Chapter 11 Obstetrics and Gynaecology
Postoperative major surgery – treatment
Respiratory care
• Upper abdominal surgery is known to cause severe and prolonged alterations in pulmonary mechanics.
• Opiates and sedatives can also affect the natural ‘sigh’ mechanism (Richardson and Sabanathan 1997).
• Respiratory physiotherapy is essential to prevent the development of atelectasis and chest infections.
• Active cycle of breathing techniques with supported huff/cough should be taught, and incentive spirometry provided for those at most risk.
• Active treatment should be undertaken when pain relief is most effective and independent work encouraged.
• For patients who develop respiratory complications, oxygen therapy, humidification and nebulisers may be necessary.
• Positive pressure devices, such as CPAP, can aid lung expansion (Cook 2004).
Initial transfers
• Patients should be taught how to move in bed, e.g. from lying to sitting via side-lying to minimise intra-abdominal pressure; moving up the bed by bending their knees and using their thigh muscles, digging in with their heels, pushing up with their hands and straightening their knees so that the hips lift up off the bed and back towards the pillow (Cook 2004).
• The occupational therapist (OT) may need to assess regarding any assistive equipment and techniques, e.g. a bed-lever may be supplied to aid general bed mobility.
Posture
• Good posture in standing and supported positions in sitting, using appropriately placed pillows or lumbar rolls, may also help to reduce backache in the postoperative period.
• Patients may benefit from a recliner chair or specialist pressure relief; a graded sitting tolerance programme should be instigated for the most severely debilitated (Reed and Sanderson 1992).
Mobility
• Early ambulation should be encouraged.
• On day one, the patient should be assessed regarding ability to transfer out to a chair, including the potential use of a hoist.
• Standing should be encouraged and the need for a walking aid assessed.
• By day two most patients should be able to walk, with the assistance of two, for a short distance and progressed to independent mobilisation as able (Cook 2004).
• Less extensive or laparoscopic surgery would require similar multidisciplinary team (MDT) input, although progress is usually quicker.
Postoperative complications
• Tumour-related complications can include:
• Immediate postoperative complications can include:
Physiotherapy management in the convalescent/post-acute phase
Counselling/information provision
• This may be an anxious time for the patient as they await pathology results.
• Gynaecological cancers have profound psychosocial implications in addition to the obvious physical manifestations. Women are confronted with cancer and its related treatments, which may impact adversely on body image, sexuality and relationships, including the possibility of imposed infertility and/or menopause.
• Altered body image is an important factor and becomes problematic when it affects the individual’s quality of life (Shearsmith-Farthing 2001).
• It is important that appropriate, timely and confidential information is provided.
• Literature and websites sponsored by cancer charities are useful; some details are supplied at the end of the chapter.
• Eighty per cent of centres now offer aromatherapy for the relief of stress and anxiety (Kohn 2003).
• Menopausal symptoms may begin quite quickly after Bilateral salpingoophrectomy (BSO); advice on the control of symptoms should be provided by the consultant surgeon/oncologist; HRT can be contraindicated in some cancers (Biglia et al 2006).
Rehabilitation (including pelvic muscle floor retraining)
• Pelvic tilting, knee rolling, abdominal bracing and knee bends may be taught as exercises for the lower abdominal muscles and lower back.
• Expert opinion also suggests that pelvic floor muscle training after gynaecological surgery may mitigate problems such as urinary incontinence both in the short and long term (Cook 2004).
• Many physiotherapists delay instruction until the catheter is removed, although there is no evidence of harmful effects resulting from undertaking pelvic floor exercises whilst a urinary catheter is in situ (Haslam and Pomfret 2002).
• Ideally these exercises should have been taught preoperatively, however in both scenarios a vaginal assessment is unlikely to be possible.
• Therefore, the use of diagrams and models to verbally describe the anatomy and function of these muscles is essential as many women find it difficult to achieve correct pelvic floor contraction on verbal instruction alone (Bø et al 1988, Bump et al 1991).
• A combination of fast, slow and anticipatory pelvic floor muscle contraction should be taught to prevent leakage and control urgency.
• Patients may present with bladder problems ranging from hesitancy and poor flow, to incontinence, frequency and urgency, which may or may not have been present before surgery and/or related to the underlying malignancy.
• Individualised advice is required as this can be difficult to manage.
• Cranberry juice may be recommended to help prevent urinary tract infections, although this is contraindicated for patients on warfarin (Jepson et al 2004, Aston et al 2006).
Constipation management
• Some patients may also develop constipation, therefore education regarding correct diet and defecation position and technique should be taught.
• This includes sitting with the knees apart and higher than the hip joints; this may require the feet to be on a support.
• The trunk should be flexed forward at the hips supported on the forearms, and with the neutral spinal curves maintained.
• A bracing technique should be adopted which means to make the waist wide and to let the abdominals bulge anteriorly (Chiarelli and Markwell 1992, Markwell and Sapsford 1995).
• Straining should be avoided.
• The use of a pad to support the perineal area may be useful.
Ascites
• Ascites (the presence of fluid in the abdomen) may sometimes be present before surgery or in the later stages of the disease.
• This makes deep breathing and expansion of the bases of the lung difficult; patients should be encouraged to breathe as deeply as possible, and provided with oxygen therapy if appropriate.
• Ascites can also affect functional activities because range of movement can be restricted and tolerance reduced.
• Some relief may be gained from paracentesis (Krishnan et al 2001).
Discharge preparation
• Before discharge, patients with stairs at home should have a supervised trial.
• If required ADL reports should be completed and adequate home-care provision organised by liaison between the hospital and community or social services.
• District nursing services to assist with the management of continence/wound/stoma and input from the community MDT to assess, facilitate and encourage mobility and independent activities are often required.
• For some, nursing home or respite care is needed, and input from voluntary sectors, such as a hospice, Marie Curie or Macmillan, can also be essential for palliative support.
Minor surgery
• Examples of minor surgery are laparoscopic hysterectomy, vaginal hysterectomy, prolapse repair, Trans vaginal tape (TVT).
• Following such surgery advice on pelvic floor muscle exercises and return to ADL should be provided.
• Additional information for those returning to high-impact sport can also be provided.
• Sources of information: Association of Chartered Physiotherapists in Women’s Health (ACPWH) leaflet Fit for Life, Royal College of Gynaecologists (RCOG).
Prostate surgery
• In some settings the WH physiotherapist may visit men who are going to have or have recently undergone either a radical prostatectomy or a transurethral resection of prostate (TURP).
• There is some evidence that suggests that pelvic floor muscle training helps prevent or restore continence.
• To undertake a pelvic floor muscle (PFM) contraction the men should be advised to contract around the back passage, bring this feeling to the front with a scrotal lift and should be held for as long as possible (Dorey 2006).
Continence
• Continence problems occur in many patients especially as they get older, although it is not an inevitable part of ageing, or can be associated with conditions such as stroke, multiple sclerosis, diabetes or post-partum.
• When undertaking general rehabilitation, either as an inpatient or as an outpatient, it is often good practice to remember that patients may need to go to the toilet more often and quickly than usual.
• Multidisciplinary input is invaluable for such patients as functional problems of access, appropriate clothing and recognition of toilet area often helps.
• During a rotation in Women’s Health, patients with pelvic floor dysfunction are assessed and advised as outpatients and can be referred by a GP, gynaecologist, urogynaecologist, obstetrician, midwife, urologist, neurologist, allied health professionals and in some areas by self-referral.
Pelvic pain
• Explain the rationale for proposed treatment modalities.
• Interventions that may be applied may include cognitive–behavioural therapy, PFM relaxation and re-education exercises, manual therapy, adjunctive therapies and pain management.
• Direct treatment to the presenting symptoms and address objective findings.
• If there is no response to treatment within a reasonable timeframe (allow 3–4 months) refer the patient for either psychosocial evaluation or pain management.
• This is a complex specialist area of treatment (Frawley and Bower 2007, Knight and Shelly 2008).
Urinary incontinence
• Following assessment it is important to teach the patient about the PFM and lower urinary tract function using diagrams, drawings and models.
• Explain a correct PFM contraction and if the woman consents vaginally assess PFM contraction.
• If active contraction is possible agree an individual training programme to be conducted at home.
• If strengthening is the main goal then the main factors to be considered are the same as for any muscle, i.e. overload, specificity, maintenance and reversibility.
• For patients with SUI recommendations are for women to exercise performing a minimum of 8 contractions 3 times a day, with training lasting for 3 months (NICE 2006).
• Ask the patient to suggest where and when exercises should be performed.
• Supply an exercise diary or ‘biofeedback back’ with computerised adherence registration.
• If the patient is unable to contract the muscles, try manual techniques such as touch, tapping, massage, fast stretch or using biofeedback, e.g. electromyography biofeedback, perineometry, ultrasound or electrical stimulation.
• In addition to a strength training regimen ask the patient to precontract and hold the contraction before and during coughing, laughing, sneezing and lifting (conscious precontraction, the ‘knack’).
Electrical stimulation (ES)
• Transcutaneous electrical stimulation (ES) is most frequently administrated using vaginal or anal plug electrodes, or percutaneous electrical stimulation, e.g. posterior tibial nerve stimulation.
• ES for Stress urinary incontinence (SUI) is focussed on improvement of the urethral closure pressure and sphincter activation, or as a kind of feedback procedure in patients who are unaware of how to contract the PFM and are unable to do so voluntarily.
• Office-based equipment as well as portable electrical stimulation devices have been developed.
• There is a lack of consistency in the ES protocols used in practice.
• The most common protocol uses a frequency of 10 Hz, pulse duration of 250 ms, and duty cycle of 1 : 2, although frequency and duration of application tend to be varied.
Biofeedback
• Biofeedback is defined as ‘the technique by which information about a normally unconscious physiological process is presented to the patient and/or therapist as visual, auditory or tactile signal’.
• By using biofeedback it raises awareness of PFM activity and improves compliance to exercise.
• The main biofeedback tools are:
• Patients who undergo a vaginal assessment receive verbal feedback on correct technique of PFM contraction and the use of further biofeedback techniques depends on patient, clinician and availability.
Advanced manual therapy
• On vaginal examination areas of reduced or nil PFM activity or areas of increased or overactive muscle fibres are often detected during a voluntary contraction.
• Manual therapy techniques such as trigger point release can be used in a patient where such muscle imbalance exists and is indicated for defecation dysfunction, Over active pelvic floor (OAPF) and urinary incontinence.
• Following such treatment in order to maintain the resting length of the muscle the patient must learn how to exercise it and a self-help technique called ‘sniff, flop and drop’ has been found to be beneficial (Whelan 2008).
• Once this technique has been established the patient can progress to an exercise programme of contracting the transversus abdominis, then the pelvic floor muscles holding these contractions while breathing in and out.
Pelvic floor stability and trunk muscle co-activation
• As with any muscle the PFM do not work in isolation, but there is debate as to the benefit of actively co-contracting transversus abdominis (TrA).
• There is evidence that a co-contraction of the TrA occurs during PFM contraction and that a co-contraction of the PFM during TrA contraction may be lost or weakened in patients with symptoms of pelvic floor dysfunction (Bø et al 2009).
Bladder training and behavioural training
Urge urinary incontinence
• It has been shown that PFMs play a role in overactive bladder and urge incontinence in women as well as men.
• Voluntary contraction of the PFMs not only can occlude the urethra, but also can inhibit or abort detrusor contractions.
• This is a skill that can be accomplished by most patients and provides significant reduction of incontinence.
• The first step in behavioural training is to help patients to identify their PFMs and to contract and relax them selectively without increasing pressure on the bladder or pelvic floor.
Medications
• There are several medications that can be prescribed to the patient with urgency or urge incontinence.
• These are mainly anticholinergic agents which abolish or try to reduce the severity of detrusor muscle contraction.
• Side effects such as dry mouth or eyes or constipation sometimes occur.
• At present there is one medication which may be prescribed for SUI (Duloxetine hydrochloride), and one for nocturia (Desmopressin).
• Intravesical Botulinum toxin A is emerging as a useful alternative in neurogenic detrusor activity.
• It is important to remember that drug treatment should be part of a behavioural package and that fluid management, drill and pelvic floor re-education remain the cornerstones of conservative management.
Bowel dysfunction
Faecal incontinence (FI)
• Principles are to keep the stool formed and keep the rectum empty.
• Stool consistency can be altered either by dietary manipulation or by use of constipation agents or both.
• It is important to recognise that the introduction of a high-fibre diet or fibre supplements in the diet can be used to soften the stool as well as to make it formed.
• This can be achieved by regulating the amount of oral fluids.
• If the stool is already liquid then the introduction of fibre supplements with limited oral fluids makes the stool firm as the fibre draws fluid from the stool itself.
• Constipating agents that work by slowing intestinal and colonic motility are also beneficial.
• The most common agents are codeine phosphate and loperamide.
• These agents increase the residue time for the stool in the colon and therefore provide a better opportunity for absorption of water from the stool.
• Keeping the rectum empty is important, particularly in the elderly patient who often has faecal loading or impaction.
• In these patients FI is secondary to the faecal impaction and often the treatment of the faecal impaction results in complete resolution of the symptom of FI.
• The simplest way of keeping the rectum empty is by regular use of glycerine suppositories and occasionally daily enemas or washouts are necessary.
• Establishing a regular complete rectal evacuation at a predictable time may be beneficial.
• Dietary management of FI or urgency is difficult to control as it is difficult to predict in different patients.
• Clinically a lot of patients derive benefit from moderating their fibre intake.
• Incontinence of flatus is difficult to control, products such as probiotics and aloe vera are reported as helpful in reducing flatus by some patients.
• Quantity and type of fluid is important.
• Alcohol seems to cause the bowels to be loose in some people and some have a bowel that is very sensitive to caffeine (Norton 2007).
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