lecture notes for physiotherapy students

1. Women's health
A.THANGAMANI RAMALINGAM
PT, MSc(PSY),PGDRM, Acspss,MIAP

2. • B. Child-bearing phase –
• a) Complications during pregnancy and its PT management
according to specific conditions/complications.
• b) Antenatal Phase– specific breathing exercise, relaxation,
postural training, pelvic floor exercise and strengthening
exercise.
• c) Physiotherapy during labor.
• d) Postnatal Phase – complication and its physiotherapy
management. Postnatal exercise after normal labour and
labour with invasive procedures like: Episiotomy, Forceps
delivery, Caesarian section

3. Stages of pregnancy
• First trimester (week 1-week 12)
• Second trimester (week 13-week 28)
• Third trimester (week 29-week 40)

4. Complications during pregnancy

5. Progesterone Estrogen Relaxin
Reduction in tone of smooth
muscles (reduced peristalsis, more
water absorption, constipation,
nausea, vomiting, urinary
incontinence, UTI, lowered diastolic
BP).
Increased temperature
Reduces alveolar/arterial pco2
(hyperventilation)
Development of breast and
glandular tissues
Increases storage of fat
Growth of uterus and breast ducts
Increases prolactin for lactation
Assists maternal calcium
metabolism
Water retention (sodium retention)
Increases vaginal glyCOGen
Replacement of collagen with a
remodeled modified form (
increases exTENSibility + pliability)
Inhibition of Myometrial activity
(up to 28 weeks)
Enhances uterine distention.
Production of supportive
connective tissue.
Softening of collagenous content of
the cervix
Mammary growth
Relaxation of pelvic floor muscles.

6.  Stretching of abdominal muscles
 Decrease in ligamentous tensile strength.
 Hyper mobility of joints due to ligamentous laxity.
 Pelvic floor drops as much as 2.5 cm.
 COG shifts upwards & forwards
 posture –
*shoulder girdle becomes rounded,
*scapular protraction, upper
*limb internal rotation.
*increase in cervical lordosis.
*knee hyperextension.
*increase in lumber lordosis
 balance – pt. walks with wider BOS

7. Potential impairments of pregnancy
• Development of faulty posture
• Upper & lower extremities stress
• Altered circulation, varicose vein LL edema
• Pelvic floor stress
• Abdominal muscle stretch & diastasis recti
• Inadequate relaxation skills necessary for labour & delivery
• Development of musculosketal pathologies

8. Antenatal Phase
• To educate about the physiological changes, labor and the puerperium
• To adopt coping skills
• To understand labor and coping skills
• To create emotional maturity
• Pregnancy back care
• Symphysis pubis dysfunction (SPD)
• Pelvic floor/pelvic
• Exercises for circulation and cramps
• Stress and relaxation
• Relaxation position for labor
• Pain relief
• Baby care
• Diet in pregnancy
• Medication in pregnancy
• Swimming and water exercises, yoga and pilates

9. Antenatal exercise
• Warm up
• Stretches
• Postural correction
• Strengthening exs
• Aerobic exs
• Back and abdominal exercise
• Ankle exercise
• Relaxation exercise
• Breathing exercise
• Pelvic floor exercise
• Cool down exs

10. labour
Three stages of
labour
Cervical
dilatation
Propulsion of the
foetus
Propulsion of
placenta
Complications of labor
 Failure to progress
 Fetal distress
 Maternal distress
 Malpresentation
 Breech presentation
 Prolapsed or
presentation of the
cord
 Inco-ordinate uterine
activity
 Hemorrhage
 Contracted pelvis
 Placental abruption
 Multiple births
 Perineal trauma
 Retained placenta
 Placenta accrete (life
threatening)
 Knots of the umbilical
cord

12. Postnatal Phase
• Routine care by mid wife
• Establishing breast feeding
• milk ejection reflex oxytocin uterine contractions (after pain)
• Problems: engorgement, sore or cracked nipples, blocked ducts and
mastitis.
• Pain management techniques
• Postnatal checking/assessment:
• Mother’s BP, breast, abdominal status uterine involution, status of
the cervix, smear test and discussing contraception

13. Post natal exercises
• Benefits of exercise
• Important information
• Principles of exercise
Exercise program
• Core muscles
• Cardiovascular fitness
• Strength
• Core stability
• Cool down
Further information

14. Exercise in
Pregnancy

15. Exercise in Pregnancy
• Exercise may also reduce the risk of developing conditions
associated with pregnancy, such as pregnancy-induced
hypertension and gestational diabetes mellitus .
The American College of Sports Medicine (ACSM) endorses guidelines
regarding exercise in pregnancy and the postpartum period set forth by the
American College of Obstetricians and Gynaecologists , the Joint Committee of
the Society of Obstetricians and Gynaecologists of Canada , and the Canadian
Society for Exercise Physiology (CSEP).

16. Physiologic Responses to Acute Exercise
during Pregnancy Compared with Pre
pregancy

17. FITT for pregnant women
• Frequency: At least three—and preferably
all—days of the week.
• Intensity: Moderate intensity (40%–60%
[V with dot above]O2 reserve [[V with dot
above]O2R]).
Because of heart rate (HR) variability during
pregnancy, consider using the rating of
perceived
exertion (RPE) (12–14 on a scale of 6–20) or
the “ talk test” (being able to maintain a
conversation
during activity) to monitor exercise intensity.
HR ranges that correspond to moderate-
intensity
exercise have also been developed for
pregnant women based on age.
• Time: At least 15 min·d-1 gradually
increasing to at least 30 min · d-1 of
accumulated moderate intensity physical
activity to total 150 minutes per week.
• Type: Dynamic, rhythmic physical
activities that use the large muscle groups,
such as walking and cycling.
Age HR(beats · min-1)
<20
20–29
30–39
>40
140–155
135–150
130–145
125–140

18. Contraindications for Exercising
during Pregnancy
Relative
• Severe anemia
• Unevaluated maternal cardiac
dysrhythmia
• Chronic bronchitis
• Poorly controlled type 1 diabetes
mellitus
• Extreme morbid obesity
• Extreme underweight
• History of extremely sedentary lifestyle
• Intrauterine growth restriction in
current pregnancy
• Poorly controlled hypertension
• Orthopedic limitations
• Poorly controlled seizure disorder
• Poorly controlled hyperthyroidism
• Heavy smoker
Absolute
• Hemodynamically significant heart
disease
• Restrictive lung disease
• Incompetent cervix/cerclage
• Multiple gestation at risk for
premature labor
• Persistent second- or third-
trimester bleeding
• Placenta previa after 26 weeks of
gestation
• Premature labor during the current
pregnancy
• Ruptured membranes
• Preeclampsia/pregnancy-induced
hypertension

19. Special considerations
• Pregnant women who are morbidly obese and/or have gestational diabetes mellitus or
hypertension should consult their physician before beginning an exercise program.
• Pregnant women should avoid contact sports and sports/activities that may cause loss of balance or
trauma to the mother or fetus. Examples of sports/activities to avoid include soccer, basketball, ice
hockey, horseback riding, and vigorous-intensity racquet sports.
• Pregnant women should avoid exercising in the supine position after the first trimester to
• ensure that venous obstruction does not occur.
• Pregnant women should avoid performing the Valsalva maneuver during exercise.
• Pregnant women should exercise in a thermo neutral environment and be well hydrated to
• avoid heat stress.
• During pregnancy, the metabolic demand increases by ~300 kcal·d-1. Women should increase
• caloric intake to meet the caloric costs of pregnancy and exercise.
• Pregnant women may participate in a strength-training program that incorporates all major muscle
groups with a resistance that permits multiple repetitions (i.e., 12–15 repetitions) to be performed
to a point of moderate fatigue. Isometric muscle actions and the Valsalva maneuver should be
avoided, as should the supine position after the first trimester.
• Generally, exercise in the postpartum period may begin ~4 to 6 weeks after delivery.
• Deconditioning typically occurs during the initial postpartum period, so women should gradually
increase physical activity levels until pre pregnancy physical fitness levels are achieved.
• Exercise should be terminated should any of the following occur: vaginal bleeding, dyspnea before
exertion, dizziness, headache, chest pain, muscle weakness, calf pain or swelling, preterm labor,
decreased fetal movement, and amniotic fluid leakage . In the case of calf
• pain and swelling, thrombophlebitis should be ruled out.