time to maximum flow is the elapsed time from onset of flow to max-
imum flow. (ORIGINAL)
3.3.2 Pressure The following measurements are applicable to each of the pressure
measurements during curves: intravesical, abdominal and detrusor pressure.
pressure flow studies
(PFS) • Premicturition pressure is the pressure recorded immediately before
the initial isovolumetric contraction. (ORIGINAL)
• Opening pressure is the pressure recorded at the onset of urine flow
(consider time delay). (ORIGINAL)
• Opening time is the elapsed time from initial rise in detrusor pressure
to onset of flow. (ORIGINAL)
This is the initial isovolumetric contraction period of micturition. Flow
measurement delay should be taken into account when measuring open-
ing time.
36
A normal detrusor contraction will be recorded as: a high pressure if there is high
outlet resistance, normal pressure if there is normal outlet resistance: or low pressure if
urethral resistance is low.
37
If after repeated free flowmetry no residual urine is demonstrated, then the finding of
a residual urine during urodynamic studies should be considered an artifact, due to the
circumstances of the test.
444 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
4 CONDITIONS
38
Bladder outlet obstruction has been defined for men but as yet, not adequately in
women and children.
39
Although dysfunctional voiding is not a very specific term it is preferred to terms such
as ‘non-neurogenic neurogenic bladder’. Other terms such as ‘idiopathic detrusor
sphincter dyssynergia’, or ‘sphincter overactivity voiding dysfunction’, may be preferable.
However, the term dysfunctional voiding is very well established. The condition occurs
most frequently in children. Whilst it is felt that pelvic floor contractions are responsible,
it is possible that the intra-urethral striated muscle may be important.
40
Detrusor sphincter dyssynergia typically occurs in patients with a supra-sacral lesion,
for example after high spinal cord injury and is uncommon in lesions of the lower cord.
Although the intraurethral and periurethral striated muscles are usually held
responsible, the smooth muscle of the bladder neck or urethra may also be responsible.
41
Non-relaxing sphincter obstruction is found in sacral and infra-sacral lesions such as
meningomyelocoele, and after radical pelvic surgery. In addition there is often
urodynamic stress incontinence during bladder filling. This term replaces ‘isolated
distal sphincter obstruction’.
42
Although acute retention is usually thought of as painful, in certain circumstances pain
may not be a presenting feature, for example when due to prolapsed intervertebral disc,
post partum, or after regional anaesthesia such as an epidural anaesthetic. The retention
volume should be significantly greater than the expected normal bladder capacity. In
patients after surgery, due to bandaging of the lower abdomen or abdominal wall pain,
it may be difficult to detect a painful, palpable or percussable bladder.
Appendix 1: ICS standardisation of terminology 2002 445
5 TREATMENT
The following definitions were published in the 7th ICS report on Lower
Urinary Tract Rehabilitation Techniques (3) and remain in their original
form.
5.1 LOWER Lower urinary tract rehabilitation is defined as non-surgical, non- phar-
URINARY TRACT macological treatment for lower urinary tract function and includes:
REHABILITATION
• Pelvic floor training defined as repetitive selective voluntary contrac-
tion and relaxation of specific pelvic floor muscles.
• Biofeedback is the technique by which information about a normally
unconscious physiological process is presented to the patient and/or
the therapist as a visual, auditory or tactile signal.
• Behavioural modification is defined as the analysis and alteration of
the relationship between the patient’s symptoms and his or her envir-
onment for the treatment of maladaptive voiding patterns.
This may be achieved by modification of the behaviour and/or envir-
onment of the patient.
43
The ICS no longer recommends the term ‘overflow incontinence’. This term is considered
confusing and lacking a convincing definition. If used, a precise definition and any
associated pathophysiology, such as reduced urethral function, or detrusor overactivity/
low bladder compliance, should be stated. The term chronic retention, excludes transient
voiding difficulty, for example after surgery for stress incontinence, and implies a
significant residual urine; a minimum figure of 300 mL has been previously mentioned.
446 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
5.4 BLADDER REFLEX Bladder reflex triggering comprises various manoeuvres performed by
TRIGGERING the patient or the therapist in order to elicit reflex detrusor contraction by
exteroceptive stimuli.
The most commonly used manoeuvres are; suprapubic tapping, thigh
scratching and anal/rectal manipulation.
ACKNOWLEDGEMENTS The authors of this report are very grateful to Vicky Rees, Administrator
of the ICS, for her typing and editing of numerous drafts of this document.
ADDENDUM The terminology committee was announced at the ICS meeting in Denver
1999 and expressions of interest were invited from those who wished to be
Formation of the ICS active members of the committee and they were asked to comment in
terminology committee detail on the preliminary draft (the discussion paper published in
Neurourology and Urodynamics). The nine authors replied with a
detailed critique by 1st April 2000 and constitute the committee: Paul
Abrams, Linda Cardozo, Magnus Fall, Derek Griffiths, Peter Rosier, Ulf
Ulmsten, Philip van Kerrebroeck, Arne Victor, and Alan Wein.
We thank other individuals who later offered their written comments:
Jens Thorup Andersen, Walter Artibani, Jerry Blaivas, Linda Brubaker,
Rick Bump, Emmanuel Chartier-Kastler, Grace Dorey, Clare Fowler,
Kelm Hjalmas, Gordon Hosker, Vik Khullar, Guus Kramer, Gunnar
Lose, Joseph Macaluso, Anders Mattiasson, Richard Millard, Rien
Appendix 1: ICS standardisation of terminology 2002 447
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Abrams P, Blaivas J G, Stanton S L, Andersen J. 1992. ICS 6th Stöhrer M. 1998. Standardisation of outcome studies in
report on the standardisation of terminology of lower patients with lower urinary dysfunction: a report on
urinary tract function. Neurourol Urodyn 11:593–603. general principles from the standardisation committee of
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techniques. Neurourol Urodyn 11:593–603. Griffiths D, Kobayashi S, Koyanagi T, Schäfer W, Yalla S,
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17:273–281. 2002. Good urodynamic practice: report from the
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16:1–18. monitoring: report of the standardisation sub-committee
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Klevmark B. 1999. Natural pressure: volume curves and van Kerrebroeck P, Abrams P, Chaikin D, Donovan J, Fonda
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Appendix 2
Standardisation of terminology of
lower urinary tract function
Reproduced with permission of the International Continence Society Committee on Standardisation of
Terminology. First published in Scandinavian Journal of Urology and Nephrology, Supplementum 114, 1988
Members: Paul Abrams, Jerry G. Blaivas, Stuart L. Stanton and Jens T. Andersen (Chairman)
1 INTRODUCTION
2 CLINICAL ASSESSMENT
2.1 HISTORY The general history should include questions relevant to neurological
and congential abnormalities as well as information on previous urinary
infections and relevant surgery. Information must be obtained on medi-
cation with known or possible effects on the lower urinary tract. The
general history should also include assessment of menstrual, sexual and
bowel function, and obstetric history.
The urinary history must consist of symptoms related to both the stor-
age and the evacuation functions of the lower urinary tract.
Pain (the site and character of which should be specified). Pain during
bladder filling or micturition is abnormal.
The use of objective or semi-objective tests for sensory function, such
as electrical threshold studies (sensory testing), is discussed in detail
in 5.5.
The term ‘Capacity’ must be qualified.
Maximum cystometric capacity, in patients with normal sensation, is the
volume at which the patient feels he/she can no longer delay micturition.
In the absence of sensation the maximum cystometric capacity cannot be
defined in the same terms and is the volume at which the clinician
decides to terminate filling. In the presence of sphincter incompetence
the maximum cystometric capacity may be significantly increased by
occlusion of the urethra e.g. by Foley catheter.
The functional bladder capacity, or voided volume is more relevant and
is assessed from a frequency/volume chart (urinary diary).
The maximum (anaesthetic) bladder capacity is the volume measured
after filling during a deep general or spinal/epidural anaesthetic, speci-
fying fluid temperature, filling pressure and filling time.
Compliance indicates the change in volume for a change in pressure.
Compliance is calculated by dividing the volume change (⌬V ) by the
change in detrusor pressure (⌬pdet) during that change in bladder
volume (C ⫽ ⌬V/⌬pdet). Compliance is expressed as mls per cm H2O (see
6.1.1.4).
3.2 URETHRAL It should be noted that the urethral pressure and the urethral closure
PRESSURE pressure are idealized concepts which represent the ability of the urethra
MEASUREMENT to prevent leakage (see 6.1.5). In current urodynamic practice the urethral
pressure is measured by a number of different techniques which do not
always yield consistant values. Not only do the values differ with the
method of measurement but there is often lack of consistency for a single
method. For example the effect of catheter rotation when urethral pres-
sure is measured by a catheter mounted transducer.
Intraluminal urethral pressure may be measured:
(a) Resting urethral pressure profile – with the bladder and subject at rest.
(b) Stress urethral pressure profile – with a defined applied stress (e.g.
cough, strain, valsalva).
Appendix 2: ICS standardisation of terminology 1988 453
In the storage phase the urethral pressure profile denotes the intralumi-
nal pressure along the length of the urethra. All systems are zeroed at
atmospheric pressure. For external transducers the reference point is the
superior edge of the symphysis pubis. For catheter mounted transducers
the reference point is the transducer itself. Intravesical pressure should
be measured to exclude a simultaneous detrusor contraction. The sub-
traction of intravesical pressure from urethral pressure produces the
urethral closure pressure profile.
The simultaneous recording of both intravesical and intra-urethral
pressures are essential during stress urethral profilometry.
Technique (a) Open catheter – specify type (manufacturer), size, number, position
and orientation of side or end hole.
(b) Catheter mounted transducers – specify manufacturer, number of
transducers, spacing of transducers along the catheter, orientation
with respect to one another; transducer design e.g. transducer face
depressed or flush with catheter surface; catheter diameter and mater-
ial. The orientation of the transducer(s) in the urethra should be stated.
(c) Other catheters, e.g. membrane, fibreoptic – specify type (manufac-
turer), size and number of channels as for microtransducer catheter.
(d) Measurement technique: For stress profiles the particular stress
employed should be stated e.g. cough or valsalva.
(e) Recording apparatus: Describe type of recording apparatus. The fre-
quency response of the total system should be stated. The frequency
response of the catheter in the perfusion method can be assessed by
blocking the eyeholes and recording the consequent rate of change of
pressure.
40
20
Bladder Functional profile length
pressure Total profile length
0
0 1 2 3 4 5 6
Distance (cm)
are given the position in the urethra should be stated. If several pressure
transmission ratios are defined at different points along the urethra a
pressure ‘transmission’ profile is obtained. During ‘cough profiles’ the
amplitude of the cough should be stated if possible.
Note: the term ‘transmission’ is in common usage and cannot be
changed. However transmission implies a completely passive process.
Such an assumption is not yet justified by scientific evidence. A role for
muscular activity cannot be excluded.
Total profile length is not generally regarded as a useful parameter.
The information gained from urethral pressure measurements in the
storage phase is of limited value in the assessment of voiding disorders.
3.3 QUANTIFICATION Subjective grading of incontinence may not indicate reliably the degree
OF URINE LOSS of abnormality. However it is important to relate the management of the
individual patients to their complaints and personal circumstances, as
well as to objective measurements.
In order to assess and compare the results of the treatment of different
types of incontinence in different centres, a simple standard test can be used
to measure urine loss objectively in any subject. In order to obtain a repre-
sentative result, especially in subjects with variable or intermittent urinary
incontinence, the test should occupy as long a period as possible; yet it must
be practical. The circumstances should approximate to those of everyday
life, yet be similar for all subjects to allow meaningful comparison. On the
basis of pilot studies performed in various centres, an internal report of the
I.C.S. (5th) recommended a test occupying a one-hour period during which
a series of standard activities was carried out. This test can be extended by
further one hour periods if the result of the first one hour test was not con-
sidered representative by either the patient or the investigator. Alternatively
the test can be repeated having filled the bladder to a defined volume.
The total amount of urine lost during the test period is determined by
weighing a collecting device such as a nappy, absorbent pad or condom
appliance. A nappy or pad should be worn inside waterproof underpants
or should have a waterproof backing. Care should be taken to use a col-
lecting device of adequate capacity.
Appendix 2: ICS standardisation of terminology 1988 455
Typical test schedule (a) Test is started without the patient voiding.
(b) Preweighed collecting device is put on and first one hour test period
begins.
(c) Subject drinks 500 ml sodium free liquid within a short period (max.
15 min), then sits or rests.
(d) Half hour period: subject walks, including stair climbing equivalent
to one flight up and down.
(e) During the remaining period the subject performs the following
activities:
(i) standing up from sitting, 10 times
(ii) coughing vigorously, 10 times
(iii) running on the spot for 1 minute
(iv) bending to pick up small object from floor, 5 times
(v) wash hands in running water for 1 minute
(f) At the end of the one hour test the collecting device is removed and
weighed.
(g) If the test is regarded as representative the subject voids and the vol-
ume is recorded.
(h) Otherwise the test is repeated preferably without voiding.
If the collecting device becomes saturated or filled during the test it
should be removed and weighed, and replaced by a fresh device. The
total weight of urine lost during the test period is taken to be equal to the
gain in weight of the collecting device(s). In interpreting the results of
the test it should be born in mind that a weight gain of up to 1 gram may
be due to weighing errors, sweating or vaginal discharge.
The activity programme may be modified according to the subject’s
physical ability. If substantial variations from the usual test schedule
occur, this should be recorded so that the same schedule can be used on
subsequent occasions.
In principle the subject should not void during the test period. If the
patient experiences urgency, then he/she should be persuaded to post-
pone voiding and to perform as many of the activities in section (e) as pos-
sible in order to detect leakage. Before voiding the collection device is
removed for weighing. If inevitable voiding cannot be postponed then the
test is terminated. The voided volume and the duration of the test should
be recorded. For subjects not completing the full test the results may
require separate analysis, or the test may be repeated after rehydration.
The test result is given as grams urine lost in the one hour test period
in which the greatest urine loss is recorded.
Findings Record weight of urine lost during the test (in the case of repeated tests,
greatest weight in any stated period). A loss of less than one gram is
within experimental error and the patients should be regarded as essen-
tially dry. Urine loss should be measured and recorded in grams.
4.1 MEASUREMENT Urinary flow may be described in terms of rate and pattern and may be con-
OF URINARY FLOW tinuous or intermittent. Flow rate is defined as the volume of fluid expelled
via the urethra per unit time. It is expressed in ml/s.
Specify (a) Voided volume.
(b) Patient environment and position (supine, sitting or standing).
(c) Filling:
(i) by diuresis (spontaneous or forced: specify regimen),
(ii) by catheter (transurethral or suprapubic).
(d) Type of fluid.
Voiding time
Time (s)
4.2 BLADDER The specifications of patient position, access for pressure measure-
PRESSURE ment, catheter type and measuring equipment are as for cystometry
MEASUREMENTS (see 3.1).
DURING MICTURITION
Definitions (Fig. A2.4) Opening time is the elapsed time from initial rise in detrusor pressure to
onset of flow. This is the initial isovolumetric contraction period of mic-
turition. Time lags should be taken into account. In most urodynamic
systems a time lag occurs equal to the time taken for the urine to pass
from the point of pressure measurement to the uroflow transducer.
The following parameters are applicable to measurements of each of
the pressure curves: intravesical, abdominal and detrusor pressure.
Premicturition pressure is the pressure recorded immediately before the
initial isovolumetric contraction.
Opening pressure is the pressure recorded at the onset of measured flow.
Maximum pressure is the maximum value of the measured pressure.
Pressure at maximum flow is the pressure reorded at maximum meas-
ured flow rate.
Contraction pressure at maximum flow is the difference between pressure
at maximum flow and premicturition pressure.
458 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Intravesical Intravesical
premicturition contraction
Intravesical pressure Maximum pressure at
pressure intravesical maximum flow
(cm H2O) pressure
Detrusor Detrusor
opening pressure at
pressure maximum flow
Detrusor
premicturition
Detrusor pressure Maximum
pressure detrusor Detrusor
(cm H2O) pressure contraction
pressure at
maximum flow
Flow rate
(ml/s) Maximum flow
Opening
time
4.3 PRESSURE FLOW In the early days of urodynamics the flow rate and voiding pressure were
RELATIONSHIPS related as a ‘urethral resistance factor’. The concept of a resistance factor
originates from rigid tube hydrodynamics. The urethra does not gener-
ally behave as a rigid tube as it is an irregular and distensible conduit
whose walls and surroundings have active and passive elements and
hence, influence the flow through it. Therefore a resistance factor cannot
provide a valid comparison between patients.
There are many ways of displaying the relationships between flow
and pressure during micturition, an example is suggested in the I.C.S.
3rd Report (4) (Fig. A2.5). As yet available data do not permit a standard
presentation of pressure/flow parameters.
Appendix 2: ICS standardisation of terminology 1988 459
4.4 URETHRAL The V.U.P.P. is used to determine the pressure and site of urethral
PRESSURE obstruction.
MEASUREMENTS Pressure is recorded in the urethra during voiding. The technique is
DURING VOIDING similar to that used in the U.P.P. measured during storage (the resting
(V.U.P.P.) and stress profiles (see 3.2)).
RESIDUAL URINE Residual urine is defined as the volume of fluid remaining in the bladder
immediately following the completion of micturition. The measurement of
residual urine forms an integral part of the study of micturition. However
voiding in unfamiliar surroundings may lead to unrepresentative results,
as may voiding on command with a partially filled or overfilled bladder.
Residual urine is commonly estimated by the following methods:
(a) Catheter or cystoscope (transurethral, supra-pubic).
(b) Radiography (excretion urography, micturition cystography).
(c) Ultrasonics.
(d) Radioisotopes (clearance, gamma camera).
460 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
General information (a) EMG (solitary procedure, part of urodynamic or other electrophysio-
logical investigation).
Specify (b) Patient position (supine, standing, sitting or other).
(c) Electrode placement:
(i) Sampling site (intrinsic striated muscle of the urethra, peri-
urethral striated muscle, bulbocavernosus muscle, external anal
sphincter, pubococcygeus or other). State whether sites are sin-
gle or multiple, unilateral or bilateral. Also state number of
samples per site.
Appendix 2: ICS standardisation of terminology 1988 461
EMG Findings (a) Individual motor unit action potentials – Normal motor unit potentials
have a characteristic configuration, amplitude and duration. Abnormal-
ities of the motor unit may include an increase in the amplitude, dura-
tion and complexity of waveform (polyphasicity) of the potentials. A
polyphasic potential is defined as one having more than 5 deflections.
The EMG findings of fibrillations, positive sharp waves and bizarre
high frequency potentials are thought to be abnormal.
(b) Recruitment patterns – In normal subjects there is a gradual increase
in ‘pelvic floor’ and ‘sphincter’ EMG activity during bladder filling.
At the onset of micturition there is complete absence of activity. Any
462 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
5.2 NERVE Nerve conduction studies involve stimulation of a peripheral nerve, and
CONDUCTION STUDIES recording the time taken for a response to occur in muscle, innervated by
the nerve under study. The time taken from stimulation of the nerve to
the response in the muscle is called the ‘latency’. Motor latency is the
time taken by the fastest motor fibres in the nerve to conduct impulses to
the muscle and depends on conduction distance and the conduction
velocity of the fastest fibres.
General information (Also applicable to reflex latencies and evoked potentials – see below.)
Technical information (Also applicable to reflex latencies and evoked potential – see below.)
Appendix 2: ICS standardisation of terminology 1988 463
Description of nerve Recordings are made from muscle and the latency of response of the
conduction studies muscle is measured. The latency is taken as the time to onset, of the earli-
est response.
(a) To ensure that response time can be precisely measured, the gain
should be increased to give a clearly defined takeoff point. (Gain set-
ting at least 100 V/div and using a short time base e.g. 1–2 ms/div).
(b) Additional information may be obtained from nerve conduction stud-
ies, if, when using surface electrodes to record a compound muscle
action potential, the amplitude is measured. The gain setting must be
reduced so that the whole response is displayed and a longer time base
is recommended (e.g. 1 mV/div and 5 ms/div). Since the amplitude is
proportional to the number of motor unit potentials within the vicin-
ity of the recording electrodes, a reduction in amplitude indicates loss
of motor units and therefore denervation. (Note: A prolongation of
latency is not necessarily indicative of denervation).
464 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
5.3 REFLEX Reflex latencies require stimulation of sensory fields and recordings from
LATENCIES the muscle which contracts reflexly in response to the stimulation. Such
responses are a test of reflex arcs which are comprised of both afferent
and efferent limbs and a synaptic region within the central nervous sys-
tem. The reflex latency expresses the nerve conduction velocity in both
limbs of the arc and the integrity of the central nervous system at the
level of the synapse(s). Increased reflex latency may occur as a result of
slowed afferent or efferent nerve conduction or due to central nervous
system conduction delays.
GENERAL INFORMATION and TECHNICAL INFORMATION. The
same technical and general details apply as discussed above under nerve
conduction studies (see 5.2).
Description of reflex Recordings are made from muscle and the latency of response of the
latency measurements muscle is measured. The latency is taken as the time to onset, of the earli-
est response.
To ensure that response time can be precisely measured, the gain
should be increased to give a clearly defined take-off point. (Gain setting
at least 100 V/div and using a short time base e.g. 1–2 ms/div).
5.4 EVOKED Evoked responses are potential changes in central nervous system neur-
RESPONSES ones resulting from distant stimulation usually electrical. They are
recorded using averaging techniques. Evoked responses may be used
to test the integrity of peripheral, spinal and central nervous pathways.
As with nerve conduction studies, the conduction time (latency) may be
measured. In addition, information may be gained from the amplitude
and configuration of these responses.
GENERAL INFORMATION and TECHNICAL INFORMATION. See
above under nerve conduction studies (see 5.2).
Description of evoked Describe the presence or absence of stimulus evoked responses and their
responses configuration.
5.5 SENSORY TESTING Limited information, of a subjective nature, may be obtained during cys-
tometry by recording such parameters as the first desire to micturate,
urgency or pain. However, sensory function in the lower urinary tract,
can be assessed by semi-objective tests by the measurement of urethral
and/or vesical sensory thresholds to a standard applied stimulus such as
a known electrical current.
Definition of sensory The vesical/urethral sensory threshold is defined as the least current
thresholds which consistently produces a sensation perceived by the subject during
stimulation at the site under investigation. However, the absolute values
will vary in relation to the site of the stimulus, the characteristics of the
equipment and the stimulation parameters. Normal values should be
established for each system.
466 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
The lower urinary tract is composed of the bladder and urethra. They form
a functional unit and their interaction cannot be ignored. Each has two
functions, the bladder to store and void, the urethra to control and convey.
When a reference is made to the hydrodynamic function or to the whole
anatomical unit as a storage organ – the vesica urinaria – the correct term
is the bladder. When the smooth muscle structure known as the m.detrusor
urinae is being discussed then the correct term is detrusor. For simplicity
the bladder/detrusor and the urethra will be considered separately so
that a classification based on a combination of functional anomalies can be
reached. Sensation cannot be precisely evaluated but must be assessed.
This classification depends on the results of various objective urodynamic
investigations. A complete urodynamic assessment is not necessary in all
patients. However, studies of the filling and voiding phases are essential
for each patient. As the bladder and urethra may behave differently dur-
ing the storage and micturition phases of bladder function it is most use-
ful to examine bladder and urethral activity separately in each phase.
Terms used should be objective, definable and ideally should be applic-
able to the whole range of abnormality. When authors disagree with the
classification presented below, or use terms which have not been defined
here, their meaning should be made clear.
Assuming the absence of inflammation, infection and neoplasm, Lower
urinary tract dysfunction may be caused by:
(a) Disturbance of the pertinent nervous or psychological control system.
(b) Disorders of muscle function.
(c) Structural abnormalities.
Urodynamic diagnoses based on this classification should correlate
with the patients symptoms and signs. For example the presence of an
unstable contraction in an asymptomatic continent patient does not war-
rant a diagnosis of detrusor overactivity during storage.
6.1.1.1 Detrusor activity In this context detrusor activity is interpreted from the measurement of
detrusor pressure (pdet).
Detrusor activity may be:
(a) Normal.
(b) Overactive.
Normal detrusor function During the filling phase the bladder volume
increases without a significant rise in pressure (accommodation). No
involuntary contractions occur despite provocation.
A normal detrusor so defined may be described as ‘stable’.
Appendix 2: ICS standardisation of terminology 1988 467
6.1.1.2 Bladder sensation Bladder sensation during filling can be classified in qualitative terms (see
3.1) and by objective measurement (see 5.5). Sensation can be classified
broadly as follows:
(a) Normal.
(b) Increased (hypersensitive).
(c) Reduced (hyposensitive).
(d) Absent.
6.1.2 Urethral function The urethral closure mechanism during storage may be:
during storage (a) normal
(b) incompetent.
(a) The Normal urethral closure mechanism maintains a positive urethral clos-
ure pressure during filling even in the presence of increased abdominal
pressure. Immediately prior to micturition the normal closure pressure
decreases to allow flow.
(b) Incompetent Urethral Closure Mechanism An incompetent urethral clos-
ure mechanism is defined as one which allows leakage of urine in the
absence of a detrusor contraction. Leakage may occur whenever intraves-
ical pressure exceeds intraurethral pressure (Genuine stress incontinence)
or when there is an involuntary fall in urethral pressure. Terms such as
‘the unstable urethra’ await further data and precise definition.
Signs The sign stress-incontinence denotes the observation of loss of urine from
the urethra synchronous with physical exertion (e.g. coughing). Incontin-
ence may also be observed without physical exercise. Post-micturition
dribble and continuous leakage denotes other signs of incontinence.
Symptoms and signs alone may not disclose the cause of urinary incontin-
ence. Accurate diagnosis often requires urodynamic investigation in
addition to careful history and physical examination.
7 UNITS OF MEASUREMENT
Table A2.1
Quantity Acceptable unit Symbol
Volume Millilitre ml
Time Second s
Flow rate Millilitres/second ml s⫺1
Pressure Centimetres of water1 cm H2O
Length Metres or submultiples m, cm, mm
Velocity Metres/second or submultiples m s⫺1, cm s⫺1
Temperature Degrees Celsius °C
1
The SI unit is the pascal (Pa), but it is only practical at present to calibrate our instruments in cm
H2O. One centimetre of water pressure is approximately equal to 100 pascals (1 cm H2O ⫽ 98.07 PA
⫽ 0.098 kPa).
SYMBOLS
References
1. Abrams P, Blaivas JG, Stanton SL, Andersen JT, Fowler CJ, 207–210. Eur Urol 1977; 3: 168–170. Scand J Urol Nephrol
Gerstenberg T, Murray K. Sixth report on the 1977; 11: 197–199.
standardisation of terminology of lower urinary tract 4. Bates P, Bradley WE, Glen E, Griffiths D, Melchior H,
function. Procedures related to neurophysiological Rowan D, Sterling A, Hald T. Third report on the
investigations: Electromyography, nerve conduction standardisation of terminology of lower urinary tract
studies, reflex latencies, evoked potentials and sensory function. Procedures related to the evaluation of
testing. World J Urol 1986; 4: 2–5. Scand J Urol Nephrol micturition: Pressure flow relationships, residual urine. Br J
1986; 20: 161–164. Urol 1980; 52: 348–350. Eur Urol 1980; 6: 170–171. Acta Urol
2. Bates P, Bradley WE, Glen E, Melchior H, Rowan D, Jpn 1980; 27: 1566–1568. Scand J Urol Nephrol 1980; 12:
Sterling A, Hald T. First report on the standardisation of 191–193.
terminology of lower urinary tract function. Urinary 5. Bates P, Bradley WE, Glen E, Melchior H, Rowan D,
incontinence. Procedures related to the evaluation of urine Sterling A, Sundin T, Thomas D, Torrens M, Turner-
storage: Cystometry, urethral closure pressure profile, units Warwick R, Zinner NR, Hald T. Fourth report on the
of measurement. Br J Urol 1976; 48: 39–42. Eur Urol 1976; 2: standardisation of terminology of lower urinary tract
274–276. Scand J Urol Nephrol 1976; 11: 193–196. Urol Int function. Terminology related to neuromuscular
1976; 32: 81–87. dysfunction of lower urinary tract. Br J Urol 1981; 52:
3. Bates P, Glen E, Griffiths D, Melchior H, Rowan D, Sterling 333–335. Urology 1981; 17: 618–620. Scand J Urol Nephrol
A, Zinner NR, Hald T. Second report on the 1981; 15: 169–171. Acta Urol Jpn 1981; 27: 1568–1571.
standardisation of terminology of lower urinary tract 6. Jasper HH. Report to the committee on the methods of
function. Procedures related to the evaluation of clinical examination in electroencephalography.
micturition: Flow rate, pressure measurement, symbols. Electroencephalography in Clinical Neurophysiology,
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473
Index
physiological filling rate 437 physical examination 405–7 alteration during 171
imaging 360–1 associated pathologies 384 contractions and 172–6
pain, definition 432 definitions 384–90 first stage 173–4
position 341 drug induced 384 pushing 176–7
pregnancy 41 patients at risk 335 second stage 176–7
pressure 336–7 prevalence 390 teaching techniques 172
closure 337 prevention 384 transition stage 174–5
factors contributing 337 skin care 420 neuromuscular control 112–13
measurement 361–2 treatment 410–21 Breech position 44, 74–5, 199
measurements during bowel retraining 411 types 75
micturition 457–8 diet 410–11 Bristol stool chart 385 (fig.)
puerperium 85 medication 411–20 British Council for Cervical Cytology,
reflex triggering 446 physiotherapy 413–20 classification of smear results
retraining 377 see also individual disorders 271
sensation 430, 438, 451, 467 Bowel function 383–425 British National Formulary (BNF) 124
urine storage 336–7, 339–41, 466–8 abnormal see bowel dysfunction Bulbospongiosus muscle 10
detrusor function 466–8 anatomy 22–23 Bulking agents, bowel dysfunction 412
urethral function 468 defaecation see defaecation Burning vulva syndrome see
voiding (emptying) see micturition normal 384–8 vulvodynia
wall, stretch receptors 339 storage 386–7
Bladder diary 352–4, 353 (fig.), 434 Bowel habits
Bladder outlet obstruction 444 diary 402–3, 403 (fig.) C
Bladder pain syndrome, definition 432 questionnaires 402–4
Blastocyst 29 Brachial plexus pain, pregnancy 156 Caesarean section 81–4, 199
Bleeding Brachytherapy 314 classical 82
breakthrough 290 Braxton Hicks contractions 36, 56 ectopic pregnancy and 84
dysfunctional uterine bleeding breathing 173 elective 197
(DUB) 291 see also uterine contractions breech presentation 75
during labour 43–4 Breakthrough bleeding 290 indications 81–2
postmenopausal 249 Breast(s) 12–13, 13 (fig.) procedure 83
see also haemorrhage antenatal care 133–4, 134 emergency, indications 82
Blood group, antenatal tests 100 awareness 270 epidural anaesthesia 193, 196
Blood, in stools 394 blood supply 13 increasing rates xxi
Blood pressure growth 12 multiple births 125
labour, effect on 64 increase in size 134 Pfannenstiel (bikini line) 82, 83
measurement menopause 13 postnatal care 237–9
labour 70 milk production 12, 85–6 exercises 238
pregnancy 98 see also breastfeeding feeding 238
pregnancy postnatal 207 massage 238
effects on 37 pregnancy effects 38 physiotherapist’s role 237–9
pregnancy-induced problems, postnatal 231–2, 243 posture 238
hypertension 48–9 Breast abscess 243 wound healing 238
Blood supply Breast cancer postoperative complications
anorectal region 23 HRT and 255, 260 83–4
breasts 13 pregnancy 44 Caffeine
urethra 21 Breast engorgement 231–2 bowel dysfunction 404, 411
Blood tests, antenatal 99–100 Breastfeeding 86, 208–10 incontinence 368
Blood volume, increase in pregnancy antenatal care 133–4 pregnancy 120, 122
36 antenatal classes 129 Calcitonin, osteoporosis treatment 263
Body image older mothers 134 Calcitriol, osteoporosis treatment 264
cancer and 303 posture advice 134–5, 217–18, 217 Calcium
postnatal 205, 220, 234 (fig.), 232 osteoporosis 258
Body mass index (BMI) 97, 119 problems 209, 231–2 pregnancy 120
Booking visit 97–8 suckling difficulty 12 Calcium channel blockers, anal fissure
Bowel dysfunction 383–425 weight loss assistance 119 396
assessment 402–10 WHO recommendations 133–4 Calorie intake
history 402–5 Breathing 170–7 defaecation difficulties 392
investigations 408–10 labour 172 pregnancy 114, 119
476 INDEX
Epidural anaesthesia 185, 192–6 liquid stool 401 Foetal hypoglycaemia, maternal
advantages 192–3 passive soiling 389 exercising 114
back pain 195–6, 228 prevalence 390 Foetal hypoxia 73–4
caesarean section 193, 196 skin care 420 Foetal malformations, maternal
complications 193–5 treatment 413, 415, 416–7, 418 temperature and 115
foetal effects 195 see also anal incontinence; anorectal Foetal movements 99
haematoma 195 dysfunction; bowel cessation 99
maternal position and 67 dysfunction Foetal positions, labour 53–4
pre-booked 165 The Faecal Incontinence Quality of Foetal thorax, compression 64
technique 193 Life Scale (FIQLS) 404 Foetus 30
Episiotomy 65–6, 78, 80, 199 Faecal softeners 413 descent of head 34 (fig.), 63
anal incontinence 400 Fallopian tubes 15 development see foetal growth
position 80 (fig.) carcinoma 280 drug sensitivity 30
Erectile dysfunction (ED) 253 ectopic pregnancy 15, 45 pethidine effects 191–2
Ergometrine 196 infections 275 HIV transmission 46–7
Estimated date of delivery (EDD) 30 surgery 313, 316 intrauterine death 46
Exercise False labour 36 labour effects 63–5
caesarean section and 238 Faradism 364 macrosomic 45
foot, DVT prevention 231 Fathers 132–3 maternal exercise effects 115–16
gentle, during labour 70 Fatigue maternal hyperventilation 171
postnatal 210–11 postnatal 232–3 positioning 53–4
community classes 220 pregnancy 109, 161 breech see breech position
educational principles 214–16 Fat, increase during pregnancy 39 head, engaged 34–5
home exercises 219–20 Female anatomy 1–25 unstable/transverse lie 49–50
return to sport 220 Ferguson’s reflex 71, 194 premature delivery 31
preconceptual 102 Fertility sex detection 101
during pregnancy 36, 103, 113–19, endometriosis 283 TENS effect 187–8
132 problems see infertility see also entries beginning foetal
benefits 118 Fibre 39, 410 Folic acid 102
contraindications 116, 116 defaecation difficulties 392–3 Food diary 405 (fig.)
(table) pregnancy requirement 121 Foot exercise, DVT prevention 231
foetal risks 115–16 Fibroareolar lateral ligaments 20 Forceps delivery 199
guidelines 116–18 Fibroids 45–6, 278–9 incontinence risk 224
low back pain 150 pregnancy 160 labour interventions 80–1
physiological effects 114–15 Fibromyoma 278 unassisted vaginal birth vs. 211–12
pre-term labour 115–16 ‘Fight or flight’ response 63–4, 110 Fracture 256–7
signs for medical review 117 Fish oils, pregnancy 120 risk reduction 259–60
walking 42 Fluid Frequency volume chart (FVC) 352–4,
water based 36, 37, 118–19 input/output during labour 70 353 (fig.), 434
External anal sphincter (EAS) 23 intake 410 Fundal height
defaecation 387, 388 defaecation difficulties 392 antenatal care 98–9
resting pressure 386 retention, pregnancy 37 gestational age vs. 34 (fig.)
External cephalic version (ECV) 44 Fluoride, osteoporosis treatment 264 Fungal infections 272, 274
Extremely low birth weight infants Fluoroscopic evaluation, rectal
(ELBW) 31 emptying 409
Foetal adrenal hormones, labour G
induction 57
F Foetal alcohol syndrome (FAS) 123 Gardnerella vaginalis 274
Foetal distress Gartner’s ducts, infection 273
Faecal impaction 398, 401 labour complications 73–4 Gastric reflex, pregnancy 39
Faecal incontinence 8, 224–5, 242, 389 maternal exercising 115 Gastrocolic reflex 386
assessment 402–10 prolonged labour 59 Gastrointestinal system
history 402–5 Foetal growth 29–31 labour effects 64–5
investigations 408–10 fundal height 34 (fig.), 98–9 pregnancy 39
physical examination 405–7 maternal exercising, effect on 115 General Medical Council Standards
biofeedback therapy 416–17 patterns 31 (table) Committee 406
elderly 390 Foetal heart 36 General practitioner (GP), antenatal
functional 401–2 monitoring 70, 73, 99 care 96
Index 479
Genetic counselling, preconceptual posture and backcare 325, 327 diseases associated 260
care 102 preoperative issues 322–6 implant 261–2
Genital assessment 435 assessment 322–3 long-term risks 254
Genital herpes, pregnancy 46 instruction/preparation 323–6 nasal spray 262
Genital muscles, external 6 patient discussion 326 oral 261
Genital organs, external 10, 11 (fig.) treatment 326 osteoporosis treatment 260–2
Genital prolapse 283–7 psychological aspects 321–2 progestogen administration 262
anterior compartment 285 radiotherapy 314 prolapse 284
HRT 284 repair 314–16 skin 252
hysterectomy 284 respiratory system 323–4 topical (vaginal) 262
middle compartment 286 rest 328 transdermal 262
physiotherapy 287 stress incontinence 317–20 Hormones
posterior compartment 286 terminology 320 joint laxity effects 41–2
surgery see gynaecological surgery wind pain 326 measurement during pregnancy
Genital tract, infection susceptibility 17 100
Genitourinary dysfunction/pain menopause
224–6, 431–3 H changes 250–3
Gestational diabetes mellitus 41, 46 replacement see hormone
Giggle incontinence 347 Haemoglobin monitoring, antenatal replacement therapy
Gilliam’s ventrosuspension 316 care 99 (HRT)
‘Glazer’ protocol 299 Haemoglobinopathies menstruation control 27, 28 (fig.),
Glycerol trinitrate (GTN) cream, anal pregnancy 49 29
fissure 395 testing in antenatal care 100 preconceptual treatments 103
Gonorrhoea 273, 274 Haemorrhage pregnancy 32–3
Gravitational oedema, puerperium 88 antepartum 43–4 pain role 143
Gravity (centre of), pregnancy effects labour complications 77, 196 see also individual hormones
42–3 postpartum 87 Hot flushes 251
Gynaecological conditions 269–308 Haemorrhoids HRT see hormone replacement
backache/abdominal pain 291–2, anal incontinence 401 therapy (HRT)
291 (fig.) ice therapy 231 Human chorionic gonadotrophin
common disorders 271–5 postnatal 231 (HCG) 29
cysts and new growths 277–83 pregnancy 158 morning sickness, role 30
emotional/psychological Hair loss, postnatal 243 Human immunodeficiency virus
implications 302–3 Hammock hypothesis 6 (fig.), 8 (HIV) 276–7
infections 271–7 Hartmann’s solution 193 pregnancy 46–7, 99
physiotherapy 276 The Health Committee (Maternity transmission 276
physical check-up 270–1 Services 1992), water births 190 Human papilloma virus (HPV)
physiotherapist attitudes 269 Health professionals, labour 273
physiotherapy 276 preparation 165 Hyperemesis gravidarum 39
screening 269 Health visitor, role xix Hyperglycaemia, maternal 45
surgery for see gynaecological Health Visitors’ Association (HVA) xix Hypertension, pregnancy-induced
surgery Heartburn, pregnancy 39, 161–2 48–9
Gynaecological health 269–71 Heart, pregnancy and 36–7 Hyperventilation 171, 171 (table), 173
Gynaecological surgery 309–32 HELLP syndrome 48 Hypnosis, pain relief in labour 189
bed mobility 324–5 Herpes genitalis 273 Hypogastric nerve 20
circulatory system 324 Herpes simplex virus, pregnancy 46 Hypogastric plexus, autonomic 22
excision 309–13 Hilum 18–19 Hypoglycaemia, maternal exercising
physiotherapy 322–8 HIV see human immunodeficiency 114
abdominal muscle exercise virus (HIV) Hypomenorrhoea 288
325, 327 Homan’s signs 230 Hypotension, pregnancy 37
mobilisation 327–8 Home births 95–6 Hysterectomy 309–13, 320
pelvic floor muscle exercise UK rates 95 abdominal 310–12
325, 326–7 Homeopathy, pain relief in labour 190 postoperative condition 311
postoperative issues 326–8 ‘Honeymoon cystitis’ 347 procedure 310–11
complications 328 Hormone replacement therapy (HRT) risks/complications 312
discharge advice 329 13, 251 endometriosis 283
leaving hospital 328 administration 261–2 indications 309–10
lifelong advice 330 benefits 255 menopause 251
480 INDEX
Pelvic floor muscles (PFM) 5–10, 11 Penthrane (methoxyflurane) 190 stress reduction 111–12
assessment PERFECT scheme 357 relaxation methods 169
biofeedback 357–60, 372–5 Periform 376 TENS 188, 189
computerised manometric Perimenopause 250 urinary function assessment 349–52
359–60 see also climacteric Phyto-oestrogens, osteoporosis
electromyography (EMG) 358–9 Perineal body 10 treatment 264
confirmation of contraction 357, 370 Perineal membrane 6, 9–10 Pilates, maternal exercising 119
damage 207 Perineal pain syndrome 433 Pinard stethoscope 99
electrical stimulation 375–6 Perineometer 358 Piriformis 7
examination 355–7 Perineum 10 Placenta 29–30
chaperone 356 assessment 355–7, 435 delivery 55, 59, 72
consent 356 chaperone 356 passage of substances across 30, 191
guidelines 355 consent 356 retained 79, 199
procedure 356–7 guidelines 355 Placenta accreta 79
exercise see pelvic floor muscle procedure 356–7 following caesarean section 83–4
exercises dysfunction/pain Placental abruption 44
function 6 ice therapy 222–3 labour complications 77
definition 436 physiotherapist’s role 222 Placenta praevia 44, 47–8, 198
gynaecological surgery 325, 326–7 postnatal 213, 221–4, 240 diagnosis 48
micturition 338–9 treatment 222–4 following caesarean section 83–4
neurological control 341 labour, effect on 65–6 Pollakisuria 342–3, 429
strength grading 357 massage 78, 182–4 Polycystic ovarian syndrome 103, 292
stress incontinence 225, 241 postnatal 85, 207 Polyhydramnios 30, 48
voluntary contraction (VPFMC) superficial muscles 7 Polymenorrhoea 288
344–5, 346 support during defaecation 391 Polyp 278
weakness 346 tears Polyuria, measurement 434
see also specific muscles anal incontinence 400 Postcoital dysuria 347
Pelvic girdle classification 78 Postmenopausal women 250
pain, pregnancy 142–9 labour complications 78–9 bleeding 249
assessment 147–9 support following 213 problems 254–5
examination 148–9 Peritron 358 (fig.) Postnatal care 208–21
management 146–7 Pethidine 191–2 breastfeeding 208–10
pregnancy effects 42 Pfannenstiel incision 82, 310 classes see postnatal classes
Pelvic inflammatory disease (PID) Phenylephrine gel 413 following caesarean section 237–9
275–6 Physiotherapy 94 physiotherapy 210–11
cause 274 bowel function assessment 402–10 postnatal check 209–10
Pelvic organ prolapse breastfeeding assistance 208–9 posture 214–15
definition 436 gynaecological surgery routine 208
lower urinary tract symptoms 431 postoperative 326–30 Postnatal classes 214–21
Pelvic pain preoperative 322–6 baby massage 220–1
childbirth during/after 5 labour education 167 community exercise classes 220
definition 432 labour preparation 166 educational principles 215
pregnancy 142–9 postnatal 210–13 home exercises 219–20
syndrome 433 assessment 211–12 relaxation 215
Pelvic radiotherapy 314 classes 214–21 return to sport 220
Pelvic splanchnic nerves 20, 22 exercise 212–13 setting up class 214
Pelvic tilt 42, 108, 227 exercise advice 214–21 teaching ergonomics 216–19
‘Pelvic trampoline’ 5, 8 individual vs. group 212 teaching points 214–15
Pelvis 1–5, 2 (fig.) posture advice 214–21 Postnatal depression (PND) 132, 233,
circulation 17 role 210–11 235
contracted 77 venue 212 baby massage 221
diameters 3 (table) postnatal check 210 long term 244
different types 3 (fig.) postnatal depression 235 Postnatal period 205–48
female vs. male 1 pregnancy after-effects of instrumental
in labour 3 back pain 143 intervention 236–40
muscles 5–10 breastfeeding 134–5 care during see postnatal care
nerve supply 17 exercise advice 117–18 circulatory dysfunction/pain
see also entries beginning pelvic interaction with father 133 230–1
Index 485
Puborectalis muscles 6 antenatal 109–10, 112 (fig.), 219 self-help 151 (fig.), 152 (fig.)
defaecation 388 benefits 168 side lying 152
during labour 55 in labour 129 TENS 152
paradoxical contraction 389 postnatal 215 Sacroiliac ligaments, ventral (anterior),
Pubovaginalis 6 techniques 167–9 posterior 2 (fig.), 3
Pubovisceralis 5–6 assessment 169 Sacrum 3–4
Pudendal nerve 10 dissociation and unblocking rotation under loading 4, 4 (fig.)
damage during labour 65 168–9 Safe Motherhood Initiative 95
elderly 399 imagery 170 Salmonella, in pregnancy 121
Pudendal nerve terminal motor Mitchell method 168 Salpingectomy 313
latency (PNTML) 409 teaching 169–70 Salpingitis 275
Puerperal infection 88 tense–relax technique 168 Salpingostomy 316
Puerperal psychosis 234–5 touch relaxation 169 Scabies 273
Puerperium 84–8 Relaxin 33, 38, 42 Sciatica 152
‘after-pains’ 84, 229–30 Renal disorders, preconceptual care Sclerosis, sacroiliac joints 150
complications 87–8 102 Scrotal pain 432, 433
defaecation difficulties 396 Reproductive tract 13–18, 14 (fig.) Seat belts, correct position 106, 107
lactation 85–6 circulation and nerve supply 17 (fig.)
loss of baby 199–200, 201 fallopian tubes 15 Selective oestrogen receptor
management 86–7 ovaries see ovaries modulators (SERMS),
perineum 85 pregnancy effects 33–6 osteoporosis treatment 263
dysfunction/pain 221–4 suspensory ligaments 17–18, 18 Sensory blockade, epidural
physical condition 206–7 (fig.) anaesthesia 194
psychological state 207 uterus (womb) see uterus Sexual abuse
psychosis 234–5 vagina see vagina bowel dysfunction 404
sexuality 300–1 Respiratory system defaecation difficulties 391
sexual problems 300 gynaecological surgery 323–4 Sexual dysfunction 295
stillbirth 200–1 labour, effect on 64, 170–1 male 253–4
uterus 84–5 maternal exercising 115 postnatal 235–6
vagina 85 pregnancy effects 37–8 see also psychosexual problems
Pulmonary embolism, postnatal 87–8, see also breathing Sexual intercourse
231 Rest labour induction 57
Pulsed electromagnetic energy after labour 86–7 lower urinary tract symptoms
(PEME), perineal antenatal 219 431
dysfunction/pain 224 Restless leg syndrome, pregnancy urinary incontinence and 347–8
159–60 Sexuality 300–3
Retraction 15 ageing 301–2
Q Rhabdosphincter (striated urogenital cancer 303
sphincter muscle) 20 climacteric 253–4, 301–2
Quality of life questionnaire, Rhesus negative blood group, pregnancy 300
incontinence assessment 360 umbilical cord clamping 72 premenopause 301
Rheumatoid arthritis, pregnancy 44 puerperium 300–1
Royal College of Midwives (RMC) xvii Sexually transmitted disease (STD)
R Royal College of Obstetricians and 273, 274
Gynaecologists (RCOG) pelvic inflammatory disease 275
Radiotherapy, pelvis 314 intimate examinations guidelines testing in antenatal care 99–100
Raloxifene, osteoporosis treatment 263 355 Sexual self rating (SSR) scale,
Randell, Minnie xvii water birth guidelines 190 premenopause 301
Rectal sensitivity training 418–19 Sickle cell disease (SCD), pregnancy
Rectoanal inhibitory reflex (RAIR) 386 49
testing 408 S Sitting
Rectocoele 285 (fig.), 287, 396–7 postnatal care 216
surgical treatment 315–6 Sacral colpopexy 316 pregnancy 144–5
Rectovaginal fistula 225 Sacroiliac joint 1 puerperium 214
Rectovaginal septum, tear 396 Sacroiliac joint dysfunction 5, 146–7, Skin
Rectum 22, 23 (fig.) 150–2 menopause 252–3
defaecation 387 treatment 150–2 pregnancy 38–9
Reflex latencies, urinary tract 462–3 Cyriax 151 Small for gestational age (SFGA) 31
Relaxation 130, 167–70 leg pull 151 Smoking
Index 487
UNICEF UK Baby Friendly Initiative, electrophysiological tests 363–4 Urinary leaking 430
ten steps of successful form 350–1 (fig.) Urinary output, pregnancy 41
breastfeeding 134 imaging 364 Urinary retention 349
Unstable lie 49–50 physiotherapy 349–61 acute 444
Ureter 19 questionnaires 360 chronic 445
Urethra 17, 20–2 urethral pressure profilometry epidural anaesthesia 194
blood supply 21 362 postnatal 225–6
distal electric conductance 363 urinalysis 352 Urinary tract 18–22
dyssynergia 349 urinary flow 456–7, 457 (fig.) bladder see bladder
function 470 urodynamic/radiological/EMG infection 361
filling cystometry 441–2 361–4 kidney 18–19
micturition 443, 444 uroflowmetry 362–3 lower see lower urinary tract
storage phase 468 VAS 360 neurophysiological evaluation
pain 432 definition 435 460–5
Urethral pain syndrome 432 detrusor overactivity 343–5, 346 electromyograph (EMG) 460–2
Urethral pressure profile (UPP) 362, idiopathic 344 evoke responses 464–5
452–4 neurogenic 344 nerve conduction studies 462–3,
definitions 453–4 terminology 344–5 464–3
female, ICS recommended VPFMC 344–5 reflex latencies 464
nomenclature 454 (fig.) exercises to prevent 108 sensory testing 465
storage phase 452–3 extra-urethral 343 pregnancy effects 41
technique 453 factors leading to 335 urether 19
voiding (VUPP) 362, 459 frequency 342, 429 urethra see urethra
Urethral sphincter 20–1, 21 (fig.) functional 348 Urinary urgency 398, 429, 433
Urethral syndrome 252 giggle incontinence 347 postnatal 226
Urethrocoele 285, 285 (fig.) history 351–2 Urine
treatment 314 caution 352 analysis during pregnancy 98
Urethrovaginal sphincter 21 infection 361 average flow rate (AUFR) 338
Urethrovesical angle 20, 338 mixed 345 increased output after labour 85
Urge incontinence 345, 377, 430 treatment 368 loss, quantification 454–6
see also urinary dysfunction and nocturnal enuresis 342, 346–7 maximul urine flow rate (MUFR)
urinary incontinence, detrusor pad test 354–5 338
overactivity paper towel test 355 pressure flow studies 442–3
Urinalysis 352 patients at risk 335 residual 459–60
Urinary dysfunction 342–82 perineal/vaginal assessment 355–6 storage 337, 339
causes 365 (table) persistant 379 storage evaluation 450–6
incontinence see urinary pregnancy 41, 162 cystometry 450–2
incontinence prevalence 334 quantification of urine loss 454–6
lower urinary tract see lower prevention 335 urethral pressure measurement
urinary tract dysfunction recent developments 335 452–4
menopause 252 sexual activity-associated 347–8 voiding see micturition
preconceptual care 103 stress see stress incontinence Urodynamic conditions 444–5
pregnancy 162 treatment 364–79 see also lower urinary tract
understanding 364 additional techniques 367–8 dysfunction
urgency 226, 343–5, 429–30 attendance 372 Urodynamic stress incontinence (USI)
Urinary function 333–42 bladder retraining 377 345–6
continence 333 continence-promoting advice Urodynamic studies 428, 436–44
problems 334 368 ambulatory 437
factors in normal 341–2 devices 379 conventional 436–7
micturition see micturition electrical stimulation 375–6 filling cystometry 361, 437–42
understanding 364 home 367, 376 pressure flow studies 362, 442–4
Urinary incontinence 20, 224, 225, persistent problems 379 symbols 471–2
343–82, 429, 430, 468–9 principles 367 units of measurement 470–1
assessment sociological problems 366 Uroflowmetry 362–3
bladder ultrasound 360–1 types 343–8 Urogenital diaphragm see perineal
cystometry 361–2 see also lower urinary tract membrane
distal urethral electric dysfunction Uterine contractions
conductance 363 Urinary infections 17, 20, 361 Braxton Hicks 36
Index 489