CHAPTER ELEVEN Case studies in women’s health
Introduction
Women’s health (WH) is a very specialised and diverse area of physiotherapy which covers problems pertaining to obstetrics (may also be referred to as maternity) and gynaecology. A WH physiotherapist may also treat women with breast cancer and men with continence issues. A placement or rotation in WH may involve one or all of these sub groups depending on the service provision within the NHS Trust.
Obstetrics is the term that refers to the care of women during their pregnancy (antenatal period) and just after the delivery of their baby (post-natal period). Antenatal care from the physiotherapist ‘aims to prevent or alleviate the physical and emotional stresses of pregnancy and labour’ (ACPWH 2007). Care may involve teaching relaxation, breathing awareness and comfort positions for labour individually or in a group setting as part of antenatal or preparation for parenthood classes with other professionals such as midwives, dieticians, speech and language therapists and agencies such as the child benefit agency. It should be noted that the provision of antenatal education and the involvement of physiotherapists varies greatly throughout the NHS. Physiotherapists also have an important role to play in treating women who have musculoskeletal problems relating to their pregnancy. Women may be seen in an out-patient department or as an in-patient in a maternity hospital. Common problems encountered during pregnancy include low back pain, pelvic girdle pain (including lumbosacral, sacroiliac and symphysis pubis pain) disc problems, hip pain, coccygeal pain, thoracic pain, carpal tunnel syndrome (CTS), lower limb oedema, varicose veins and diastasis recti. Women may also be treated for bladder and bowel dysfunction, including constipation.
The physiotherapists’ role in the post-natal period is to assist in the recovery of the mother by treating a painful perineum, incontinence problems or any presenting musculoskeletal issues associated with childbearing mentioned above. Teaching exercises and general back care and advising the mother on returning to exercise is also important. The care of the post-natal woman begins after the delivery of her baby when she is still in the obstetric unit/maternity hospital and can extend to a number of months after the birth when the patient will be seen as an outpatient. The involvement of physiotherapy services with post-natal women vary within the NHS. Treatment of musculoskeletal problems by an obstetric physiotherapy service may stop as early as 6 weeks after delivery. However, involvement by the physiotherapist may continue through post-natal exercises classes for example, where on-going advice regarding exercise can be provided as well as progressions of exercises covered in the immediate post-natal period.
Gynaecology refers to ‘the science of dealing with the diseases of the female reproductive system’ (Brooker 2003). Depending on local services, the physiotherapist working in this area of women’s health may be involved with the pre-operative assessment and post-operative intervention of women undergoing gynaecological surgery, where care would take place within an in-patient hospital setting. The role of the physiotherapist in treating patients immediately post gynaecological surgery is similar to that of a respiratory physiotherapist treating a patient post anterior resection, for example, in that ‘the immediate objectives are to achieve good respiratory and vascular function and early mobilization’ (Cook 2004). The reader should refer to Chapter 5 cases 5–8 for more information in dealing with respiratory problems post surgery. Depending on the type of gynaecological surgery the woman has had, the physiotherapist may progress post-operative intervention to teaching pelvic floor muscle exercises, abdominal muscle exercises and advising on posture and back care. The physiotherapist may also have to help the patient deal with the psychological reactions they may have to their surgery. Treatment of women (and men) suffering from bladder and bowel dysfunction at any stage of life may also be included in the area of gynaecology and will usually take place in an out-patient setting within a specialised department or within a general out-patients department. Treating continence problems requires specialised post-graduate training and, therefore, students and junior members of staff are not usually as involved with this aspect of women’s health other than in an observatory capacity.
Due to the similarities between the role of the physiotherapist treating patients post-gynaecological surgery and other forms of abdominal surgery and the specialised role of the physiotherapist treating continence problems, only obstetric cases have been included in this chapter. The reader is referred to Mantle et al (2004; Chapter 10, Gynaecological surgery) for more information on specific types of gynaecological surgery and associated physiotherapy input.
CASE STUDY 1 Antenatal out-patient
Subjective assessment
SH
Currently 32 weeks’ pregnant in her second pregnancy Age 27 in full-time employment as a Training and Development Officer. Planning to work to 37 weeks of pregnancy
PMH
Mid-cavity forceps delivery with a large blood loss 20 months ago. Has experienced intermittent problems with low back pain where she felt as if it locked or seized. This was relieved by moving around, but after-effects were short lived. Returned to work when baby was 6 months and has no sickness record noted
No other medical conditions and is not currently on any medications
Objective assessment
Observation
Posture in sitting/standing: reasonable
Neurological tests – no abnormality detected
TABLE 11.1 Movement Loss and Pelvic Assessment
| Standing | Flexion and extension within normal limits for the third trimester. Right iliac crest, PSIS and ASIS higher than left Stork/step test abnormal showing right sacroiliac (SI) joint blocked Palpation of pelvic and lumbar area shows tenderness and muscle spasm in right quadratus lumborum muscle and non-specific tenderness over right SI joint area |
| Sitting | Right PSIS higher than left and moves upwards when flexing showing right SI joint is blocked |
| Supine lying | Apparent leg length by comparing medial malleoli levels shows right leg shorter Posterior ilial glide test (Squish test) blocked or hypomobile on right Right and left active SLR reduced due to discomfort in lower back No irritability detected Levels of pubic symphysis normal and no tenderness apparent |
CASE STUDY 2 Antenatal out-patient
Subjective assessment
Special questions
No altered sensation or saddle anaesthesia
No history of any accidents recently or outwith any of her pregnancies
PMH
During first pregnancy 30 months ago had mild anterior pelvic pain from around 30 weeks. She noticed occasional discomfort associated with higher activity levels. This type of discomfort was also noticed pre-menstrually. She had a mid cavity forceps delivery of a baby weighing 9 lb 3 oz and sustained a 2nd degree tear to her perineum. On returning to work after 6 months she became aware of left sided anterior pelvic pain. This was assessed and treated at a sports injury clinic and states had her pelvis ‘fixed’ on five occasions along with advice and an exercise programme but she never returned to her pre-pregnancy level of fitness
Objective assessment
Observation
Posture in standing sitting good
Lordosis increased but normal for gestation
TABLE 11.2 Movement Loss and Pelvic Assessment
| Standing | Flexion and extension within normal limits for this gestation in pregnancy. Iliac crest, PSIS and ASIS levels equal. Step test normal but very unsteady. Finds standing on one leg very painful |
| Sitting | Iliac crest and PSIS levels equal. Seated flexion test normal |
| Supine lying | Medial malleoli levels equal. ASIS levels equal. Posterior ilial glide test (Squish test) normal. Pubic rami and pubic tubercle levels equal but symphysis pubis very tender and feels puffy/swollen Active SLR – painful left and right. Easier with compression of the pelvis at the ASISs |
Questions
CASE STUDY 3 Painful perineum and recti diastasis following mid-cavity forceps delivery
Subjective assessment
Handover from the midwives
Patient is not mobilising very well and does not seem motivated to care for her baby independently. She has not been taking her painkillers; the staff keep finding them at her bedside
