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Pregnancy in Acute Care Part II

Pregnancy in Acute Care Part II. Women’s Health Overview Implications for Physical Therapy Jane Frahm , PT, BCIA PFMD Rehab Institute of Michigan/WSU. PHYSICAL THERAPY INTERVENTION: HIGH RISK PREGNANCY. All Assessment and Rx needs to respect patient’s diagnosis and activity restrictions.

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Pregnancy in Acute Care Part II

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  1. Pregnancy in Acute CarePart II Women’s Health Overview Implications for Physical Therapy Jane Frahm, PT, BCIA PFMD Rehab Institute of Michigan/WSU

  2. PHYSICAL THERAPY INTERVENTION: HIGH RISK PREGNANCY All 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

  3. LABOR AND DELIVERY • VAGINAL BIRTH • Vaginal delivery after cervix is fully dilated • CAESAREAN BIRTH • Surgical birth through incisions in abdominal wall and uterus

  4. POSTPARTUM • PHYSIOLOGICAL/HORMONAL CHANGES AFFECT REPRODUCTIVE ORGANS • Lower Urinary Tract • Perineum • GI System • Breasts

  5. POSTPARTUM MUSCULOSKELETAL/POSTURAL Target Rehab program for specific area of dysfunction Emphasize Body Mechanics for Child care and ADLs – with special attention to Abdominals / DiastasisRecti Pubic Symphysis / Movement difficulty and pelvic instability Pelvic Floor / Incontinence Lumbo-Pelvic Mechanics / SI Dysfunction

  6. 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)

  7. 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

  8. Slight SYMPHYSIS PUBISSeparation • Normal – 1st Degree • Amt of separation: 0 - <0.5 to 0.9 cm (5-9 mm) • Common Symptoms: none • Common Treatment: none

  9. 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

  10. Severe SYMPHYSIS PUBIS Separation • 3rd degreeAmt of separation: >2cm (20 mm) • Common Symptoms: • Same as Moderate Separation • Distinct waddling gait- or inability to walk at all • Urinary Incontinence

  11. PATIENTS AFFECTED • Pregnant women 1st to 3rd trimesters • Post-Partum women: within 12 - 36 hours of delivery

  12. ETIOLOGY: • Influence of pregnancy hormones specifically relaxin on soft tissue. Hormones are responsible for: Uterine growth Stretching of soft tissue Pelvic joint relaxation Renders the pelvic ring unstable at the symphysis The stretching of a vaginal delivery can further contribute to the instability

  13. 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.

  14. 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

  15. 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

  16. 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

  17. SEROLA S-I BELT www.serola.net

  18. 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 • Patientusuallyknows how to initiate movement-in the least painful way.

  19. 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

  20. 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

  21. 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

  22. 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.

  23. 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

  24. 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

  25. 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

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