Chapter 11 Obstetrics and Gynaecology
The role of the women’s health physiotherapist
• Physiotherapy has been involved in obstetric care since the early 1900s due to the ground-breaking work of Minnie Randell at St Thomas’ Hospital, London (Moscucci 2003).
• The formation of the Obstetric Physiotherapy Association in 1948 made it one of the first physiotherapy clinical interest groups.
• Obstetric physiotherapists expanded their role to encompass gynaecology, with the clinical interest group reflecting this in the title Association of Chartered Physiotherapists in Obstetrics and Gynaecology (ACPOG) in 1976.
• As physiotherapy has developed during the last 40 years, so has the management of women’s health and in 1994 the association was renamed as the Association of Chartered Physiotherapists in Women’s Health (ACPWH), to recognise the work done for women’s health in general.
• This, however, does not reflect the volume of work carried out by many women’s health (WH) physiotherapists treating male incontinence and erectile dysfunction.
• With 700 members worldwide the association is also a founder member of the International Organization of Physical Therapists in Women’s Health (IOPTWH).
• WH physiotherapists are involved in the 4 spheres of physiotherapy; health promotion, prevention, treatment and rehabilitation, as defined by the World Confederation for Physical Therapy (WCPT 1999).
• This may involve promoting healthy lifestyles and posture in pregnancy or preventing pelvic floor dysfunction through teaching normal bladder and bowel function; treating musculoskeletal dysfunctions occurring in pregnancy or urinary incontinence as the consequence of pelvic floor dysfunction. These problems require the WH physiotherapist to draw on core skills of rehabilitation in order to improve or resolve a patient’s problems.
• Physiotherapy departments which provide women’s health services vary in the breadth of care they offer.
• The following list outlines services that WH physiotherapists may be involved in:
Physiological changes in pregnant women
• The physiological changes that occur through pregnancy place increasing demands on a woman’s body, which should not be underestimated (Mantle et al 2004).
• Pregnant women are often not aware of the rapid changes that occur to their body and may present with symptoms that concern them greatly.
• WH physiotherapists have the ability to inform and educate pregnant women about the normal physiological changes that occur during this period and in turn reduce their anxiety.
• Physiotherapists can also identify neuromusculoskeletal changes, treat and manage dysfunctions with their knowledge of the body.
• It is therefore important that physiotherapists working in obstetrics fully understand the normal physiological and musculoskeletal changes in pregnancy in order to identify possible abnormalities.
• The following sections discuss some of the more common physiological and musculoskeletal changes in pregnancy, however this is not inclusive.
• The changes during pregnancy can be broadly split into:
Hormonal changes and their consequences
• There remains a lot to learn about the hormonal changes in pregnancy and importantly for the physiotherapist their role as a causative factor of musculoskeletal pain.
• It seems that progesterone, oestrogen and relaxin have an important role in some of the physiological and anatomical changes in pregnancy.
• All three are produced by the corpus luteum up to 10 weeks of gestation, when the placenta also starts to produce them and fully takes over this role from the second trimester onwards (12 weeks).
• Relaxin is thought to peak in the first trimester and then drops by 20% to remain steady for the remaining trimesters.
Effects of progesterone
• Reduction in tone of smooth muscle, resulting in:
• Increase in nasal and vaginal production.
• Increase in temperature by 0.5–1.0°C. Pregnant women often feel warm and the temperature of the treatment area needs to considered, so they do not feel uncomfortably warm.
• Reduction in alveolar and arterial pCO2 tension.
• Pregnant women will be increasingly short of breath, even at low levels of exercise, which may lead to hyperventilation.
• Development of the alveolar and glandular milk-producing cells in the breasts. Breast size enlarges from early on in pregnancy which can change posture and cause strain to the thoracic or cervical spine.
Effects of relaxin
• Gradual replacement of collagen with a remodelled modified form that has greater extensibility and pliability.
• Inhibition of myometrial activity during pregnancy up to 28 weeks, after which women can then become aware of Braxton Hicks contractions.
• Uterus distends from its usual ‘small pear’ size holding 6 ml of fluid to its full-term size of holding 5000 ml of fluid.
• There is controversy surrounding the role of relaxin as a cause of musculoskeletal pain. Since being discovered in 1926, relaxin has traditionally been thought to be the main reason for musculoskeletal pain in pregnancy.
• It has been presumed that manual therapy is not beneficial for joints that are in effect hypermobile.
• However, recent research has found that there is no correlation between serum levels of relaxin and pain.
• There is also no evidence to confirm that those with increased joint laxity or stiffness have an increased incidence of pain.
• It is now generally considered that relaxin is a causal factor in musculoskeletal pain in pregnancy; however pain is not caused by general increase in mobility, rather an asymmetrical difference between joints, particularly the sacroiliac joints.
Cardiovascular system changes
• Blood volume increases by 40% to supply the increasing demands of the uterus and placenta.
• This is not accompanied by an increase in red blood cells, only plasma, so the haemoglobin levels fall to around 80%. This is known as physiological anaemia, which may result in tiredness and malaise.
• The heart increases in size and accommodates more blood, so the stroke volume rises and the cardiac output increases by 30–50%. Exercise will produce an increase in cardiac output, therefore this should be considered when teaching an exercise programme to a pregnant woman.
• Later in pregnancy, the weight of the fetus may compress the aorta and vena cava in the supine position causing dizziness and in extreme circumstances unconsciousness. This is known as supine hypotension. Not all women will suffer from this condition, however. Physiotherapists need to be aware about the potential effects of supine lying later on in pregnancy.
• Prolonged vigorous exercise should be avoided as this will result in redistribution of the cardiac output to the working muscles and away from the abdominal organs, importantly the uterus and placenta (Artal et al 1991).
Changes associated with the growth of the fetus
Respiratory system
• The growth of the fetus causes changes to the respiratory system by displacing the diaphragm upwards by 4 cm or more.
• This causes the ribs to flare outwards and the subcostal angle to increase from 68° to 103° and can cause breathlessness, as the respiratory excursion is limited at the lung bases.
• The costochondral junctions may become more hypermobile and therefore costal margin pain or rib ache is not uncommon.
Urinary system
• Throughout pregnancy there is an increase in blood supply to the urinary tract in order to cope with the additional demands of the fetus for waste disposal.
• The size and weight of the kidneys increase, whilst the ureters become dilated and elongated to circumvent the enlarging uterus.
• This may cause ureteral reflux or kinking with possible pooling and stagnation of urine leading to an increased risk of urinary tract infections.
• Later on in pregnancy the bladder becomes an intra-abdominal organ, the supporting fascia is stretched and the urethrovesical angle may be altered.
• Pregnant women may therefore complain of frequency, urgency and stress incontinence.
Musculoskeletal adaptations
• Posture will generally change in pregnancy due to a woman’s adaption to the change in the position of her centre of gravity.
• The breasts increase in size by an average of 400–800 g, causing altered thoracic and cervical posture.
• There is a general thought that all spinal curves increase in pregnancy; however Ostgaard et al (1993) found that women generally had an exaggeration of their pre pregnancy posture and those at most risk were those with a naturally large lordosis.
• The distance between the vertical bands of rectus abdominus muscles will widen during pregnancy as the linea alba stretches and sometimes splits.
• A doming of the abdominal muscles occurs during the actions of sitting forward or pulling to get out of bed. Women may need reassurance that this is a normal part of pregnancy. They should be educated about the correct way to get in and out of bed, e.g. rolling onto the side and swinging the legs over the edge of the bed, whilst simultaneously pushing the trunk up using a hand on the bed. This may help to reduce the occurrence of diastasis.
• There is a general increase in water retention resulting in oedema, generally to the dependent areas of the body. This can lead to symptoms of carpal tunnel syndrome as the median and ulnar nerves are compressed. Problems such as facial nerve palsy and meralgia paraesthesia are also seen as a result of pregnancy.
• The common musculoskeletal conditions encountered in WH include:
Assessment
• It is important to understand the normal anatomical, physical and emotional changes that occur in pregnancy and the puerperium in order to understand the abnormal dysfunction that can occur which may lead to pain.
• The physiotherapist will need to draw upon core assessment skills irrespective of the specialist area they work in, with assessment involving history taking, screening and the use of specific tests or measures, and evaluation of the results of examination through analysis and synthesis within a process of clinical reasoning (WCPT 1999).
• A holistic approach to the assessment is important in order to understand the demands both physically and emotionally the woman has in her life.
