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