Post on 17-Dec-2015
PREGNANCY IN ACUTE CARE
PART IIWomen’s Health Overview
Implications for Physical TherapyJane Frahm, PT, BCIA PFMD
Rehab Institute of Michigan/WSU
PHYSICAL THERAPY INTERVENTION: HIGH RISK
PREGNANCYAll Assessment and Rx needs to respect
patient’s diagnosis and activity restrictions.
THERAPY RX GOALS: Maximize strength and joint range with bed
mobility / ADLs usually performed supine or sidelying
Stimulate circulation, help prevent DVT No Intra-Abdominal Pressure allowed, do
not activate abdominals during movement Counteract physiological effects of bedrest
with no increase in IAP
LABOR AND DELIVERY
VAGINAL BIRTH Vaginal delivery after cervix is fully
dilated
CAESAREAN BIRTH Surgical birth through incisions in
abdominal wall and uterus
POSTPARTUM
PHYSIOLOGICAL/HORMONAL CHANGES AFFECT REPRODUCTIVE ORGANSLower Urinary Tract Perineum GI System Breasts
POSTPARTUM
MUSCULOSKELETAL/POSTURAL Target Rehab program for specific area of
dysfunction
Emphasize Body Mechanics for Child care and ADLs – with special attention to Abdominals / Diastasis RectiPubic Symphysis / Movement difficulty
and pelvic instabilityPelvic Floor / IncontinenceLumbo-Pelvic Mechanics / SI Dysfunction
SYMPHYSIS PUBIS SEPARATION
DEFINITION: Widening of the Symphysis pubis on x-ray – (Normal symphysis: about 1/2 cm. -5 mm)
Anything wider, with symptoms, in a pregnant or post partum female, should be treated as a symphysis separation.
May be widening of one or both S-I joints, in addition to widening of the symphysis pubis. (JAOA, 97:3, March 97, 152-155)
CHANGES IN THE PUBIC JOINT Normally -very stable But even a small
degree of hypermobility leads to inflammation and pain
Pubic hypermobility usually accompanied by SI hypermobility /vice versa - check for both
Muscle forces on pelvis - in walking - can be painful, increase hypermobility, and create torque or shear
SI belt is a must The larger the separation, the easier the
delivery usually
Slight SYMPHYSIS PUBIS
Separation
Normal – 1st Degree Amt of separation: 0 - <0.5 to 0.9 cm (5-
9 mm) Common Symptoms: none Common Treatment: none
Moderate SYMPHYSIS PUBIS Separation
2nd degree - 0.9-2 cm (9- 20 mm)
Common Symptoms: • Pain in pubes, groin, may also
be in SI area• Fear of moving• Urinary problems• Gait changes (if able to walk)• No postpartum pooch
Severe SYMPHYSIS PUBIS Separation
3rd degree Amt of separation: >2cm (20 mm)
Common Symptoms: Same as Moderate Separation Distinct waddling gait- or inability to walk
at all Urinary Incontinence
PATIENTS AFFECTED
Pregnant women 1st to 3rd trimesters
Post-Partum women: within 12 - 36 hours of delivery
ETIOLOGY: Influence of pregnancy hormones
specifically relaxin on soft tissue. Hormones are responsible for:
Uterine growthStretching of soft tissuePelvic joint relaxation
Renders the pelvic ring unstable at the symphysisThe stretching of a vaginal delivery can further contribute to the instability
ETIOLOGY: Other precipitating factors (Intrapartum)
Assisted deliveries, i.e., forceps, vacuum extraction, large baby, shoulder dystocia, 2 persons supporting mother’s legs in deep knee – chest during pushing
(Post partum) Mother suddenly turns or twists, missteps
over an elevated sill, e.g., or may create shear forces over the pubes just getting into or out of bed.
PRESENTING SYMPTOMS:
Incredible pain over pubis
Sudden inability to walk (patient may have been walking after delivery and suddenly cannot)
Inability to move in the bed
Patient may appear unreasonable
ALL MOVEMENT JUST HURTS
THERAPIST FINDINGS Positioned supine (usually), presents with
legs in abducted
Pt presents with mobility that is painful
Patient may be frustrated with pain and apparent lack of understanding of staff
Careful questioning of patient
Observation of patient
Palpation of pubes may not be possible due to pain
Physical Therapy RX SYMPHYSIS PUBIS Separation
Strap pelvis Abdomino-pelvic binder Specific pelvic belt (Com-pressor- OPTP
or Serola SI belt)
Other Medical Treatments Inject hydrocortisone,chymotrypsin into
symphysis Bed rest to moderate activity as
tolerated
SEROLA S-I BELT www.serola.net
P.T. INTERVENTION/TREATMENT
Apply external support ABDOMINAL BINDER
Placed low over greater trochanters and fastened over pubes Placement with pt. supine Sometimes 2 persons have to slide the
support under the patient Facilitate bed mobility - Observe first, then
make suggestions Patient usually knows how to initiate
movement-in the least painful way.
P.T. INTERVENTION/TREATMENT
Patient will keep her body in straight planes, - rolling to her side may not be feasible
“Rule of thumb” - think of how a post-op THA patient moves
P.T. INTERVENTION/TREATMENT
Standing may be all patient can do on day one- due to inflammation over the pubes
Some require pain or anti-inflammatory meds or both; and bed rest for 12 – 24h
P.T. INTERVENTION/TREATMENT
GAIT (Rolling walker required) Often inability to swing-through and heel strike with either extremity
Patient may "slide" or "scoot" the extremity - often painfully slowly
P.T. INTERVENTION/TREATMENT
All prime L/E movers and stabilizers attach to the pelvis Movement is slow, but will progress over
several days. YOU MUST BE PATIENT WITH THESE
PATIENTS ! L.O.S. can be increased with this
diagnosis.
P.T. INTERVENTION/TREATMENT
Pending the hospital system you are employed at: Share your assessment/
recommendations with medical team
They may NOT be aware of etiology
You may be the one to recommend x-rays
TREATMENT PROGRESSION AMBULATORY ASSIST / OTHER
EQUIPMENT• Ask unit secretary to order an abdominal
binder• Overhead trapeze ideal, but often not
available • B.S.C. may be needed- assess after you
see patient• Rolling walker is needed in all cases
TREATMENT PROGRESSIONREFER TO OP PT
Introduce Lumbar"stabilization” right away:
“Engagement of the obliques and transversus before and during each step will help stabilize the pelvis.
Possible for patient to practice this, even though the abs have major “Stretch” weakness