Textbook of Physiotherapy For Obstetric and Gynecological Conditions MASUD PDF

Textbook of
Physiotherapy for Obstetric

and Gynecological Conditions
Textbook of
Physiotherapy for
Obstetric and
Gynecological
Conditions
GB Madhuri
MPT(Orthopedics) PGDPC DYT
Lecturer in Physiotherapy
DCMS College of Physiotherapy
Owaisi Hospital and Research Center
Hyderabad, Andhra Pradesh
India
JAYPEE BROTHERS
MEDICAL PUBLISHERS (P) LTD
New Delhi
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672
Rel: 32558559 Fax: +91-11-23276490, +91-11-23245683
E-mail: jaypee@jaypeebrothers.com Visit our website: www.jaypeebrothers.com
Branches
• 2/B, Akruti Society, Jodhpur Gam Road Satellite
Ahmedabad 380015, Phones: +91-079-26926233, Rel: +91-079-32988717
Fax: +91-079-26927094 e-mail: jpamdvd@rediffmail.com
• 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East
Bangalore 560 001, Phones: +91-80-22285971, +91-80-22382956
Rel: +91-80-32714073 Fax: +91-80-22281761 e-mail: jaypeemedpubbgl@eth.net
• 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road
Chennai 600 008, Phones: +91-44-28193265, +91-44-28194897
Rel: +91-44-32972089, Fax: +91-44-28193231, e-mail: jpchen@eth.net
• 4-2-1067/1-3, Ist Floor, Balaji Building, Ramkote Cross Road
Hyderabad 500 095, Phones: +91-40-66610020, +91-40-24758498
Rel:+91-40-32940929 Fax: +91-40-24758499, e-mail: jpmedpub@rediffmail.com
• 1-A Indian Mirror Street, Wellington Square,
Kolkata 700 013, Phones: +91-33-22451926, +91-33-22276404, +91-33-22276415
Rel: +91-33-32901926, Fax: +91-33-22456075, e-mail: jpbcal@dataone.in
• No. 41/3098, B & B1, KURUVI Building,St. Vincent Road, Kochi 682 018 (Kerala)
Phones: +91-0484-4036109, +91-0484-2395739, +91-0484-2395740
e-mail: jaypeekochi@rediffmail.com
• 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel
Mumbai 400 012, Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896
Fax: +91-22-24160828 e-mail: jpmedpub@bom7.vsnl.net.in
• “KAMALPUSHPA” 38, Reshimbag Opp Mohota Science College, Umred Road
Nagpur 440 009 (MS), Phone: Rel: 3245220, Fax: 0712-2704275
e-mail: jaypeenagpur@dataone.in
Textbook of Physiotherapy for Obstetric and Gynecological Conditions
© 2007, GB Madhuri
All rights reserved. No part of this publication should be reproduced, stored in a retrieval
system, or transmitted in any form or by any means: electronic, mechanical, photocopying,
recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original.
Every effort is made to ensure accuracy of material, but the publisher, printer and author
will not be held responsible for any inadvertent error(s). In case of any dispute, all legal
matters are to be settled under Delhi jurisdiction only.
First Edition: 2007
ISBN 81-8061-813-7
Typeset at JPBMP typesetting unit

Printed at Ajanta Press
To
My Father
and
Beloved Husband
Ramesh
Preface
The book titled Textbook of Physiotherapy for Obstetric and Gynecological Conditions
has been designed to cater the needs of the students of the Bachelor of
Physiotherapy degree especially in their second year, third year and final year.
This book is also useful for professionals of physiotherapy, obstetricians,
gynecologists, rehabilitation professionals, other paramedics and every woman
in her childbearing year.
This book has been prepared as per the curriculum of obstetric and
gynecology for Bachelor of Physiotherapy degree course devised as per MCI
regulations and universities syllabus.
Not many books on physiotherapy for obstetrics and gynecology are available
in India. Especially the book is written for the students of physiotherapy in
India. This subject is essential and is a basic subject of physiotherapy for the
undergraduate and as well as for the postgraduate courses. None of the books
by the Indian authors are available. Very few textbooks by foreign authors are
available in the market. To avoid confusion in understanding each topic of the
entire subject and students referring many books for topics in the syllabus, this
Textbook of Physiotherapy for Obstetric and Gynecological Conditions has been
written in a systemic manner in a very simple approach for the students,
professionals of physiotherapy, teachers, doctors, rehabilitation professionals,
obstetricians, gynecologists, other paramedics and to every woman who is in
childbearing year. Recently, lots of advances have taken place in the field of
obstetrics and gynecology. Utmost efforts have been made to cover all the
necessary aspects of electrotherapy. All the chapters have been written in a very
simple manner and clearly expressed.
In ancient times, woman who is pregnant was asked to be under regular
medical supervision and medication. In recent times every woman is preferring
to exercise for the health benefits. This is taught by the physiotherapist by a
specially designed exercise regime during pregnancy. Physiotherapy is an ever-
advancing field. Recent advances have made physiotherapy very interesting
and playing an important role in working women with regard to ergonomics at
work place to prevent further complications like low backache, etc. for fitness
throughout pregnancy, regaining shape back to normal, woman will be learning
stress-free techniques like relaxation and breathing techniques which are useful
during normal labor and every woman prefers today because of minimal
complications and to get back shape easily. All these techniques are found to be
viii Textbook of Physiotherapy for Obstetric & Gynecological Conditions
effective by every woman nowadays. Utmost efforts have been made to update
this textbook starting from the introduction of physiotherapy for obstetric and
gynecological conditions to the recent advances; all the aspects have been
covered with details.
I have tried to give a fairly complete coverage of the subject describing the
most common method known to the women employed by physiotherapist at
appropriate time. The intention is to explain how the method works and their
effect upon the woman and fetus. In the initial chapter, I have tried to lay the
foundation of the principles of physiotherapy for obstetric and gynecological
conditions because a thorough understanding of these principles will ultimately
lead to safer and more effective pregnancy, labor and postpartum period.
Introduction covers about physiotherapy in obstetrics and gynecology
starting from the definition of physiotherapy, need of physiotherapy during
pregnancy, fitness during pregnancy, exercise regime during antenatal period,
perinatal period, puerperium, postnatal period, after six months period, regain
shape back and electrotherapy treatment have also been added.
Chapter one covers about anatomy of bones and joints of pelvis, abdominal
and pelvic floor, female reproductive system, ovaries, fallopian tubes, vulva
and perineum.
Chapter two has been explained in detail about female reproductive system,
hormonal regulation, menstrual cycle, ovulatory phase and postovulatory phase.
Chapter three is about National Women’s Health Policy, fitness in
childbearing year and role of physiotherapy during pregnancy.
Chapter four has tests done for the confirmation of the pregnancy and the
tests that are harmful for the fetus also explained in this chapter.
Chapter five covers introduction to biomechanics, sacral region, its
movements and functions, posture in detail.
Chapter six consist of definition of kinesiology, types of muscle tissue, aims
of kinesiology, care during pregnancy, lower body exercises, upper body
exercises, abdominal and pelvic floor exercises and muscles contraction and
action done.
Chapter seven covers definition of ergonomics, aims of ergonomics, risk
assessment, risk factors, high risk areas and tasks, risks association with lifting,
low back pain, workplace ergonomics. Risk control, task rationalization and
implementation. Consideration of movements, planning lifting activities.
Chapter eight is about pregnancy weight gain, pelvic viscera, fascia,
ligaments, urinary system, pulmonary system, cardiovascular system,
musculoskeletal system, thermoregulatory system, posture and balance changes.
Chapter nine explains about physiotherapy assessment include general
assessment, pelvic floor assessment and also diastasis recti assessment.
Preface ix
Chapter ten covers definition of relaxation, practicing relaxation, relaxation

techniques, and whole body relaxation, training for labor, Yoga-nidra.
Chapter eleven consists of definition, techniques of breathing and breathing
during labor.
Chapter twelve is about definition of massage, techniques of massage,
massage sessions for back, legs, face, neck, shoulder, abdomen and self-massage.
Chapter thirteen describes fetal physiology, placenta, maternal nutrition,
fetal circulation, renal function, central nervous system, alimentary track,
respiratory system, transfers of placenta, water, gas, carbohydrate, amino acid,
fat and fetal hypoxia, and also includes embryonic developments during first,
second, third, fourth, fifth, sixth, seventh, eighth and ninth months.
Chapter fourteen explains about the problem usually woman faces and
their treatment like anemia, bleeding gums, breathlessness, constipation, cramps,
heart burns, nausea, edema, piles, pre-eclampsia, vaginal discharge, varicose
veins, gestational diabetes, urinary frequency, fainting, vulval varicosities,
backache, tender breast, carpal tunnel syndrome and insomnia.
Chapter fifteen is about definition, causes, hypertension, pulmonary
embolism. Addiction, drugs, cardiac disease, pulmonary disease, renal disease,
diabetes, infectious disease, family history, rheumatic disease, thyroid,
hematological diseases, genetic disorder and liver diseases.
Chapter sixteen is in detail regarding the show, the waters, contractions,
first stage, induction, pharmacological pain relief, epidural anesthesia, fetal
monitoring, transition, second stage, episiotomy, assisted delivery, cesarean
section and third stage.
Chapter seventeen includes material on introduction, how to start, feeding
times, diet for mother, equipment required, breastfeeding problems, bottle-
feeding and bottlefeeding equipment.
Chapter eighteen describes about introduction, Apgar score, measurement
of the baby, common musculoskeletal disorders, congenital dislocation of hip,
congenital talipes equino varus, metatarsus adductus, talipes calcaneo valgus,
brachial plexus injury and sternocleidomastoid tumor.
Chapter nineteen consists of introduction to exercise regime, principles of
exercise regime, the concentration, the breath, the girdle of strength, flowing
movements, relaxation, importance of exercise sessions, aims of physiotherapy,
plans of physiotherapy, guidelines for exercise in pregnancy, contraindications
for exercise in pregnancy, effects and uses of exercises in pregnancy, sequence
of exercise regime, management during pregnancy, aims and plan, first trimester,
second trimester, third trimester, management during postnatal stages, aims
and plans, first-three months after the birth, three to six months after the birth,
six months plus, cesarean section, preoperative physiotherapy, postoperative
physiotherapy, high-risk pregnancy, aims and plans.
x Textbook of Physiotherapy for Obstetric & Gynecological Conditions
Chapter twenty is in detail about definition, muscle stimulation, inferential

therapy, TENS, microwave diathermy, ultrasound, short-wave diathermy, infra-
red radiation, laser therapy, cryotherapy and electrotherapy treatment during
antenatal period, labor, postnatal periods and cesarean.
Chapter twenty one describes about hemoglobin status, pelvic floor
problems, backache, pubic symphysis joint subluxation, sacroiliac joint
dysfunction, separation of rectus abdominis, weight gain, nerve compression
syndrome, painful perineum, puerperal infection, breast infection,
thrombophlebitis, and incontinence.
Chapter twenty two covers about infection control for physiotherapist
working with women’s health. Universal precaution, protection from infection,
use of gloves, handwashing, cleaning, work areas, catheters, vaginal and anal
electrode, perineometer, ultrasound head and inferential electrodes are also
explained in this chapter.
Glossary of terms and Bibliography are also given at the end of the book.
Any suggestions from the teachers and students will be highly appreciated, so
that further improvement in the information can be made in the subsequent
editions in the light of the same.
GB Madhuri
Acknowledgements
Textbook of Physiotherapy for Obstetric and Gynecological Conditions is a book that

provides basic knowledge and methodology. Exercise regimes along with
updated knowledge of the important aspects of physiotherapy in obstetrics
and gynecology.
I am indebted to G Anandarao, my father for inspiring me and encouraging
me at every step of my life.
I am thankful to my husband, Mr. Ramesh for always supporting me and
motivating for writing this book and endured two years of emotional stress
while I was deeply engrossed in preparing this book.
This book is a complete, authoritative, latest and easily readable book. This
book has been designed to effectively meet the needs and requirement of the
undergraduate students. The book focuses on the basic principles and their
application during pregnancy.
In preparing this book, I have consulted and utilized the knowledge of
many authors and books. I wish to express my appreciation and gratitude to all
of them who helped me with their valuable suggestions in this venture.
I have made every effort to keep the book comprehensive without eliminating
basic information. The emphasis has been laid entirely on accuracy, authenticity,
simplicity and reproducibility by the student. How far I have succeeded in my
efforts is for students and teachers to judge. I shall welcome their suggestions
and comments.
I especially thank Dr Aditya Sir and Dr Mohankrishna Sir who have
encouraged me a lot for bringing this book out. My special thanks to
Mr Md Fakruddin (Graphics and Design—mdfakruddin007@yahoo.com) and
Mr Md Zubair Mohiuddin Farooqui who helped me a lot in setting up the
material.
I owe my special thanks to Shri JP Vij, Chairman and Managing Director,
M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi and his whole
team for publishing this book in such a nice manner.
Contents
1. Anatomy ...................................................................................................... 1
2. Physiology ................................................................................................... 7
3. Women’s Health and Role of Physiotherapy ...................................... 11
4. Pregnancy Tests and Investigations ..................................................... 14
5. Biomechanics ........................................................................................... 17
6. Kinesiology ............................................................................................... 21
7. Ergonomics ............................................................................................... 31
8. Physiological Skeletal Changes during Pregnancy ............................ 36
9. Physiotherapy Assessement Chart ....................................................... 39
10. Relaxation ................................................................................................. 45
11. Breathing Techniques ............................................................................ 49
12. Massage .................................................................................................... 54
13. Embryonic and Fetal Development ...................................................... 58
14. Relieving Pregnancy Discomfort .......................................................... 75
15. Identification of High Risk Woman ...................................................... 82
16. Labor and Delivery ................................................................................. 86
17. Breastfeeding ......................................................................................... 100
18. Assessment and Handling of Newborn ............................................ 105
19. Exercise Therapy Regime .................................................................... 110
20. Electrotherapy ........................................................................................ 150
21. Complications of Pregnancy ................................................................ 171
22. The Methods of Infection Control for Physiotherapist
Working with Women’s Health .......................................................... 182
Glossary .................................................................................................... 184
Bibliography ............................................................................................. 189
Index ......................................................................................................... 190
Introduction
Pregnancy is the time of great change and growth, for someone it is an exciting,
challenging state, for others it is the time of stress, emotional change and lifestyle
reassessment.The physiotherapy plays an vital role and physiotherapist must
consider all the factors when designing the exercise throughout the pregnancy
and postpartum period. So the concept of fitness in pregnancy must encompass
emotional and psychological aspects in addition to physical fitness.
The physiotherapist needs to be aware of normal pregnancy weight gains
and should refer the women to a dietician if indicated. The physiotherapist
need to recognize the different needs of the woman who wishes to continue to
exercise safely during pregnancy to cope with the physical demands of
pregnancy and labor. So assessment must be done which includes physical
aspects, history and psychological influences.
In the promotion of healthy lifestyle in the childbearing years, physiotherapist
must reinforce the value of exercise and back care as a part of multidisciplinary
team involved in the antenatal care. Physiotherapist must have the expert and
skill to provide the pregnant woman, who wishes to exercise safely during her
pregnancy and the physiotherapist should have the ability to understand the
biomechanical and physiological changes during pregnancy and their influence
on exercise, must be able to assess muscle strength, muscle length and posture,
analyze movement, design appropriate exercise regime, must be able to reinforce
the principles such as relaxation, breathing techniques, back care, lifting and
bending technique, etc. and manage the musculoskeletal problems associated
with the childbearing
Pregnancy is the time of great change and growth. A physiotherapist offer a
best service by promoting its benefits to the well-being of the pregnant and
postpartum woman by arranging the exercise classes and demonstrating the
exercises which are specially designed to meet the needs of the woman in the
childbearing year. Thus, fitness is very important.
A Physiotherapist will give an accurate idea of physiological changes of
pregnancy and puerperium, postpartum period, preventive practices,
ergonomics, safe exercise guidelines, specific exercises for strengthening and
stability, physical management of pregnancy and discomfort, musculoskeletal
problems and its management, relaxation techniques, breathing techniques,
positioning throughout pregnancy, labor and postpartum period, coping skills
for labor, massage, fitness program, baby handling, baby massage, specific
xvi Textbook of Physiotherapy for Obstetric & Gynecological Conditions
treatment modalities in the form of electrotherapy for complications after delivery

for pain relief, muscle stimulation, strengthening, promotion of healing of acute
and chronic tissue problems, breast engorgement, mastitis and blocked ducts,
etc.
Exercise regime is the ideal gentle and effective exercise system during
pregnancy for woman’s health at all stages of the pregnancy, helps to cope up
with labor, childbirth, care of newborn, breastfeeding, handling of newborn,
identifying for the early pediatric problems and regaining her shape back by
specific exercises designed.
Thus, physiotherapy is useful in the months leading up to baby’s birth and
in the weeks following to get woman’s body back in shape and achieve the
longer, leaner and stronger.
CHAPTER
1
Anatomy
BONES AND JOINTS

The bones of the pelvis comprising hips, sacrum and coccyx form a cavity
through which the fetus passes during labor. The two large hip bones meet
together in the midline, anteriorly forming the symphysis pubis and the sacrum,
posteriorly form two sacroiliac joints. These joints allow a small amount of
movement during birth-giving the fetus an easier fit. The hormone relaxin
increases ligament laxity.
The pelvis brim divides into the false pelvis above and true pelvis below.
The brim is known as the pelvis inlet and in the female it is wider and deeper
than in the male. It is apple-shaped. The pelvic outlet at the base of the true
pelvis comprises of tip of the coccyx, posteriorly ischial spines, laterally
tuberosities, and anteriorly pubic arch. It is a diamond-shaped. At midcavity
the true pelvis assumes circular shape. It is the shape of the bony pelvis that
allows the fetus accommodation during the process of birth (Fig. 1.1).
MUSCLES
The abdominal and pelvic floor muscles are very important during pregnancy
and labor.
Abdominal Muscles
It forms a four way stretch elastic support for the abdominal contents. They are:
2 Textbook of Physiotherapy for Obstetric & Gynecological Conditions
Fig. 1.1: Bones and joints of the pelvis
Rectus Abdominis
Origin: Pubic creast and pubic symphysis.
Insertion: Cartilage of fifth to seventh ribs and xiphoid process.
Nerve supply: Branches of thoracic nerves T7-T12.
Action: Compresses abdomen to aid in defecation, urination, forced expiration
and childbirth, a flexes vertebral column. It stretches on either side of the linea
alba ligament attaching to its midline running from the pubic arch below the
ribs and xiphoid process and helps in flexion of the spine and gives support the
growing pregnant uterus not only stretches the abdominal muscles but due to
the laxity of linea alba caused by relaxin, the recti separates, leaving a gap of
some 1 to 3 cm between the two muscles by the end of the pregnancy.
Transverse Abdominis
Origin: Iliac crest, inguinal ligament, lumbar fascia and cartilages of last six
ribs.
Insertion: Xiphoid process, linea alba and pubis.
Nerve supply: Branches of thoracic nerves T8-T12, iliohypogastric and
ilioinguinal nerves consist of horizontal fibers.
Anatomy 3
Action: Compresses abdomen.
Oblique Muscle
Internal oblique:
Origin: Iliac crest, inguinal ligament and thoracolumbar fascia.
Insertion: Cartilage of last three or four ribs and linea alba.
Nerve supply: Branches of T8-T12, iliohypogastric and ilioinguinal nerves.
Action: Contraction of both compresses abdomen, contraction of one side alone
bends vertebral column laterally, laterally rotates vertebral column.
External oblique:
Origin: Lower eight ribs.
Insertion: Iliac crest, linea alba.
Nerve supply: Branches of T7-T12 and iliohypogastric nerve.
Action: Contraction of both compresses abdomen, contraction of one side alone
bends vertebral column laterally, laterally rotates vertebral column. Two pairs
of oblique muscles interlaced diagonally deep to the recti, take part in trunk
rotation, side flexion, along with pelvic floor helps to maintain intra-abdominal
pressure.
The deepest of the groups is the transverse abdominis muscle. The internal
and external oblique muscles cover it. From each side these three muscles insert
into a broad aponeurosis that connects the linea alba, this tendinous raphe,
which is wider above the umbilicus than below, is formed by decussating
aponeurotic fibers. The two recti abdominis muscle which runs in sheaths
reinforces the aponeurosis formed in the aponeurosis on either side of the linea
alba. The each rectus abdominis muscle has three transverse fibers insertions
that are firmly attached to the anterior wall of the enclosing sheaths. The lower
intersection is above the level of the umbilicus and sheaths are deficient posterior
in the lowest portion.
Muscles of Pelvic Floor

Structure
Levator ani and coccygeus muscles. Levator ani muscles comprise two parts
ilio coccygeus and pubococcygeus, which helps to form the floor of the pelvis
and separate the pelvic cavity from the perineum. This forms a major portion of
the floor of the pelvis. Medial borders of the right and left muscles are separated
by the visceral outlet through which pass the urethra, vagina and anorectum.
Pubococcygeus
Origin: Posterior aspect of the pubis.
Insertion: Sphincter, urethra, wall of vagina, pineal body and rectum.
Nerve supply: S3-S4 and perineal branch of pudendal nerve.
Action: Supports and slightly raises pelvic floor, resists increased intra-abdominal
pressure, draws anus toward pubis and constricts.
Iliococcygeus
Origin: Ischial spine, obturator fascia.
Insertion: Last two coccygeus segments.
Nerve supply: S3-S4 and perineal branch of pudendal nerve.
Action: Supports and slightly raises pelvic floor, resists increased intra-
abdominal pressure draws anus toward pubis and constricts.
Coccygeus
Origin: Spine of the ischium.
Insertion: Lower sacrum and upper coccyx.
Nerve supply: Sacral nerve S3 or S4.
Action: Supports and slightly raises pelvic floor resists intra-abdominal pressure
and pulls coccyx forward following defecation or parturition (childbirth).
Voluntary contraction of the levator ani muscle help to constrict the opening in
the pelvic floor (urethra and anus) and prevented unwanted micturition and
defecation (stress incontinence). Involuntary contraction of these muscles occur
during coughing or holding ones breath when the intra-abdominal pressure is
raised. In women these muscles surround the vagina and help her to support
the uterus. During pregnancy the muscles can be stretched or traumatized and
result in stress incontinence. When ever intra-abdominal pressure is raised.
The coccygeal muscle assist the levator ani in supporting pelvic viscera and
maintaining intra-abdominal pressure.
FEMALE REPRODUCTIVE SYSTEM

The female organs of reproduction include the ovaries, which produce secondary
oocytes (cells that develop into mature ova only after fertilization) progesterone
and estrogen (female sex hormones) inhibin and relaxin, the uterine (fallopian
Anatomy 5
tubes) which transport ova to the uterus, the uterus in which embryonic and
fetal development occurs, the vagina and the external organs that constitute the
vulva or pudendum. The mammary glands are also considered as part of the
female reproductive system.
The specialized branch of medicine that deals with the diagnosis and
treatment of the disease of the female reproductive system is called gynecology.
Ovaries
The ovaries and female gonads are paired glands. These are in almond size and
shape. Ovaries descend to the brim of the pelvis during the third month of the
development. They lie in the upper pelvic cavity one on each side of the uterus.
Three ligaments hold the ovaries in position, broad ligament of the uterus
attaches to the ovaries by a double-layered fold of peritoneum called the
mesovarium. The ovarian ligaments anchors the ovaries to the uterus and
suspensory ligaments attaches them to the pelvic wall. Each ovary contains a
hilus, the point of entrance for blood vessels and nerves and along which the
mesovarium is attached. Each ovary consists of the following parts—ovarian
follicles, graafian follicles, and corpus luteum.
Uterine Tube (Fallopian Tube)

Females have fallopian tubes also called oviducts that extend laterally from the
uterus and transport the ova from the ovaries to the uterus. It is 10 cm long,
tubes lie between folds of the broad ligament of uterus. The funnel-shaped
distal end is called infundibulum. It ends in finger-like projections called
fimbriae.
Uterus
The uterus or womb forms a pathway for sperm to reach the uterine tubes. It is
site of menstruation, implantation of a fertilized ovum, development of fetus
during pregnancy and labor and it is situated near urinary bladder and rectum.
The shape of uterus is inverted pear. Uterus has dome-shaped portion called
the fundus, central portion called body and inferior narrow opening into vagina
called cervix.
Vagina
It is tubular fibromuscular organ lined with mucous membrane and measures
about 10 cm in length. It serves as a passage way for menstrual flow and
childbirth. It also receives semen from the penis during sexual intercourse.
Vulva
It is called external genitalia of the female. It has mons pubis, labia majora, labia
minora, clitoris, and vestibule.
Perineum
It is a diamond-shaped area between the thighs and buttocks of both males and
females that contain external genitalia and anus.
Mammary Glands
The mammary glands are modified sudoferous (sweat) glands, which produce
milk. They lie over muscles like pectoralis major and serratus anterior and
attaché by layer of connective tissue.
Internal Structure
Each mammary gland consists of 15 to 20 lobes separated by adipose tissue. In
each lobe are several smaller compartments called lobules, composed of
connective tissue in which clusters of milk-secreting glands called alveoli. Alveoli
convey milk to secondary tubules to mammary ducts, then to the lactiferous
sinus where milk is stored, lactiferous ducts end in nipple. The pigmented area
of skin around nipple is called areola. It has modified sebaceous glands, Cooper’s
ligament support the breast.
The structure of the glandular elements of the mammary glands varies
considerably at different periods of life as follows:
A. Before the onset of puberty the glandular tissue consists of ducts, connective
tissue and fat.
B. During pregnancy ducts undergo proliferation and branching their terminal
parts develop into alveoli, each lobe is called tubuloalveolar glands, at the
end of the pregnancy alveoli starts secreting milk and alveoli becomes
distended. The development of the breast tissue during pregnancy takes
place under the influence of hormones produced by cerebri.
Physiology 7
CHAPTER
2
Physiology
FEMALE REPRODUCTIVE SYSTEM

The female organs of reproduction include the ovaries, which produce secondary
oocytes (cells that develop into mature ova only after fertilization), progesterone
and estrogen (female reproductive sex hormones), inhibin and relaxin, uterine
tubes (fallopian tubes) which transport ova to the uterus, the uterus in which
embryonic and fetal development occurs.
Female Reproductive Cycle

During the reproductive years, nonpregnant females normally experience, a
cyclic sequence of changes in the ovaries and uterus. Each cycle takes about a
month and involves both oogenesis and preparation of the uterus to receive
fertilized ovum. The principal events all are hormonally-controlled. The ovarian
cycle is a series of events associated with the maturation of the ovum. The
uterine or the menstrual cycle is the series of changes in the endometrium of the
uterus. Each month endometrium is prepared for the arrival of the fertilized
ovum that will develop in the uterus until birth. If the fertilization does not
occur the stratum functionalis portion of the endometrium is shed. Female
reproductive cycle has ovarian and uterine cycles occur due to hormonal changes
regulate them and cyclical changes in the breast and cervix.
HORMONAL REGULATION
The uterine cycle and ovarian cycle are controlled by gonadotropin-releasing
hormone (GnRH) from the hypothalamus. GnRH stimulates the release of the
follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the

anterior pituitary gland. FSH stimulates the initial development of the ovarian
follicles and secretion of estrogen by the follicles. LH stimulates the further
development of ovarian follicles, brings ovulation and stimulates the production
of estrogen, progesterone, inhibin and relaxin by the corpus luteum.
Estrogen
It promotes development and maintenance of female reproductive structures;
secondary sex characteristics and fat distribution to the breasts, abdomen, mons
pubis, hips, voice pitch, broad pelvis and hair pattern. They help to control the
fluid and electrolyte balance, they increase protein anabolism. Estrogen
inhibition causes inhibition of GnRH, LH, FSH use for contraceptive.
Progesterone
It works with estrogen to prepare the endometrium or implantation of a fertilized
ovum and mammary glands for milk secretion.
Inhibin
It is secreted by the corpus luteum of the ovary. It inhibits the secretion of
FSH,GnRH, LH. It helps in decreasing secretion of FSH and LH towards the
end of the uterine cycle.
Relaxin
It is produced in its highest concentration by the corpus luteum and placenta
during the last trimester of pregnancy. It relaxes the pubic symphysis and helps
to dilate the uterine cervix to ease delivery.
PHASES OF FEMALE REPRODUCTIVE SYSTEM

The female reproductive cycle normally ranges from 24 to 35 days, events occur
during the cycle are divided into three phases.
1. Menstrual phase.
2. Preovulatory.
3. Postovulatory.
Menstrual Phase (Menstruation)

The menstrual phase lasts for 5 days. It has 50 to 150 ml of blood, tissue fluid,
mucus, epithelial cells derived from the endometrium. This discharge occurs
because the declining level of estrogens and progesterone causes the uterine
Physiology 9
spiral arteries to constrict. As a result the cells they supply become ischemic
and start to die. Entire stratum functionalis tears off. At this time the endometrium
is very thin because only the stratum basalis remains. The menstrual flow passes
from the uterine cavity to the cervix and through the vagina to the exterior.
During this stage FSH begins to increase by 25th day of the previous cycle,
primordial follicles begins to develop into primary follicles. Towards 4 to 5 day
of menstrual cycle, primary becomes secondary (growing) follicle. It has
secondary oocytes.
Preovulatory Phase
It is the second phase of the female reproductive system. It is the time between
menstruation and ovulation. It lasts from 6 to 13 days in 28 days cycle. Out of 20
follicles, one gets mature into vesicular ovarian (graafian) follicle or mature
follicle, a follicle ready for ovulation. This follicle is visible as a blister-like bulge
on the surface of the ovary. Fraternal or nonidentical twins may results if two
vesicular ovarian follicle forms. All hormonal production increases like estrogen,
FSH, GnRH, progesterone. Estrogen is liberated into the blood by ovarian follicle
stimulate the repair of the endometrium. Cells of the stratum basalis undergoes
mitosis and produce stratum functionalis. As endometrium thickens becomes
4 to 6 m. Preovulatory phase is also called proliferative phase because
endometrium is proliferating. The menstrual phase and preovulatory phase
together called follicular phase because ovarian follicle are growing and
developing.
Ovulation
It is the rupture of the vesicular ovarian (graafian follicles) with release of
secondary oocytes into the pelvic cavity usually occurs on the 14 day in a 28
days cycle. During ovulation, the secondary oocytes remains surrounded by
cells called corona radiata. It generally takes 20 days for a primordial follicle to
develop into mature vesicular ovarian. During this time the developing ovum
completes reduction division (meiosis I) and reaches metaphase of equatorial
division (meiosis II).
At the time of ovulation the secondary oocytes are in metaphase of equatorial
division. The fimbriae of the uterine tubes drape over the ovaries and become
active near the time of ovulation. Movements of the fimbriae and uterine tube
mucosa and ciliary’s action creates currents in the peritoneal serous fluid that
carry the secondary oocytes into the uterine tube.
All the hormonal levels increase. This sudden surge of LH triggers
ovulation.The sign of ovulation is an increase in basal temperature (body
temperature at rest). It is 0.4 to 0.6 degree Fahrenheit. Ovulation occurs about 14

days after the start of the last menstrual cycle and due to increasing levels of
progesterone. The 24 hours following this rise in temperature is the period
immediately after ovulation and is the best time to become pregnant.
Another sign of ovulation is the amount and consistency of cervical mucus.
Its secretion is regulated by estrogen and progesterone. At midcycle increasing
levels of estrogen causes secretory cells of the cervix to produce large amounts
of cervical mucus. As ovulation approaches, the mucus becomes clear and very
stretching, if grasped with forceps; the mucus may stretch as far as 12 to 15 cm.
This type of mucus indicates the time of greatest fertility.
The cervix also exhibits signs of ovulation. The external os opens, the cervix
rises and becomes softer. Some women also experiences a pain in the area of
one or both ovaries around the time of ovulation. Such pain is called
mittelschmerz meaning pain in the middle and may last from several hours to
a day or two.
Postovulatory Phase
It is the most constant in duration and last for 14 days from 15 to 28 in a 28 day
cycle. It represents the time between ovulation and onset of next menses. After
the ovulation LH secretion stimulates remains of vesicular ovarian follicle to
develop into corpus luteum. Corpus leuteum secrets more quantity of estrogen
and progesterone. This phase called luteal phase. Progesterone is responsible
for preparing the endometrium to receive a fertilized ovum. Preparatory activities
include growth and coiling of endometrium glands, which begin to secrete
glycogen, vascularization of the superficial endometrium, thickening of the
endometrium and increase in the amount of the tissue fluid. These changes are
maximum about one week after ovulation. This phase is also called secretory
phase because secretory activity of the endometrial glands.
If fertilization and implantation do not occur the rising levels of both
progesterone and estrogen secreted by the corpus luteum inhibit GnRH and LH
secretion. As LH decreases, the corpus luteum degenerates and become corpus
albicans or white body. This decreased secretion initiates another menstrual
phase.
Once fertilization and implantation occur hormonal regulation maintained
by placenta. Corpus luteum maintained by human chorionic gonodotropin
(hCG) a hormone produced by the chorion, which develops into the placenta.
Corpus luteum secrets estrogen and progesterone. The presence of hCG is an
indication of pregnancy. The placenta secretes estrogen to support pregnancy
and progesterone to support pregnancy and breast development, corpus luteum
becomes minor.
CHAPTER
4
Pregnancy Tests and
Investigations
Pregnancy tests and investigations are useful for diagnosing whether a woman
is pregnant or not and if pregnancy helps to rule out the further problem. It is
confirmed by the following tests:
URINE TEST
This test is performed after six weeks from the last menstrual period to sixteen
weeks. It is a diagnostic test that depends on the presence of human chorionic
gonodotropin (hCG) in the urine. hCG is found in the concentrated form in the
first urine passed in the early morning. The test is highly-reliable. If performed
before six weeks or later sixteen weeks will get a negative result.
ROUTINE TEST
In each antenatal visit the midstream urine is examined for the presence of
sugar, protein, ketones which cause potential problems, and presence of bacteria
in the early pregnancy where antibiotic treatment is given to prevent further
problems.
ROUTINE BLOOD TEST

This test is done for hemoglobin estimation, detecting anemic, blood group,
rhesus factor to find out cross-matched blood in the event of hemorrhage during
pregnancy, labor or puerperium, rhesus incompatibility between mother and
infant blood types, serological tests for syphilis or other venereal infection
Pregnancy Tests and Investigations 15
(VDRL), rubella antibodies are tested to know if the woman is immune, if so, it
results in fetal abnormalities like deafness, cataract, heart defects or if woman is
susceptible, vaccination is usually offered after the birth of the baby.
SPECIFIC BLOOD TESTS

Hemoglobin electrophoresis to detect conditions such as sickle cell anemia and
thalassemia, serum alpha-fetoprotein is to detect open neural tube defects such
as spinal bifid or anencephaly. Hepatitis (A, B, C) screening to detect the presence
of hepatitis and avoid infection of health care workers during blood taking or
delivery. Glucose tolerance test to measure the woman’s ability to stabilize
blood sugar levels after the ingestion of glucose, a random finding of glucose in
the urine is common in pregnancy, to exclude diabetes mellitus in pregnancy
when there is family history of diabetes, marked obesity, history of previous
baby weighing over 4.5 kg or unexplained stillbirth. The test is done with fasting
blood sugar or urine specimen, the woman takes glucose by mouth, the blood
and urine samples are collected at half-hourly intervals for two hours.
ULTRASOUND
Diagnostic ultrasound is commonly used in obstetrics for the identification of
early pregnancy, accurate pregnancy dating, assessment fetal growth, early
diagnosis of multiple pregnancy, estimation of fetal health, diagnosis of certain
abnormalities, localization of placental site and amniocentesis.
AMNIOCENTESIS
Amniotic fluid is taken from the uterus for analysis of detection of fetal
abnormalities such as Down’s syndrome, open neural tube defects, identification
of sex in sex-linked disorders such as hemophilia and Duchenne muscular
dystrophy and identification of biochemical disorders must be performed by 16
to 18 weeks, complications include abortion, preterm labor and limb deformities.
CHORIONIC VILLUS SAMPLING

It is used for fetal abnormality between nine and twelve weeks of pregnancy,
guided by ultrasound a small tissue sample is taken from the edge of the
placental (the chorion) and tested to exclude abnormalities such as Down’s
syndrome, spinal bifida, sex-linked disease or chromosomal abnormalities, risk
of complications such a miscarriage. Test is conducted earlier in the pregnancy
results in three days.
ESTRIOL TESTS
Assessment of the amounts of estriol or human placental lactogen (hPL) gives
an indication of the functioning of the placenta. The estriol tests and blood tests
are conducted three times over five days to determine if the estriol level is stable
or failing. It is rarely used.
FETAL MOVEMENTS RECORDING KICK CHART

One sign of healthy baby is vigorous movement, the pregnant woman may be
asked to record the time it takes for the fetus to more 10 minutes (any time from
a few minutes to twelve hours) low movements counts indicate a need for closer
fetal monitoring.
ANTENATAL CARDIOTOCOGRAPHY
Fetal heart rate traces can be recorded. A normal trace shows a fetal heart rate
between 100 and 160 beats per minute and abnormalities may give warning to
deliver fetus and indications are low movement count, evidence of placental
insufficiency, antenatal bleeding following amniocentesis, multiple pregnancy.
CHAPTER
5
Biomechanics
Pregnancy results in an alteration of every organ system with in the woman’s

body. The effects of pregnancy on the biomechanics of the chest wall are apparent
during the second half of the pregnancy especially during the last trimester.
Progressive uterine distension repositions the diaphragm cephalad with a
resultant increased chest circumference (Fig. 5.1).
Fig. 5.1: Biomechanical changes during pregnancy

SACRAL REGION
Five sacral vertebrae fuse to form triangular structure called sacrum. The base
of the triangle is formed by first sacral vertebrae articulates with the lumbar
vertebrae. The apex of the triangle has fifth sacral vertebrae articulates with
coccyx. Two sacroiliac joints consist of the articulation between the left and
right articular surfaces on the sacrum which are formed by the fused portions of
first, second and third sacral segments, and left and right iliac bones, sacroiliac
joints are unique in that both the structure and functions of these joints change
significantly from birth through adulthood (Fig. 5.2).
Fig. 5.2: The sacroiliac joints
MOTIONS AT SACROILIAC JOINTS

The movements at sacroiliac joints are nutation and counternutation.
Nutation
It is commonly used term to refer to movement of the sacral promontory of the
sacrum anteriorly and inferiorly while the coccyx moves posteriorly in relation
to the ilium (Fig. 5.3).
Fig. 5.3: Nutation

Biomechanics 19
COUNTERNUTATION
It refers to the opposite movement in which the anterior tip of the sacral
promontory moves posteriorly and superiorly while the coccyx moves anteriorly
in relation to the ilium (Fig. 5.4).
Fig. 5.4: Counternutation
The change in position of the sacrum during nutation and counternutation

affects the diameter of the pelvic brim and pelvic outlet. During nutation the
anteroposterior diameter of the pelvic brim is reduced and the anteroposterior
diameter of the pelvic outlet is increased. During counternutation the reverse
situations occur. The anterior-posterior diameter of the pelvic brim is increased
and diameter of the pelvic outlet is decreased. These changes are important
during pregnancy and childbirth. Most motions that occur at the sacroiliac
joints may occur in pregnancy and childbirth when the joint structures are
under hormonal influences and ligamentous structure is softened.
FUNCTIONS OF SACRAL REGION: STABILITY AND MOBILITY

During pregnancy, relaxin a polypeptide hormone is produced by the corpus
luteum and deciduas. This activates the collagenolytic system that regulates
new collagen formation and alters the ground substance by decreasing the
viscosity and increasing the water content. The action of relaxin is to decrease
the intrinsic strengthen and rigidity of the collagen, softening of the ligaments
supporting the sacroiliac joints and symphysis pubis. So, joints become more
mobile and less-stable and the likelihood of injury to these joints is increased.
The combination of loosened posterior ligaments and anterior weight shift
caused by a heavy uterus may slow excessive movement of the ilia on the sacrum
and result in stretching of the sacroiliac joint capsule.
Posture
Normal pregnancies are accompanied by a weight gain, an increased in weight
distribution in the breast and abdomen and softening of the ligamentous and
connective tissue. The location of the woman’s center of gravity changes because
of the increase in weight and its distribution anteriorly. Postural changes in
pregnancy include an increase in the lordotic curves in the cervical and lumbar
areas of the vertebral column, protraction of the shoulder girdle and
hyperextension of the knees, head position, anterior pelvic tilt. The lumbar
angle increased by an average of 5 to 9 degrees, the anterior pelvic tilt increased
by average of 4 degree, head become more posterior as pregnancy progressed
from first through third semester.
These changes in posture represent adaptations that help to maintain the
center of gravity centered over the base of support. Softening of ligamentous
and connective tissues especially in the pelvis, sacroiliac joints, pubic symphysis
and abdomen changes the support and protections offered by these structures
and predisposes pregnant women to strains in supporting structures. So, many
women experience backache during pregnancy.
Kinesiology 21
CHAPTER
6
Kinesiology
DEFINITION
Kinesiology is the study of how muscles work and contract muscle tissues.
AIMS OF KINESIOLOGY
1. To maintain, develop, strengthen or endurance in major muscle groups
2. To promote good posture
3. To develop body awareness and control
4. To maintain and develop muscle tone, improving body image.
Exercises are categorized into:

1. Lower body exercises: Quadriceps, straight leg extension, hamstring curls, toe
pull ups or foot lifts, side-leg lifts, lying on side, heel raises.
2. Upper body exercises: Press-ups, triceps extension, lateral pulls, trapezius
squeezes.
3. The abdominal muscles: Rectus abdominis, internal oblique, external oblique
muscles, abdominal curls, static abdominal contraction.
4. The pelvic floor: Levator ani and coccygeus.
Lower Body Exercises

Quadriceps
Four muscles make quadriceps muscle group. They are rectus femoris, vastus
lateralis, vastus medialis, and vastus intermedius. These are located in the
anterior surface of the thigh and these muscles extend the leg by straightening
the knee when running and walking. The quadriceps contraction helps slow
down and stabilizes the body when coming to land after jumping. And also
keep the knees straight when standing; the rectus femoris also flexes the hip.
Advantages
1. Strengthening of quadriceps aids in ability to bend and lift effectively and
correctly.
2. Strong quadriceps allows performing effectively so walking is an excellent
way of working aerobically while pregnant, thereby, minimizing on relaxin
affected joints.
3. Quadriceps helps in taking the increasing pressure of extra-weight and
potentially-increased instability caused by relaxin hormone and stability of
the knee joint is maintained by vastus medialis.
4. Leg exercises that contract the quadriceps muscle group include: half squats,
straight leg extensions.
Half Squats
Position of patient: Standing with or without support, feet should be hip distance
apart.
Technique: Bend the knees into half squat position, do not take knee joint beyond
the range of foot, and try to keep in line, come back to the normal position. Work
for 8 to 10 repetitions, this can be worked as aerobic work, pool environment,
dryland.
Uses: Warmup muscle tissue, mobilizing hip joint.
Straight Leg Extension

Position of patient: Seated on a chair, feet should touch floor and or stability; hold
the sides of chair under the seat.
Technique: Lift one foot from the floor and straighten leg out in front until the
knee is fully-extended. Return the foot to floor. Movement should be smooth
and controlled, not jerky. Try 8 to 10 repetitions, then do the same with the other
leg, then alternate legs, totally perform 2 or 3 sets.
Hamstring
These are the group of muscles situated at back of upper thigh. They are
semimembranosus, semitendinosus and biceps femoris. The function of these
muscles is to flex or bend the knee and to extend the hip when the knee is flexed,
rotation of the knee can occur.
Kinesiology 23
Position of patient: Standing with support of a chair, wall, and exercise barre in
pool holding the scum rail.
Technique: Both the legs on ground until toes touching ground. Bend the knee of
one leg and touch the buttock with heel. This action is by hamstrings. Return
the foot to the ground by extending and straightening knee.
Advantages: Improving the strength of the hamstrings helps the pregnant
woman’s ability to bend and lift with good technique, reducing stress on the
vertebral column as pregnancy advances, maintain correct pelvic tilt, maintains
correct alignment between pelvic tilt and spinal column thus, helping good
posture and alleviate backache. Repetitions should be decreased in the third
trimester as increasing body weight makes more difficult to maintain correct
body posture while exercising.
Toe Pull-ups or Foot Lifts

Tibialis anterior works for this.
Origin: Upper two-thirds of the tibia.
Insertion: Inner surface of foot, first metatarsal
Nerve supply: Deep tibial nerve.
Action: Inversion and plantar flexion of the foot.
Position of patient: Seated on a chair, on the floor or standing in a pool. If using a
chair ensure that both feet touch the floor, if not use lumbar support (towel or
sweat shirt) to move the buttock forward a little. If seated on the floor place both
hands behind and to the side as necessary to give support while working.
Upright seating position in last trimester of pregnancy is tiring for the back
muscle so frequent rest periods by leaning back on the hands between sets of
repetitions.
Technique: Seated on chair, pull the upper part of the foot up towards the lower
leg dorsiflexing the ankle and return the foot to the floor. This exercise can be
performed with the both feet together or alternate feet seated on floor sit with
legs straight out in front, hip distance apart. Pull the upper part of the foot up
towards the tibia of the lower leg, dorsiflexing the ankle as this is performed.
Return the foot to the starting position. Repeat 8 to 10 times, rest, and rotate to
different muscle groups, return and repeat.
Advantages: It gives support to the long arch of the foot when the soles of the foot
are turned inwards (inversion) and helps counteract flat feet. The added weight
of pregnancy and extra stress imposed on the ankles and foot can be considered
by exercising the tibialis anterior muscle.
Side-leg Lifts
Muscles are tensor fascia lata, gluteus medius, gluteus minimus.
Tensor fascialata:
• Origin: Anterior superior iliac spine.
• Insertion: Inferior tibial tract.
• Nerve supply: Obturator nerve.
• Action: Bends and abducts hip and straighten the knee joint.
Gluteus medius:
• Origin: Outer surface of ilium.
• Insertion: Greater trochanter.
• Action: Abuction and medial rotation of hip.
Gluteus minimus:
• Origin: Outer surface of ilium.
• Insertion: Greater trochanter.
• Action: Abduction and medial rotation of hip.
Position of patient: Standing with support, e.g. chair, wall, and lying on floor on
side.
Technique: In standing she has to take weight on supporting leg and lift opposite
leg out to the side and return to starting position, small lift will be sufficient as
the high leg lift will create stress on the pubic symphysis joint at the front of the
pelvis as the inside leg muscles are attached to this joint. Great care must be
taken as relaxin hormone has affected of the pelvic girdle an increasing weight
of the uterus and its contents. Perform eight repetitions before changing side,
avoid tiredness especially last trimester (6-9) months of pregnancy. Pregnant
women tire easily so ensure that support is available. Free-standing should be
avoided.
Lying on Side
Ensure clean, warm and safe floor surface. Teach and observe the correct
technique for pregnant women to get down safely on the floor or exercise mat.
Position of patient: Adapt the position on the floor, bottom leg should slightly
bent with knee in front of body line. Top leg should be straight. Support head on
hand with bent arm position, upper arm and hand can be used to support by
placing hand on the floor in front of chest.
Kinesiology 25
Technique: Lift straight leg up, and then lower back down to starting position.
Do not lift the leg too high as this caused stress on the pubic symphysis joint.
Rests when you need to do approximately eight repetitions, if felt tired do less.
Advantages:
1. This helps to strengthen leg and gluteal muscles to aid women correct bending
and lifting technique.
2. Helps to maintain pelvic stability.
Heel-Raises
The gastronemius and soleus muscles are used during this movement called
calf musculature, situated in the lower legs.
Gastrocnemius:
• Origin: Lower end of femur.
• Insertion: Achilles tendon at the back of the heel.
• Nerve supply: Posterior tibia nerve.
• Action: It helps in propelling the body forwards and upwards when running,
jumping, hopping and skipping. Heel-raises exercises with the knees fully
locked out.
Soleus:
• Origin: Upper two-thirds of tibia and fibula.
• Insertion: Achilles tendon.
• Nerve supply: Posterior tibial nerve.
• Action: Soleus is one of the most important plantar flexors of the ankle. It is
effective when the knees are slightly bend. Any movement with body weight
on the foot with the knees flexed or extended produces contraction of the
soleus muscle. Running, jumping, hopping, skipping and dancing activates
the soleus.
Position of patient: Stand with support, e.g. using chair, wall.
Technique: Stand with feet hip distance apart, toes pointing forward, feet flat on
floor. If using a chair as a support ensure that the back rail is the correct height
for the participant. Raise heel together from the floor, lower and return to starting
position. Use of double heel rises if working on land. It increases stability.
Advantages:
1. Mobility of the ankle joints helps maintain general mobility of walking or
performing exercises routine using the legs in antenatal and postnatal
exercise class.
2. Maintaining mobility can alleviate physiological edema or swelling in the
ankles in last trimester.
3. The natural pump effect of these muscles when contracting can aid in
maintaining venous return from the calf back to the heart, thus minimizing
the risk of varicose veins and improving blood flow.
Upper Body Exercises

These exercises include:
1. Press-ups
2. Triceps extension
3. Lateral pulls
4. Trapezius squeeze.
Press-ups
The pectoralis major muscle that is used during this exercise is situated on the
anterior surface of the chest wall, either side of the sternum, filling these space
of the chest region between the shoulder girdle and the sixth rib.
Pectoralis major
• Origin:
A. Upper fibers: From clavicle.
B. Lower fibers: From the first six ribs.
• Insertion: In bicipital groove on humerus bone in the upper arm.
• Nerve supply: Nerve to pectoralis major.
• Action: (1) When arm is held in the horizontal position, this muscle draws
the arms across towards the chest midline, (2) When the arm is away from
the body (abducted), and pectoralis major moves the arm down towards the
body, (3) It is also responsible for internally rotating the humerus bone in
the upper arm intowards the body.
Position of patient: Seated on a chair or on the floor, standing either on land. In
box position, on your hands and knees on the floor called quadripued position.
Technique:
Seating or standing: Both the arms with elbows bent, hands uppermost draw
both arms inwards towards midline to meet and return back to normal position.
Advantages:
A. Improve the ability to lift a carry both antenatally and postnatally.
B. Muscle tone is improved by giving extra-support to the breast tissue.
C. Helps in improving the shape of the breast.
D. Blood supply to the breast area is increased; lactation is improved as prolactin
levels are elevated for those who are regular exerciser.
Kinesiology 27
Triceps
Triceps brachii muscle is situated on the back of the upper arm and is responsible
for extending or straightening the elbow.
Origin: Scapula bone.
Insertion: On ulna.
Nerve supply: Radial nerve.
Action: Pushing movements and hand balancing, extension of shoulder joint.
Position of patient: Standing or seating.
Technique: Keep the shoulders relax, do not tense up slightly bent the arms and
a loose fist, place the upper arms into close contact with the body and slide the
elbows back until they are behind the body and return to the starting position
by flexing at the elbow joint. And other way is working by clasping both the
hands above the head with bent elbows, and straightening the arms in this
position will also contract triceps brachii muscle. Minimize the repetitions in
this position due to potential rise in blood pressure.
Advantages: Pushing activities such as prams and pushchairs and carrying
and balancing activities such as travelling with baby and toddler, i.e. carrying
changing bags, shopping with. Baby is better coped with and performed with
greater care if the triceps brachii is well-toned or exercised.
Lateral Pulls
The latissimus dorsi muscle is situated either side of the spinal column, on the
back, lower six thoracic vertebrae (T6 to T12), lowest three ribs, lumbar region of
the spine and the sacrum.
Origin: Iliac creast, back of sacrum, thoracic, lumbar vertebrae, lowest three
ribs.
Insertion: Intertubercular groove of humerus bone.
Nerve supply: Long thoracic nerve.
Action: To pull the abduction arm down to the side and towards the midline of
the body, e.g. rope climbing, dips on parallel bars, rowing and pulling a bar on
weights down towards the shoulder will contract the muscle.
Position of patient: Free-standing or side-standing with support or sitting on a
chair or in hest deep water in swimming pool.
Technique: Standing with both the hands above the head, grasp an imaginary
rail down behind the head towards the shoulders. Return both arms to starting
position. Maintain the anterior pelvic tilt, try to reduce lumbar lordosis if
standing, keep the movement smooth, relax before performing next repetition,
minimize repetitions to 8 to 10 as prolonged arm raising can effect the blood
pressure, if seated on a chair, make sure that there are no chair arms, as they
inhibit performance of the exercise and bruise the elbows.
Trapezius
The trapezius is situated on either side of the spinal; column in the cervical and
thoracic areas on the back extending up into the base of the skull and out to the
sides of clavicle an scapula.
Origin: Muscle fibers originate on the base of the skull, cervical and thoracic
vertebrae.
Insertion: In clavicle and scapula.
Nerve supply: Thoracic nerves.
Action: It is responsible for pulling upwards and raising arms above the head.
When arm are held out at the side of the body, the head. When arms are held out
at the side of the body, the trapezius fixed the scapula in place and allows this
to happen. When lifting the hands, e.g. heavy bags, the trapezius contracts and
also carrying baby or heavy objects on the edge of the shoulder contracts the
trapezius muscle.
Position of patient: Standing on floor or in water, sitting on a chair or on the floor
Technique:
Standing: Raise arms with bent elbows, push the shoulder backwards, drawing
shoulder blades closer together on the upperback, while pulling the elbows
towards the back of the body, return to the starting position. Other is taking both
arms above the head. Imagine you are grasping a rail above your head. The action
of taking the arms above your head and pulling down the imaginary rail behind
your head towards your shoulder contacts the trapezius and will activate
latissimus dorsi muscle. In standing when performing either exercise think about
maintaining correct posture throughout, feet hip distance apart, do not lock knee
joints, avoid excessive lumbar lordosis by tucking bottom in and trying to maintain
a pelvic tilt that does not stress the lumbar region of the spine.
Sitting: If seated ensure that feet touch the floor. If they do not tuck a rolled up
towel or sweatshirt behind too to bring your bottom further forward on the
chair.
Kinesiology 29
Advantages: Well tones trapezius muscles will help to ease the stress of lifting
and carrying. Helps in lifting and carrying tasks involving equipment, e.g.
prams, push chairs, changing bags, all the paraphernalia that goes with having
a baby and toddlers. Lifting and carrying children and push chairs of the car,
up and down escalators can be exhausting, coping more efficiently by regularly
exercising the trapezius muscle.
The Abdominal Muscles

The area of the body that usually concerns most women before, during and
definitely after pregnancy is the abdominal corset or stomach area. The
abdominal muscles fill the gap between the ribs and pelvis and form a natural
elastic corset. The muscles are rectus abdominis, internal obliques, external
obliques, transverse abdominis and quadratus lumborum.
Function
A. They act as a protective splint for the spine.
B. They help to maintain the correct pelvic tilt and realign the pelvis with the
spine.
C. They support and protect the abdominal contents.
D. They allow and produce controlled movements.
E. They provide support for the pregnant uterus.
F. They aid expulsive movements such as coughing, vomiting, defecation and
pushing during the process of childbirth during the second stage of labor
when the transverse abdominals act as secondary powers to help the
contracting uterus push out and expel the baby along the birth canal, all
utilize the contraction of abdominal corset muscles.
Static Abdominal Contraction—Pelvic Tilt: On Bed
Position of the patient:

• Standing or sitting position lie on firm surface on bed or floor with the knees
bent, feet hip distance apart, hands placed either side on abdomen.
• Technique: Breathe in as she exhales push the back down towards the floor
or bed, tighten the abdominal muscles pulling them in. Hold this tightening
for a few seconds and as she releases breathe out, ready to repeat again.
Remember to breathe out on the exertion phase of the exercise i.e as she
tighten and pull in the abdomen. Remember three Ts, i.e. tuck, tilt, and
tighten. Perform 6 to 8 repetitions, repeat 3 or 4 times.
Pelvic Floor
A sling of muscle attached to the pelvic bone at the front, passing in two halves
to the sacrum and coccyx at the back of the pelvis. The two halves to the sacrum
and coccyx at the back of the pelvis. The two halves fan out to form the floor of
the pelvis. Three opening pass through this urethra, vagina and rectum.
Role of Pelvic Floor

To support abdominal contents, to control leakage of urine. Stress incontinence
occurs if muscles of the pelvic floor loose tone and the reflex tightening of the
sphincters around the vagina, urethra, rectum is slowed down due to poor
muscle action, if good tone is present then the fast twitch muscle fiber react
quickly to close up urethra and rectum.
Pelvic Floor Muscles

It is made up of two layers—a deep layer of muscle and a superficial layer of
muscle. Deep muscle layer: The levator ani in two halves consist of the ilio-
coccygeus, ischiococcygeus and pubococcygeus. These react very quickly to
changes in intra-abdominal pressure, e.g. coughing, vomiting, sneezing,
defecation. These are made of fast twitch muscle fibers that produce a reflex
action for a quick contraction of short-duration.
Superficial Muscle Layer

It forms transverse perineum as bulbocavernous and ischiocavernous.
Exercising the Pelvic Floor

Position of patient: Standing, sitting with knees apart, lying with both knees bent
or sitting in a chair.
Technique: Tighten the muscles of vagina and pull up inside, hold for 4 to 6
seconds then release.
1. Hold your breath. Once you have tightened your pelvic floor take a slow
deep breath in and breath out then release the pelvic floor muscle.
2. If holding for much longer time 6 seconds or more will make it stronger or
faster because made up of fast twitch fibers.
3. Tailor sitting, sitting with the soles of feet together, squatting or sitting with
knees pulled up and apart. Stretch inner thigh muscles and increased
flexibility in this area may make the second stage of labor position more
comfortable for women.
Ergonomics 31
CHAPTER
7
Ergonomics
DEFINITION
It is scientific study of the relationship between people and their working
environment. Term environment means environment, with tools, materials and
their methods of work and the organization of their work, either as individual
or working group.
Today’s women often carry responsibilities involving one hour of duty.
Women employed in industry or with major home care responsibilities can be
involved in variety of tasks requiring strong mental, physical, emotional and
social abilities. The careers of woman with a family is all faced with the
challenges of coin with prolonged demands on both their energy and time.
Some traditional female jobs in the work force are also susceptible to special
stresses, these include nursing, computer operation, repetitive work on an
assembly line.
There are many tasks performed by women in which the sitting or standing
position is maintained for long periods, if correct height relationships are not
assumed their posture is inadequate and static work by specific muscle groups
must be sustained for prolonged periods. Household and industrial tasks require
that the head, trunk or arms be held in antigravity positions or strain and
aching of the muscles of the shoulder girdle, neck and upper back may soon
result.
Many industrial task require repetitive small movements involving the
elbows, forearms, wrist and finger, if there is insufficient time for relaxation,
muscles are liable to fatique, soft tissue injuries. Shoulder susceptible to sub-
deltoid bursitis followed by repetitive shoulder motion, elbow to contusions
and bursitis due to rapid, repetitive forearm rotation and the wrist tendinitis
from repetitive movements of hand. Prolonged standing with poor posture can
also lead to the development or aggravation of leg pain, foot pain, arthritis and
varicose veins. Low back pain in women is also common.
Women are not as strong physically as men they cannot lift the same weight,
stretch or reach as far, nor they stand as straight, but work under same conditions
as men. So, they are prone for repetitive task and at greater risk of musculoskeletal
injury because of overuse of muscles involved, muscles strains associated with
the sustained posture to a large extent are the reasons for the occurrence of
injuries or the development of specific symptoms such as fatigue or pain can be
found in the neglect of personal requirements in design of the machine,
workplace or last.
It is, therefore, important to examine the risk to which women are exposed
to consider the areas presenting those risks, and to apply principles which
would ensure resolution of potential problem to health and welfare such an
approach is embodied in the practice of ergonomics.
Ergonomics is concerned with ensuring that the workplace is designed that
work-induced injuries, diseases or discomfort are prevented and safety is
ensured and that efficiency and productivity are maintained or increased.
AIMS OF ERGONOMICS
1. Reduce health and safety risks.
2. Ensure appropriate workloads both physical and mental.
3. Develop usable system and products
4. Achieve a good quality of working life and job satisfaction.
5. Increasing a good quality of working life and job satisfaction. Increase
productivity, e.g. by increasing output rate, decrease absenteeism, turn over
and improving quality.
Factors Causing Risk

For risk control and protection of the woman against musculoskeletal and
posture load, it is important to evaluate the risk in the workplace. Analysis of
workplace characteristics and identification of risk factors involve
considerations of the many factors, which could influence workload. These
could include:
1. The general layout
2. The design of implements
3. The task itself
4. The persons working technique
5. The general organization.
Ergonomics 33
Risky Areas
It is important to identify high-risk areas. Depending on the woman’s
circumstances in the home, these could be the kitchens, the bathroom, laundry
and the bedroom. High risk women involve lifting, e.g. a heavy household
implement, loads of washing or a small child, reaching a high-storage levels,
stooping to do gardening, to reach low storage or low electrical outlet or to
manipulate household objects, placing an infant into a car seat, bending over a
bath or cot, standing at the kitchen sink or at the ironing board.
All the above precipitating events of female back injury include working in
confined spaces such as toilet or bathroom, moving heavy objects with
insufficient assistance, carrying out tasks which are beyond the woman’s
capacity, acting hastily without consideration of safety measures and
transferring young or disabled children or elderly parents from one position or
level to another.
Lifting and Its Risk

The high incidence of low backache in women emphasizes the need to consider
closely the particular risks associated with lifting. The factors that influence the
load on the spine. These include:
1. The weight of the object to be lifted.
2. The horizontal distance from the body from which or to which it is lifted.
3. The body posture of the worker.
4. The duration of period of lifting.
5. The frequency of lifting.
6. The size and bulk of the object lifting.
7. The height or vertical distance of the lift.
8. The speed of the lift.
9. The stability and steadiness of the load.
Causes of Injury
Fatigue is commonly associated with pregnancy, especially in the first trimester
and at term, e.g. carrying loads and walking up slope are example of activities
which cause the fatigue. Fatigue can also affect posture, influence stability of
the spine.
Variety of approaches such as relaxation program, which include breathing
exercises, awareness of specific muscle activation for the maintenance of stability
may help a woman to cope with demands more effectively. Physiological
changes in pregnant woman’s weight gain and increase in abdominal depth
which can impose increased demands for postural alignment and can limit
performance and endurance of everyday activities and tasks.
ERGONOMICS APPLICATION
Once a risk has been identified, it is important to decide whether it can be
eliminated or minimized. It is better to eliminate the risk and this could be
achieved by changing the work process to remove the need for the activity
creating the hazard.
This often requires considerable adaptations, since most people develop
patterns of behavior and work, which can be difficult to change. It is the role of
the physiotherapist in controlling the risk and prevention strategies should
initially focus upon where woman herself will learn to identify and control risk
factors in her own work situation. If stress is high long-term planning can often
minimize the problem. At office stress could be alleviated during periods of
peak demand by directing telephone calls to an answering service at times. At
home too the severe stress can be relieved by careful planning of priority tasks.
ERGONOMIC SOLUTION
Solution to control the risk for injury in women at home or workplace by taking
into consideration of space requirement, dynamic and static posture, the physical
work load, the work environment and organization factors pertaining to
efficiency and stress reduction. The important aspect of the ergonomic approach
is the concern for careful specifications of the work—task relationship within
the design process so that the load on the locomotor system is reduced. It is
important to design the process to avoid peak strains and static loads.
SAFETY MEASURES
The physiotherapist must take care of woman involving in lifting children or
weight has persistent demands placed on her spine and need to show an
appropriate a safe method of handling which will ensure maintenance of
balance, postural control and avoidance of stress on the spine.
The physiotherapist advising on correct lifting procedures should
recommend the following practice:
1. Plan ahead.
2. Avoid lifting heavy objects alone, seek assistance.
3. Ensure adequate space is available.
4. Use a wide base of support.
5. Keep the weight close to the body.
6. Bend the knees and hips comfortably and maintain normal spinal curvatures
where possible.
7. Avoid lifting combined with rotation.
8. Minimize the distance over which the load is carried.
Physiotherapist should teach about alternative equipment and procedures
are available to substitute for manual lifting. These include walking belts, gait
Ergonomics 35
belts, use of slings for hand-gripping, mechanical hoists, e.g. hoyer, trans-aid,
ambu lift, power–driven overhead lift system. Out of these ambu lift is the most
effective.
If women working at hospital situation include bath shower grab rails,
sliding boards, overhead trapezes, hand blocks and drag sheets.
Alternative to lifting and pulling methods designed following a
biomechanical evaluation. One and two person pulling methods of transferring
patients are significantly less stressful.
Women need to receive advice an education on ergonomic principle which
they can apply to their own work situation using appropriate self-assessment
guides.
CHAPTER
8
Physiological Skeletal Changes
during Pregnancy
PREGNANCY WEIGHT GAIN

The amount of weight gained during pregnancy in kilograms is as follows.
Fetus is 3.36 to 3.88 kg, placenta is 0.48 to 0.72 kg, amniotic fluid is 0.72 to
0.97 kg, uterus and breasts is 2.42 to 2.66 kg, blood and fluid is 1.94 to 3.99 kg,
muscle and fat is 0.48 to 2.91 kg and the total weight put around is 9.70 to 14.55
kg (Fig. 8.1).
Fig. 8.1: Distribution of weight gain during pregnancy

Physiological Skeletal Changes during Pregnancy 37
PELVIC VISCERA, FASCIAE AND LIGAMENTS

The uterus increases from a prepregnant size of 5 by 10 cm to 25 by 36 cm. It
increases 5 to 6 times in size, 3,000 to 4,000 times in capacity and 20 times in
weight by the end of pregnancy. By the end of pregnancy each muscle cell in the
uterus has increased approximately 10 times its length prior to pregnancy.
Once the uterus expands it becomes abdominal organ. Uterosacral ligament
provide suspensory support for the uterus.
URINARY SYSTEM
Kidneys increase in length by 1 cm. The ureter enter the bladder at a
perpendicular angle because of uterine enlargement. This causes urine to flow
in a back into the ureter so chance of developing urinary tract infection because
of urinary stasis.
PULMONARY SYSTEM
Edema and tissue congestion of the upper respiratory tract occurs in early
pregnancy. Changes in rib position increases subcostal angle anteroposterior
and transverse chest diameter each increases by 2 m. Total chest circumference
increases by 5 to 7 m. The diaphragm is elevated by 4 cm. There is increase in
oxygen consumption to meet the increased oxygen demands of pregnancy.
Dyspnea is common with mild exercise by 20 weeks of pregnancy.
CARDIOVASCULAR SYSTEM
Blood volume increases by 2 liters during pregnancy and will come back to
normal by 6 to 8 weeks after delivery. Plasma volume increases than RBC so it
leads to physiological anemia, this to because of hormonal stimulation to meet
oxygen demands. Venous pressure in the lower extremity increases when
standing as a result of increased uterine size. Pressure in the inferior vena cava
rises in last trimester in supine position because of compression of uterus.
Aorta is compressed in supine position. Heart size increases and heart is elevated
because of movement of diaphragm. Heart rate increases 10 to 20 beats per
minute by 9 months and return to normal by 6 weeks after delivery. Cardiac
output increases in left side lying position, uterus has least pressure on aorta.
Blood pressure decreases in the first 3 months, still decreases by 5 months then
rises and becomes normal by 6 weeks after delivery.
MUSCULOSKELETAL SYSTEM
Abdominal muscles are stretched, muscle contraction is decreased, and shift of
center of gravity is decreased. Ligament strength is decreased because of change
in relaxin and progesterone level. Joint becomes hypermobile which leads to

joint and ligament injury, e.g. back, pelvis, lower limb. The pelvic floor muscles
must take weight of the uterus and pelvic floor drops by 1 inch, may be stretched,
torn during birth process. The degrees of incision in the perineal body is called
episiotomy. First degree is only skin, second degree includes underlying muscle,
third degree extends to anal sphincter, fourth degree tears into the rectum.
Pudendal nerve gets stretched when baby’s head comes out of birth canal during
second stage of labor so affects both muscles and nerves of the pelvic floor.
THERMOREGULATORY SYSTEM
Basal metabolic rate and heat production increases to 300 kilocalories per day
to meet metabolic needs of pregnancy. The fasting blood glucose levels will be
less.
POSTURE AND BALANCE CHANGES

Center of Gravity
The center of gravity shifts upward and forward because of the enlargement of
the uterus and breasts. Shoulder girdle gets protracted, upper extremity, internal
rotation because of breast enlargement, pectoralis muscles get tightened and
scapular muscles get weakened. Cervical lordosis increases in the upper cervical
spine a forward head posture develops. Lumbar lordosis increases for shift of
center of gravity, knees hyperextended for change in line of gravity. Weight
shifts towards the heels and bring center of gravity posteriorly. Child care also
causes faulty posture. So, correction must be emphasized at the earliest.
Balance
Woman walks with wider base of support, increased external rotation at the
hips, activities like walking, stooping, stair climbing, lifting and reaching will
become difficult.
Physiotherapy Assessment Chart 39
CHAPTER
9
Physiotherapy
Assessment Chart
The patient should be positioned facing away from the door and should carry
out the physiotherapy assessment in the private room where questioning cannot
be overheard and where there is no fear of intrusion for the other staff members.
The physiotherapy assessment should include:
1. Name
2. Age
3. Weight of woman
4. Occupation
5. Residential address
6. Doctor under consultation
7. Chief complaints if any, list the problems in order of importance as perceived
by the patient.
HISTORY
Medical History
Hypertension, cardiac disease, respiratory conditions, diabetes, hypothyroidism,
irritable bowel syndrome, back pain and cystitis.
Obstetric History
Long, active second stage, forceps, large babies, precipitate delivery, cesarean
section, prolonged epidural, episiotomies, tear –2nd, 3rd, 4th degree, close
pregnancies. Previous complications as premature labor, miscarriage, type of

delivery [vaginal, cesarean, assisted (forceps or vacuum extraction)].
INVESTIGATIONS
A. Urinary: Microurine, urine culture, cystoscopy, IVP, urodynamics.
B. Gynecological: Papanicolaou smear.
C. Anorectal: Barium enema, sigmoidoscopy, colonoiscopy, and anorectal
physiology, studies: EMG study, colon transit study, videoprocography.
PREVIOUS MANAGEMENT AND EFFECTS

a. Medical—drugs
b. Surgery—effect
c. Physiotherapy—define modalities
d. Other—diet, acupuncture, herbal remedies.
SUBJECTIVE ASSESSMENT
a. Fitness/obesity activities
b. Hormonal status and influence—Effect of menstrual cycle, lactation
c. Pain
d. Current medications—effects
e. Genuine stress incontinence
I. Urine loss on sneeze, cough, laugh, and lift, run, rising from a chair, sexual
activity.
II. Amount of loss—spot, wet pants, wet-clothing. If more than small amount
with each event the cause may be detrusor instability triggered by increase
in intra-abdominal pressure.
III. Midstream flows stop—note effect of attempted stop.
IV. Urethral hypofunction—intensive loss, greater loss with movement.
V. Aggravated by alpha-adrenergic blockers.
f. Urgency and urge incontinence
1. Sensory urgency: mucosal hypersensitivity, infection, and inflammation
2. Motor urgency: detrusor overactivity, instability.
I. Loss—large volume, frequency
II. Triggers—sexual activity, moving and bending
III. Ability to defer—less than 2 minutes, 2 to 5 minutes, less than 10 minutes
IV. Would you be wet if you did not go to the toilet immediately
V. Do you get wet as you try to undress
VI. Aggravated by caffeine, alcohol, and diuretics.
g. Overflow incontinence
i. Decreased detrusor contractility—hesitancy, slow to start, poor stream,
strain to void prolonged time to void incomplete emptying, frequent and
small voids
ii. Frequent urinary tract infections
iii. Retention/overflow—detrusor contractility, urethral obstruction
distended palpable bladder, pain, continual dribble loss day and night,
infection
iv. Self-catheterization
h. Reflex incontinence
i. Nocturnal enuresis
j. Fluid intake—amount of fluids and type small amount less than 600 ml and
large amount more than 3 liters intake
k. Frequency/volume chart—3 days recommended output greater than fluid
intak except in hot weather. Note minimum average and maximum volumes,
occasions of loss day/night ratio regular output less than 6 to 700 ml
indicates decrease bladder sensitivity and overstretch.
l. Anorectal function—frequency, awareness, urgency, puts off urge, strain to
empty completeness of emptying content consistency, pain where and when,
bleeding.
m. Diet—details of daily food and fiber intake like cereal, bread, fruit, and
vegetables, bulking agents, laxatives.
OBJECTIVE ASSESSMENT
a. Defecation: Position, stimulated pattern, waist, lower abdomen, lumbar spine
b. Muscle assessment:
Pelvic Floor Muscles

Muscles like perineal, pubococcygeus, puborectalis are good, moderate, weak,
none, comment
Pelvic Floor Assessment

This physiotherapy assessment is done to all aspects of the pelvic floor
dysfunction.
Digital Assessment
A waterproof underpad, covering sheet, vinyl or latex gloves, a bin is required.
The patient is positioned in crook-lying with a neutral lumbar spine, hips
abducted and feet apart. Through hand-washing must be done and open wounds
should be covered.
1. The perineum, noting scars and skin condition, excoriated skin indicates
sustained wetness or soiling
2. Ask the patient to tighten her muscles and draw in and around the introitus.
There should be closing of the opening and a lift towards the head.
3. Ask the patient to cough and observe any descent, bulging or urine loss
4. Gently stretch anal area, note skin tags and hemorrhoids. Observe skin
puckering and any perineal lift.
5. Separate the labia gently, slide the palmar surface of the fingers along the
posterior vaginal wall to full finger length check whether there is rectocele.
Watch patient’s face for signs of discomfort while doing this.
6. While pressing posteriorly, ask the patient to draw in strongly around the
vaginal opening and lift up towards your head. Feel the anterior shift.
This is the puborectalis
7. Palpate laterally to one side feel the medial shift and elevation. This is
pubococcygeus.
8. Check the superficial perineal muscle at the introitus. It is easier to detect
their contractions using fingers so feeling a compression effect.
The strength of the pelvic floor muscles can be taken as follow.
Grade-0—No movement palpable
Grade-1—Minimal or very small muscle bulging on palpation
Grade-2—Small range of movement, weak with brief hold
Grade-3—Definite muscle movements, up to half range
Grade-4—Firm muscle movement closing around finger, half to three quarter
range
Grade-5—Very firm muscles pull which compresses finger, full range and
strong hold.
Testing in standing and lying is also done.
Perineometers: Air-filled pressure probes is used to register vaginal pressure as

an indication of pelvic floor strength.
Perineal palpation: A hand held against the perineum can detect quite small
degrees of perineal lifts. This is useful way for girls and others to detect the
correct muscle action for them.
Stop test: The patient is asked to stop or slow the flow of urine in midstream.
This action probably reflects the strength of the periurethral and pelvic floor
muscles, intensity of the detrusor muscle activity.
Vaginal weights: Weights such as femina cones of increasing mass are developed
as a method of providing BFB and resistance for pelvic floor musculature.
Electromyography: This is the most effective method of objectively recording the
muscle activity and the data is collected by a fine wire or needle electrodes.
External electrodes are placed on the perineum records superficial muscle
activity. Surface electrodes are used intravaginally or intraanally in some
rehabilitation used as biofeedback mechanism.
Diastasis assessment: This is the separation of the rectus abdominis muscle in the
mid-line at the linea alba, the cause is unknown, but the continuity of the
abdominal wall disrupted.
Diastasis Recti Test

Position of the patient: Woman in crook-lying. Ask the woman to raise slowly her
head and shoulders off the floor, reaching her hands towards the knees, until
the spine of the scapula leaves the floor. The therapist places the finger of one
hand horizontally across the midline of the abdomen at the umbilicus. If a
separation exists, the finger will sink into the gap. The diastasis is measured by
the number of fingers that can be placed between the rectus muscle. Diastasis
can also present as a longitudinal bulge along the linea alba. Since a diastasis
recti can occur above or below or at the level of the umbilicus. This should be
tested at all three areas.
PHYSIOTHERAPY MANAGEMENT DURING
Antenatal Period
Period from the day of pregnancy confirmation to the 20 weeks of pregnancy.
Perinatal Period
It is the period just before and after birth; it is from 20 to 29 weeks to 1 to 4 weeks
after birth.
Puerperium
It is the final phase in the child-bearing continuum and is for the period of 6 to
8 weeks following delivery in which women’s genital tract returns to a non-
pregnant stage.
Postnatal Period
This is the period after puerperium from 8 weeks to 6 months.

• Physiotherapy treatment plan
• Aims of physiotherapy
• Plans of physiotherapy
• Home program
• Next appointment.
CHAPTER
10
Relaxation
DEFINITION
The ability to relax is called relaxation.
Relaxation is spending quiet times, spent listening to music or reading a
book, allow mother to tune into baby and be away from the other distraction of
her life.
Relaxing women’s body and mind during pregnancy create a sense of well-
being. It allows physical recovery and helps to prevent the tension that can lead
to high blood pressure. It also helps the parts of women’s body that may ache,
e.g. back, legs, abdomen, and rest from the extra weight and effort of holding her
body upright because it sharpens women’s mental faculties and releases natural
painkillers. It can be particularly helpful in managing her in labor.
A relaxed body is closely linked to a related mind. Stress and worry can
manifest as headache or backache while physical pain or exhaustion increase
worry and stress. Throughout pregnancy a woman should try to find a little
time everyday to devote to herself. By doing this, she will feel more energetic
towards her work. Try to get plenty of sleep. If women’s work situation is so
stressful that she is finding it hard to cope, should take to the employer about
starting the maternity leave early or working part-time for a while.
PRACTICING RELAXATION
Relaxation is very simple. The art of relaxation lies in taking time for practicing.
Relaxation can be practiced for a period of 15 to 20 minutes in the morning, or
after return from work or, after bath, or before going to the bed. Relaxation time
is never go waste because it helps woman to take up the responsibility of mother,

handling of newborn with free of stress and to cope in all areas of daily living.
RELAXATION TECHNIQUES
These are some of the ways, which can be practiced any where any time in
sitting, lying positions. They are:
1. Raise your shoulders up towards your ears count five and go back to initial
position.
2. Bring shoulders to front and then back to normal and take them each five
times.
3. Try to bring both the eyebrows near to each other as you are frowning, press
your lips and tighten your eyes, hold them and count five and release them.
4. Relax all the features of face one by one.
WHOLE BODY RELAXATION (FIG. 10.1)

Breathing techniques and general relaxation are very much useful for a woman
during her pregnancy, breathing techniques can be used as an instant-free of
stress followed by general relaxation. Take time in a day and try to spend
minimum of 10 minutes or more on focused relaxation. Find a quiet spot and lie
comfortably with a small pillow under head lie down in a calm area, lose your
idea and try to imagine each part of your body and relax them part by part.
Fig. 10.1: Whole body relaxation
Procedure
Woman in supine-lying or half-lying, the mind is concentrated on normal
breathing. All the major and minor parts are mentally viewed, their shapes are
recalled and visualized, and let loose one after another continuously in the
following sequence.
Relaxation 47
Upper Limb
Thumb—forefinger—middle finger—ring finger—little finger—back of the
palm—the palm—wrist forearm—upper arm—shoulder (both sides).
Lower Limb
Big toe—second toe—third toe—fourth toe—little toe—the upper part of the
foot—sole—heel—ankle—calf—knee—thigh—thigh joint (both sides).
Back
From the bottom of the backbone to the neck—the right side of the back—the
back of the right shoulder—the left side of the back—the back of the left
shoulder—the back of the neck.
Abdomen Chest and Throat

Navel—the left side of the navel (including urinary organs)—the right side of
the navel—the upper side of the navel—the central part of the chest—right
breast—left breast—the pit below in the throat—throat.
Head
Chin—lower lip—tongue—right nostril—right cheek—right ear—right eye—
left eye—left ear—left cheek—left nostril—tip of the nose—the center of the
eyebrows—forehead—right side of the head—back of the head—left side of the
head—top of the head.
Each part should be concentrated for 10 to 20 seconds. The shape should be
visualized by the mind with closed eyes. While looking so, the concentration
spot should be freely let loose. The entire process may be completed by 15 to 30
minutes. This is called one round.
ADVANTAGES
1. It helps in relieving stress and tension.
2. It helps in getting peaceful sound sleep.
3. Mind and body gets complete rest. They are totally relaxed.
4. Quality of sleep improves, sleep duration is reduced, time is saved.
5. Tiredness of the body is relieved.
6. All the part of the body are relaxed to their maximum and they are re-
charged with energy.
7. Tension, anxiety, depression, stress, strain, negative thoughts, high blood
pressure are controlled.
8. The woman feels physically stable and mentally peaceful.

9. Memory, will power, inner energies and knowledge are developed.
10. Regular practices play a big role in the higher practices of concentration,
meditation and self-realization.
In the later stages of pregnancy the women can be comfortable in side-lying.
Always end your relaxation session slowly, gently, yawning, stretching, and
shaking your limb and woman can adapt this everyday irrespective of place
whenever she feels tensed, so first concentrate on breathing slowly and
rhythmically, breath in through nose and breath out through mouth, relax the
shoulders by raising up, down front, backwards positions, tighten your fingers
and loosen them, speak softly if she has to so. This quick relaxation technique is
very helpful during labor and birth and in the early weeks of motherhood when
the baby is crying or mother having sleepless nights with baby. This helps in
relieving the tension situation and helps the mother to tackle the situation of
her baby well.
TRAINING FOR LABOR

Relaxation techniques play a major role in preparing the woman for labor.
Tension in any part of the body will make her labor difficult, e.g. if woman’s
neck and shoulders are tensed or if she is clenching her teeth or fit it will effect
her birth canal in such a situation partner can help her to get through she will
be free to concentrate on relaxing her abdominal muscle.
Antenatal educators generally teach relaxation techniques and also will
explain what should be expected from labor, thereby reducing the fear of labor
which is perfectly natural in women before they expect her baby to come into
this new world. Fear cause the body to tense, making delivery more difficult by
producing a cycle of fear–causes tension and pain. Thus, relaxation is vital
throughout pregnancy, delivery and postpartum period.
CHAPTER
11
Breathing Techniques
DEFINITION
Taking air in through nose and leaving out through nose is called breathing.
IMPORTANCE OF BREATHING TECHNIQUES

Breathing techniques are most important during pregnancy and labor. In a
non-pregnant woman the air consist of oxygen which passes through the walls
of the lungs enters the blood stream and circulates through out the whole body
giving nourishment to the internal organs there by purifies the blood in and
also takes the metabolic waste products in the form of carbon oxide which is
breathe out through nose. In a pregnant woman the oxygen also passes through
the walls of the womb into the placenta where it supplies oxygen to the growing
baby and the metabolic waste products of the baby are carried in the form of
carbon dioxide to the lungs of mother.
During this procedure the diaphragm moves up and down. Thereby giving
massing effect to the internal organs and muscles. Irregular breathing leads to
irregular movement of the diaphragm and overall performance and function
reduces. Taking breaths to fast causes residual air will be left over in the body,
which impedes the flow of oxygen, the rest of the body and to the baby.
TECHNIQUE-1
Breath in through the nose and breath out through the mouth and during the
muscle contraction never hold the breath as this can impede the blood flow and
cause dizziness which is very dangerous especially when women is pregnant.

So breathe moderately deep and regular.
When relaxing, concentrate on breathing and this comes through the practice
of meditation, first stage called breath awareness. It is the step of concentrating
the mind through breath awareness.
Preparing to feel the touch of breath: the back of one palm is placed very ear
to nose, with out touching, breath in normally and breath out forcefully, the
touch is felt on the skin of palm. this is done for 2 to 3 minutes.
TECHNIQUE-2
Each of the following steps should be practiced for 2 to 5 minutes.
1. Either sitting comfortably or lying, the breath is inhaled and exhaled in
natural way. The touch of breath should be felt on the skin inside the nostrils
while inhaling and exhaling. This should be felt continuously for few
minutes.
2. The coolness should be felt in the nostrils while inhaling and the warmth
while exhaling. The cool and warmth feeling should be continuously felt
inside the nostrils for sometime.
3. While breathing in, it should be felt that the body is being energized by the
oxygen that is inhaled and while breathing out, it should be felt that the
impurities of the body and mind are sent out in the form of carbon dioxide.
The woman should feel that his body is energized, the mind and body are
purified with every breath continuously for sometime.
4. The divine bliss should be felt entering inside while inhaling the breath and
while exhaling it should be felt that, the pains, sorrow, diseases, agony and
tension are being eliminated with every breath continuously for sometime.
5. While breathing in it should be felt that the noble qualities such as love,
affection, friendship, kindness, sympathy, etc. are being further developed
and while breathing out the negative tendencies such as anger, lust, passion,
hatred, jealousy, ego, etc. are being eliminated from the mind. Thus, every
breathe one feels that she is becoming better person.
6. While inhaling, the mind should follow the breath, through the nose, throat,
windpipe and deep into the lungs. Similarly, while exhaling, the mind should
start from the lungs, pass through the windpipe, throat and nose and go out
of the body. The mind should follow the breath, continuously for sometime.
Practicing the above six processes, it should be tried gradually to acquire
efficiency in them in few days. It may take generally three to four days. Each
process is to be practiced two-to-five times at the beginning.
Breathing Techniques 51
Advantages
The main purpose of the above activities is to make the practitioner in
1. using his time in a better way for a good cause.
2. developing concentration
3. making the meditation techniques easy
4. giving up the ill thoughts.
5. reducing the depression and anxiety in the mind.
6. strengthening the welfare and good thoughts etc.
Second Method
Breathing techniques can also be practiced this way (Figs 11.1Ato C):
Level-1: Sit in a relaxed position. Hold a feather about 15 cm (6 inches) away,
slowly breathe out so that the feather should flutter slightly but remain upright.
Level-2: The feather should move more rapidly and should bend slightly but
perceived away from the practitioner.
Level-3: The feather should clearly bend away from the practitioner.
A B
Figs 11.1A to C: Breathing technique—second method

TECHNIQUE-3
Level-1: Sit in a relaxed position so that your partner can place the palms of his
hands against your back just below the waist he can either sit in front or back.
Woman can lie on her side with him sitting or lying next to her. He should feel
the slight movement under his hands when she is doing level-I breathing
correctly. Ask him to move his hands up, so that they are in the middle of her
back behind her ribs.
Level-2: Breathing should cause movement under his hands here.
Level-3: Breathing her partners hands should be below her nape where he should
feel very slight movement (Figs 11.2A to C).
B
A
C
Figs 11.2A to C: Breathing technique-3
Breathing Techniques 53
Breathing during Labor

Controlled breathing is taught as a technique for managing the pain of
contraction in labor. Breathing regularly helps her to avoid the tendency to
tense up with fear and discomfort, which then increases pain. To prepare for
childbirth, different ways of breathing are there when labor begins, these
techniques will offer a way to work with her body and adapt as the demands
upon it changes.
Level-1: Relax and start breathing in and when she breaths out make a little
more effort than she would normally do. All the air in her lungs are being
emptied out. Breathe in and breathe out again in the same way, keeping the
slow, regular, gentle rhythm. Breathe this way between contractions.
Level-2: Use this as she feels a contraction coming. Breathe a little more quickly
and do not empty your lungs as you exhale. Continue breathing quickly without
emptying your lungs completely through the peak of the pain. As she feels the
contraction ending revert to slower breathing so that when the contraction is
over, she will be at level-1. Signal the end of contraction with a long breath out.
Level-3: During transition or towards the end of the first stage of labor, her
contraction may be intense requiring all her strength and concentration. Quick,
shallow breathing will help. Breathe in quickly and blow out then breathe in
quickly again. Some women will find it help to vocalize on the breathe out, say
hoo hoo as she does so, to maintain rhythm and concentration.
CHAPTER
12
Massage
DEFINITION
Massage is the systemic and scientific manipulation of the soft tissues of the
body
It is rubbing and kneading of the body to reduce pain and stiffness and
gives relaxation. Massage is a soft tissue technique. Massage has mechanical,
chemical, physiological and psychological effects. Which has effect on muscles,
ligaments, tendons, fascia and skin. Massage stimulates, refreshes, relaxes and
gives comfort. It is pleasurable. Massage has therapeutic benefits. It improves
circulation, alleviates digestive and excretory problems and helps with minor
aches and stiffness and encourages sleep.
Massaging a partner is a wonderfully intimate thing to do. Using a light
lotion or vegetable oil including a few drops of essential oil which makes
massage more pleasant and relaxing can do this. But during pregnancy weaker
solution of essential oil should be used to allow for increased skin sensitivity
and to prevent damage to fetus. So, make the skin smooth and soft use essential
oil with carried oil and also add vegetable oils.
CLASSIFICATION
Massage is broadly divided into four categories. They are:
1. Stroking: Includes stroking and effleurage
2. Friction: Includes circular, transverse
3. Pétrissage: Includes kneading, picking up, wringing, rolling, shaking and
pounding
Massage 55
4. Percussion or tapotement: Includes clapping, hacking, vibrations, beating and

tapping
INDICATIONS
Lower limb edema, constipation, and muscle relaxation.
CONTRAINDICATIONS
Hypertension.
MASSAGE TECHNIQUES
Some of the techniques are:
Stroking
This is performed with the whole hand or fingers. It comprises of the moving of
the relaxed hand or fingers over the patients skin with a rhythm and pressure.
Effects
Relaxing and sedative effect.
Effleurage
In this technique, the hands pass over the skin with pressure and speed that is
both soothing and will assist fluid to flow through tissue spaces, lymph vessels
and veins. The hands move in the direction of the lymph and venous blood flow
(distal to the proximal in the limbs and generally each stroke ends at the site of
a group of superficial lymph glands. It can be done on both upper and lower
limbs.
Effects
1. It helps in removal of edematous fluid from tissue spaces into lymph vessels.
2. Increases tissue fluid, lymph and venous flow.
Kneading
In this technique the hands are placed on the skin and allowed to mould to the
part, then they move in a circular direction with pressure gradually applied
over the top of the circle and released towards the bottom of the circle. The
hands move the muscles and subcutaneous tissues applying alternate
compression and release. To localize the effects the fingers and thumbs may be
used.
Effects
1. This helps in increase in flow of blood circulation.
2. Reduce tone of muscle, which are in state of excess tension.
3. It reduces chronic edema, when fibrin within the fluid can be stretched, so
facilitate drainage of fluid into lymph vessels.
Hacking
It is the manipulation done using the ulnar border of medial three fingers.
Effects
1. This helps in stimulating muscles and organs.
2. Helps in maintaining tone of the muscle.
3. Helps in increasing blood circulation.
MASSAGE SESSION
Lie on side. Bend lower leg slightly and draw upper leg up to a 90 degree angle,
bending at the knee, place a cushion under the bent knee. Place other pillows or
cushions around body to aid for comfort, one under head, one under abdomen
or shoulder. The massager should kneel or lie beside the woman.
1. Start with the back and use effleurage on either side of the backbone move
from the waist to the shoulder and back again covering the sides of the back.
Repeat the sequence.
2. Grasp and squeeze the flesh of the back all over, starting from the spine and
working towards the side, first on one side then on other side.
3. Kneading manipulation with whole hand, fingers and thumbs too all over
the back. The press should be quiet firm, make sure that the manipulation is
not uncomfortable.
4. Repeat the same sequence of manipulations on the buttocks.
5. Now continue over the rest of the body including hands, legs and feet.
6. The abdomen can be massaged gently. Using the flat of your hand, apply
light circular strokes. First works around the navel then work outward from
it, concentrating on keeping the movements flowing and rhythmic.
SELF-MASSAGE
The manipulations done on her own body called self-massage. This is done to
relieve tension and energize at any time required. Basically, this is stated with
face and ends with legs.
Massage 57
Face
The manipulations used are stroking, effleurage, finger kneading, etc. Massaging
the face is the gentle way to relieve headache. Use a mild oil to avoid stretch to
the skin. Place hands over the face and stroke slowly out towards the ears. With
the eyes closed, move hands up the cheeks, make small circles over forehead
with the tips of the fingers, and smooth the fingers up and across eyebrows.
Neck and Shoulders

The manipulations used are stroking. Relieve stiffness and aching by stroking
down one side of neck, over the shoulders and down the arm to the elbow.
Repeat the same on the other side.
Legs
The manipulations used are stroking, effleurage, squeezing, etc. Use smooth
movements from the ankle to the thigh. Squeeze and release the flesh on the
thighs and calves, and then stroking is done to relieve cramps. Effleurage is
done to relieve edema where fluid is drained into the nearby lymph nodes.
CHAPTER
13
Embryonic and Fetal
Development
The childbearing year is a term defined as, the time from conception to
postpartum adjustment. Pregnancy is divided into three trimesters. Each
trimester consists of three months and there are totally four trimesters, i.e. nine
months of pregnancy plus the first three months after the birth of the baby.
THE FETUS
Fetus Physiology
This is the function of human body in the first 38 weeks from the embryonic
period with active growth and maturation to till past birth into infant and
adult. Inside the uterus the fetus is well-protected, living in a gravity-free
environment, suspended in amniotic fluid. There is no light, temperature, very
little touch, sensation and sound. This is separated from the extra-uterine life
by the process of uterine contractions and passage down the vagina called
labor.
Fetal Growth
A single-celled ovum is produced and gets fertilized by a sperm. The fetus
grows completely by 38 weeks and cells multiply to 6 billion cells, and growth
is very fast.
Placental Size and Function

Large placenta are associated with a large mean birth-weight. The fetal/
placental weight ratio increases from 32 weeks, the fetus growing faster than
Embryonic and Fetal Development 59
the placenta late in the pregnancy the fetal growth rate while that of placenta
continues to grow at a slower rate.
Sex
Till last week of pregnancy in both male and female fetuses grow at same rate.
After 32 weeks male grows rapidly and by 38 weeks will be 150 grams heavier.
Maternal Nutrition
Extreme malnutrition leads to diminish fetal growth.
Fetal Circulation
It starts by age of 21 days.
Renal Function
Kidneys do not have vital role during intrauterine life. After birth and removal
of placenta baby will be able to excrete nitrogen waste products and controlling
salt and water balance soon.
Central Nervous System

It develops early in fetal life between 12 and 16 weeks of gestation.
Peripheral Nervous System

Ganglia and nerves appear in human embryo between 28 to 35 days.
Skin Physiology
Skin is major organ of water balance in early pregnancy.
Alimentary Tract
During intrauterine life, nutrition is provided through placenta and alimentary
tract has no immediate functions.
Respiratory System
Breathing movements are present in the fetus from 11th week of gestational age.
Placental Transfer
Nutrition come from the mother’s blood across the placenta, fetal katabolites
are passed back into the mother’s circulation and disposed by mother’s kidney.
Water Transfer
Transport between mother and fetus, placenta and amniotic fluid occur by
perfusion exchange.
Gas Transfer
Respiratory gases (oxygen and carbon dioxide) cross the placenta by simple
diffusion.
Fetal Hypoxia
Diminution of oxygen and increased carbon dioxide concentration due to
impaired gas exchange.
Carbon Dioxide Transfer

Glucose is a major substrate for energy production and metabolism in the fetus.
Amino Acid Transfer

Amino acid levels in fetal blood are higher than maternal circulation.
Fat Transfer
Fats are insoluble in water and carried in blood stream as free fatty acids to
albumin or lipoprotein. Placenta picks up fatty acids and phospho lipids and
converted to simpler forms in the membrane.
THE FIRST TRIMESTER
The first trimester of pregnancy is first three months of pregnancy. The pregnant
woman will be experiencing. During the first three months of your pregnancy
you will experience:
• The excitement of learning that a new life has begun.
• Physical changes that nurture the unborn baby.
• Hormonal shifts that aid the formation of the baby’s major organs.
• Mood swings—mind and body adjust to new role.
• This is the time to choose the physiotherapist for guiding antenatal care.
THE FIRST MONTH

This is the period from first day of the last menstrual period to six weeks
duration.
Mother
The first month includes the menstrual cycle before implantation and the body
will be preparing the womb for the potential pregnancy, then fertilization takes
place, the blastocyte divides and travels down to the fallopian tube hormones
cause the endometrium to thicken making the uterus ready for implantation,
once the implantation occurs hormones suppress ovulation. The woman may
not be aware that she is pregnant and will be waiting for the positive signal as
the indication is going for a pregnancy test after forty-five days to three months
(Fig. 13.1).
Baby
Five to seven days after the egg is fertilized, the blastocyte reaches the womb
and becomes embedded in the lining of the womb called embryo. The embryo
secretes its own protective substances which helps the mother’s body to accept
the baby, because the immune system is getting activated, this is possible. The
baby’s genetic make up comes both from the parents sharing 50 percent of
genes that will produce the antibodies in the mother’s body.
The outer cells of the embryo start to reach out in the following week,
attaching to the mother’s blood cells and forming the first lining with the mother
system. This causes formation of chronic villi, which becomes placenta later.
The human choronic gonodotrophin that circulates is produced and
circulates throughout the mother’s body and appears in blood and urine too.
The inner cells of the embryo starts dividing into three layers, the blastocyst
increases in size from full stop to 6 mm in diameter.
• 5–7 Days: The blastocyst settles in the uterine wall
• 12–15 Days: Chronic villus, shape of umbilical cord and baby starts
appearing.
• 21 Days: Somites or sections of tissue form that will become nerves and
muscles of the embryo.
• 26–27 Days: The organ, limb buds, head with a mouth and eyes appears.
Total Weight Gain

Some woman start to put on weight right from the first month itself and will be
nearly one kg or 21 lb or more in the hips, breast and thighs. Because mother’s
baby need extra-weight to sustain during pregnancy and breastfeeding. A
woman totally will put on 10 to 16 kg or 22 to 35 pounds of weight, most of this
in the second trimester. In the last few weeks 250 grams or half pound will be
accumulated.
Pregnant woman should be strict regarding weight gain, so should have
control on their weight which should be increased steadily, need a healthy diet
Fig. 13.1: The first month
and a good level of fitness, thereby prevents varicose veins and backache.
Woman will be normal regarding body and womb in the first pregnancy and
would not be obvious at the end of the first month.
THE SECOND MONTH

This is the period from 7 to 11 weeks duration.
Mother
Placenta starts functioning completely. The feeling of nausea and constipation
starts because of the hormones level increases. There will be increased demand
on the circulatory system, which produces 21 ml or 3 pints of blood in the
course of the 40 weeks because of this woman become puffy and will regularly
urinate. Sickness starts and causes loss of appetite and contribute to feeling of
fatigue. Woman’s priority is to eat well and to take plenty of rest. There is every
chance of miscarriage in one in six pregnancies so the good news can be told to
every one only after the end of third month with confidence (Fig. 13.2).
The Placenta
Placenta is the baby’s life-supporting system, develops in the second month
and will be functioning completely by 10 to 12 weeks and function of the
Fig. 13.2: The second month
placenta is to collect oxygen and nutrients from mother’s blood stream,

processing them and passing them on to the baby. Bring out baby’s waste
including carbon dioxide that returns across the placenta for disposal. It also
acts as a filter clearing out harmful substances before it reaches baby. But sends
the immunities of mother through placenta to protect the baby a mother.
The placenta develops from the chronic villi. The chorion becomes the outer
surface of the sac and placenta to hold the embryo, the finger-like villi grows out
of the chorion, on one side the villi burrows into the uterine wall to receive
nourishment from the mother and on the other side becomes flat. It reaches to
full thickness in diameter of about 2.5 cm or 1 inch by the 16 weeks and weighs
about 500 grams or 1 pound and is about 20 cm or 8 inches by the time of
delivery.
Baby
Between the 7th and 11th weeks of pregnancy, the embryo is recognized as
human form by the 8th week, head develops and is bigger than rest of the body
and bends forward to the chest, the spine is straight. The tail will become shorten
and disappear.
The embryonic period is complete by the 10th week after conception, after
this baby enters into the fetal stage called fetus. So, formation of internal organs
like brain, nervous system, and skeleton which is very important occurs in this
month.
The embryo contains three layers of cells. The baby’s nervous system starts
to form when the top layer folds into tube and form as neural tube from this
baby’s spinal cord and brain will develop. In the second month, the second
layer of cells forms major internal organs like lungs, liver, kidneys and digestive
system will get established well. The third layer the embryonic cells become the
heart, fetus has its own blood vessels some blood vessel get connected to the
mother’s blood system in the uterine wall and this becomes umbilical cord later
which holds blood vessels and source of placenta to send and take away the
required material of the baby.
The umbilical cord has elongated and the fetus will be floating freely in the
amniotic sac, which protects the baby throughout the pregnancy. The limb
buds get extended and will be recognized as arms, legs and the depressions
seen in the hands and feet show the fingers and toes. The facial features become
more obvious, mouth and tongue are formed, eyes and nostril which are formed
at the sides of the head are now at the front and the ears at the neck towards the
head. By the eighth week the embryo becomes round shape and ultrasound
scan shows heart beating. At the end of ninth week the embryo grows double
the size of before and measures about 16 mm.
THE THIRD MONTH

Mother
Pregnancy sickness decreases by 14th week the levels of hCG drops. Breast will
become larger and more tender than before and color of the face and body
changes. Uterus moves slightly up because the organs in the pelvic area are
being displaced, so woman may notice a small bump in the abdominal area.
Tiredness will be common in the first trimester. So, have plenty of carbohydrates
to have energy and diet must be a well-balanced diet. Take frequent meals, and
never skip a good breakfast. Try to eat number of small meals, nutritious snacks
throughout the day if having and small appetite. Avoid tea, coffea, cola and
eliminate alcohol (Fig. 13.3).
Try to take rest at frequent intervals, and snap in the afternoon will make
evening fresh. Be sure work is stress-free, go for a brisk walk, travel safely in
bus, avoid standing and sit in a seat if possible, avoid rush places. If having
sleeping problem try out relaxation, meditation and find out the cause and rule
out. Share your problems with your partner and any fears regarding child birth,
in the evening go for a brisk walk, listen to music, read books and watch a
Fig. 13.3: The third month
favorite movie, try out for a fruit tea or warm milk, a warm water bath with a few
drops of lavender essential oil added which also gives relaxing effect.
Baby
All the baby’s organ and limbs are completely formed by the end of the 12th
week. Growth and maturation of the baby occurs in the preceding weeks.
Function of placenta is full, hormones function well. The umbilical cord is
barrier between baby and mother to carry nutrients and remove metabolic waste
products. Baby has more space to move and float in the amniotic sac which is
about 100 ml and also functions as supplying nutrients, maintaining sterile
environment at constant environment and protecting from blows and jerks.
Baby swallows little amniotic fluid and the development of sucking reflex takes
place and moves lips, which is called as first stage of development.
The baby also produces drops of sterile urine which is removed by placenta.
The fingers get separated and hands are fully-developed with cuticles but finger
nail are not yet developed. If the baby’s position allows the gender of the baby
can be known with the help of ultrasound scanning because the external sex
organs are now developed. Skeleton is made up of soft cartilage and complete
in structure. The baby’s face has tiny nose and chin, the eyelids have developed
over the eyes. The teeth are present inside the gums. Ears are developed well. At
the end of 14th week the baby will be 3 inches long or 80 mm as size of small
pear. The baby’s hands are 6 mm or ¼ inches long with full development and
recognizable.
THE SECOND TRIMESTER
As the new life starts growing it becomes obvious to all, the second three months
are best. During this period:
• Mother hair shines and skin glows.
• Tests conform baby’s health.
• Mother will be conscious of baby moving and growing.
THE FOURTH MONTH

Mother
The discomforts of pregnancy are reduced and mother feel energized. By the
end of the fourth month the uterus size increases to twenty fold in size and will
rise out of pregnancy. The circulatory changes will bring puffiness in the face
because of water retention; woman may feel thirsty and perspire more because
blood volume increases because of increased production of body fluid and
corpuscles. Size of heart increases and pumps more powerfully to move a greater
volume of blood throughout the body. The skin pigmentation occurs because of
the hormonal circulation in the body. Moles and freckles start appearing and
become more prominent. A dark line called linea nigra appears from navel
down the center of abdomen to the top of pubic bone. Nipples get darken and
areola may begin to spread across the breast. The color fades after birth of baby.
Facial color also changes; light patches appear on forehead, nose, and cheeks
appears as mask. Stretch marks on abdomen appear which are pink or red in
color (Fig. 13.4).
Baby
The baby starts moving vigorously and energetically with arms, leg, head and
torso rolling and kicking. The mother may not perceive the movements of her
baby because of amniotic fluid or water. This is absent in the first pregnancy
and baby movements are felt in the second pregnancy because of abdominal
muscles become lax. Baby’s major organs start working and heartbeating is
around 120 to 160 beats per minute.
Fig. 13.4: The fourth month
Eyebrows and eyelashes start to grow. The baby’s hair begins to grow by 16
weeks. Soft inner hair called lanugo also grows all over the body and it functions
as protecting the baby and also maintaining skin temperature. The baby will be
17 m or 6 and ½ inches long and weighs about 140 grams or 5 ounces. The baby
will be aware of the sound and light which can be perceived in the uterus as a
faint, reddish glow, heartbeat can also be heard. Pregnancy can be noticeable
and abdomen become round.
THE FIFTH MONTH

It is the period between 20 and 24 weeks.
Mother
The woman looks like pregnant and will feel energetic and healthy, skin will be
clear. Hair will be richer in oils, become thicker and glossier and there will be
hair loss throughout the pregnancy. The mother gets the feeling of baby
movements, which are fluttering initially and later becomes strong and frequent
as the days and weeks goes on. This sensation is called quickening. These help
in formation of healthy limbs and muscle tissue. Movements are only felt when
the inner wall of the abdomen is lose to the outer wall of the uterus. Kick is felt
when the baby is facing outwards. As pregnancy comes to end, baby cannot
change the position frequently because there will be less space available for
active kicking and punching. The best time to feel the movement is a couple of
hours after a meal. Lie down and put either mother’s or partner’s hand on the
abdomen. Count the movements 10 in 10 minutes. This is indication that fetus
is in good health. When baby is sleeping she will become quiet. If mother cannot
feel the movements have a glass of juice and lie on left side. If still not felt then
consult obstetrician (Fig. 13.5).
Fig. 13.5: The fifth month
Baby
Baby movements will be more energetic, activated more complex. From this
period onwards till the end of pregnancy the baby recycles the amniotic fluid in
womb, by swallowing excreting through his or her bladder and urethra. In this
way the baby exercises immature swallowing and digestive mechanisms.
Around 20 weeks the baby’s skin develops, and a greasy whitish substance
called vernix is present all over body till the birth. Babies born after 37 or 38
weeks it gets diminished.
Premature babies will have more than normal. The function of vernix acts as
waterproofing and helps to maintain the skin texture and temperature. The
muscle tissue becomes stronger and skeleton becomes bonier. Babies can hear
more clearly and baby jump in response to a loud noise. The teeth are present in
the jaw and most babies are born with no teeth but occasionally with one. The
baby’s hands and feet are well-developed to flex the toes and suck fingers.
THE SIXTH MONTH

This is the period from 25 to 28 weeks.
Mother
The uterus grows rapidly and weight is gained quickly. Mothers will be healthy
fit and will maintain a high level of activity. Woman should be careful not to
exhaust themselves because the heart and lungs will work 50 percent harder.
Woman starts to produce colostrum or early milk for some little of milk leaks out
from nipple. The baby’s heartbeat can be heard clearly either with the stethoscope
or putting ear on the abdomen a listening to beat. The influence of estrogen and
progesterone in the first five to six months of pregnancy, the milk duct system
expands and more lobules are formed. As the lobules enlarge, protein starts to
accumulate in the cells lining the alveoli. In the later pregnancy and after
childbirth, a yellowish watery substance that contains proteins, sugar and
antibodies. Milk is not produced until after the birth but the breasts are capable
of producing milk after six months, so when woman give birth to premature
baby milk can be fed (Fig. 13.6).
Baby
Baby will be growing continuously and has very little fat, so looks thin, but
becomes bigger and stronger and if baby is born can survive at this stage but
lung are not mature enough to function alone, if baby is born as early as this,
neonatal intensive care is required. At 25 weeks the baby will be about 34 cm or
13 and ½ inches long and weighs about 600 grams or 21 oz. There will be
creases on the soles of the baby’s feet and on the palm of his hands. A unique set
of fingerprints start to appear on the fingertips. The eyes open by 25th week and
baby starts responding to light. The baby’s skin is translucent because does not
contain body fat.
THE THIRD TRIMESTER
• This trimester becomes increasingly excited to feel the baby moving, kicking
• For some women this trimester passes slowly
• This trimester causes discomfort and contributes to fatigue
Fig. 13.6: The sixth month
• The third trimester is a time of rapid growth and maturity for the baby. The
baby will be strong and healthy.
• If the baby is born in the beginning of this trimester then he or she need a lot
of specialist care to survive.
THE SEVENTH MONTH

Mother
Woman will be healthy and energetic and will have swelling around face,
hands and ankles because of retaining fluid. And must have a regular checkup
or it leads to pre-eclampsia means severe swelling, high blood pressure and
protein in the urine. The skin of the abdomen will feel stretched and thin because
of pressure on diaphragm and bladder by the baby. Breast will secrete little
colostrum, woman should go for a blood test, check for rhesus antibodies and
anemia to find out if the baby is at any risk. Babies born before 37th week the
cause is unknown and can be due to mother’s habits of cigarette smoking,
alcohol abuse, drugs, poor diet, inadequate weight gain, high blood pressure,
diabetes, heart problems, carrying twins or triplets, exposure to synthetic
estrogen drug, babies born before 23 weeks rarely survive, at 24 weeks half
survive, at 25 weeks 50 percent survive, 26 weeks 75 percent survive, 28 weeks

85 percent survive, 35 percent are fine (Fig. 13.7).
Fig. 13.7: The seventh month
Baby
Will be started to produce fat in the seventh month, so skin looks less-translucent
and papery because of fat beneath the outer layers and functions as energy for
survival during her first few days of life and help to regulate her body
temperature, baby looks very small and skinny. Lungs start getting mature,
baby is born has to survive on respirator. The baby’s head starts to look more in
proportion to the rest of the body and cheek are formed. In baby boy the testes
descend into the scrotum by 29 weeks. Baby’s thighs and arms become chubbier
because of fat deposition and baby measures about 40 centimeters or 16 inches
in length and weighs about 1.3 to 1.8 kilograms or 3-4 pounds.
THE EIGHTH MONTH

Mother
The uterus bulges above the ribcage and the navel may have popped out. Mother
has to go regularly for the antenatal visit. The ultrasound is one to check the
placenta, if it is low then the condition is called placenta praevia. Depending

on this the decision can be taken whether the birth is normal or can be cesarean
because placenta blocks the way for the baby to get out. The baby’s position in
the uterus becomes increasingly significant. The baby moves around a lot and
can be in any position in the uterus. At rest they are in breech position, it is feet
or bottom towards the vagina. By the end of the eighth month 95 percent have
turned around to be in a better position for birth. This head own position is
known as vertex or cephalic position for birth. If baby is still at the breech
position the baby is changed and turned manually using the ultrasound
guidance called external cephalic version. The baby’s eyes will be in blue or
brown color and it changes after birth. Extra fat makes the baby plumper and
rounder and skin becomes less-wrinkled. Hair may be more or normal, its color
and texture changes during growing years. Lanugo on face and body disappears
but vernix starts remaining. The finger and toenails are grown completely. The
movements at the end of this month will be strong kicks. The baby measures
about 43 centimeters or 17 inches and weighs 2.1 to 2.6 kilograms or 4 ½ to 5 ½
pounds (Fig. 13.8).
Fig. 13.8: The eighth month

THE NINTH MONTH

This is period from 37 weeks to term duration.
Mother
By 36th or 37th week the baby’s head may start engaging into the vagina that
eases pressure on the diaphragm and in subsequent pregnancy will engage. In
10 percent of pregnancy baby head would not engage till the labor starts and in
some pelvis is too small for the baby’s head, so cannot engage properly and will
be spotted before labor begins and cephalopelvic disproportion is diagnosed,
either woman is asked to start the progress of labor for vaginal delivery or
cesarean section is done (Fig. 13.9).
Fig. 13.9: The ninth month
The pressure on the ribs reduces and woman finds breathing easier but will
have pressure on urinary tract so need to urinate frequently. The adoption of
position in the uterus is called presentation or lie.
• Right occiput position: The baby is head down with face towards the front
and crown to the right.
• Left occiput anterior: The baby is head down with his face towards back an
crown to the left.
• Breech position: The baby is sitting in the pelvic cavity so that baby’s bottom
will be first out
• Footling breech: The baby is sitting in the pelvic cavity with one or both feet
extending towards the cervix.
Baby
The baby’s head sinks down into the pelvis in the preparation for birthing the
last few weeks the baby gains 200 grams a week and grows about 10 centimeters
or 4 inches in length the baby’s eyesight develops rapidly and can differentiate
between light and dark. From 36 weeks onwards the baby co-ordinate sucking
and swallowing efficiently and has a powerful sucking instinct. Arm and leg
movements are less and overall movements are restricted because less space.
Baby’s lungs start getting matured and practices light breathing movements.
Amniotic fluid passes into the airways from time to time and gets an occasional
bout of hiccups which is a series of light rhythmic movements. By the time of
term the average baby is 1.53 centimeters or 21 inches long and weighs 3.2
kilograms. The amount of vernix and lanugo covering the baby’s skin diminishes
and will have little. Baby is born at or after the term.
Relieving Pregnancy Discomfort 75
CHAPTER
14
Relieving Pregnancy
Discomfort
ANEMIA
Cause
During pregnancy, the volume of blood in the body increases. This can lead to
drop in the blood hemoglobin level, that is the proportion of the blood that is the
red, oxygen carrying cells. If this level is too low, the woman is said to be
anemic. This is common in pregnancy. The heart has to work more to keep her
baby supplied with oxygen. She will be tried easily and will less-likely to cope
up with the labor.
Treatment
Woman has to take plenty of iron in diet, sources of iron are meat, liver and sea
food, egg-yolk, dried fruits, wheat grams a pulses. Eat plenty of vitamin C in
order to increase the absorption of iron. Iron tablets are not suggestible because
they have side effect.
BLEEDING GUMS
Cause
The hormonal changes will lead to the problem of mild bleeding gums disease
and the gums may be little tender and swollen.
Treatment
Woman has to clean the teeth thoroughly and regularly. Use new toothbrush,
use floss, avoid eating sugar especially snacks between meals. Woman can
have fresh fruit, bread or toast whenever she feels hungry.
BREATHLESSNESS
Cause
Woman feel breathlessness as pregnancy advances even with slight exertion.
This is due to pressure of the growing baby on to the lower lungs and also the
movement of blood away from the lungs to the growing womb.
Treatment
Woman should take every care not to exert her in any activity or it may affect
fetus.
CONSTIPATION
Cause
Woman has common complaint of constipation in her early pregnancy because
of the hormonal changes. In the later pregnancy the woman faces the same
problem because of ligament becomes relax and soften.
Treatment
If the woman is vegetarian, she should eat plenty of fiber in food such as brown
rice, whole meal bread and pulses and more amount of liquid drink everyday.
CRAMP
Cause
Ischemia, pressure of uterus on nerves, phosphates in milk. This can occur on
and of during pregnancy and usually in the lower legs and often in the night.
The cause is not known but suspected because of low salt diets and also
imbalance between calcium and magnesium.
Treatment
Calf stretch should be one, support stocking should be worn, take calcium
source on doctor’s advice, massage, eat more yoghurt, cheese, and leafy
vegetables and drink more milk. Exercise before going to bed, try out flexing and
extension of feet, circling the ankle and pointing the toes up and down. This
will stimulate circulation and the frequency can be reduced. Avoid excessive
plantar flexion, when woman feels cramps in the beginning, stretch into
dorsiflexion and massage.
INDIGESTION AND HEART BURN

Cause
Tea, coffee and spicy foods are common cause. In the early stage progesterone
in early pregnancy causes lower emptying, causes increase in reflux, cardiac
sphincter more relaxed. Heart burn is more common in later pregnancy because
the baby will be growing so big, the uterus starts to press on the stomach. The
muscle between the esophagus and stomach relaxes the enlarged uterus, pushes
acid from the stomach upwards and causes a burning sensation in the chest.
Treatment
Take light frequent meals and take it by sitting straight, so it helps giving room
for everything going inside, sleep in semirecumbent position, restrict intake
prior to sleeping, take milk, avoid fatty foods, coffee and smoking which causes
antacid preparation.
NAUSEA OR MORNING SICKNESS

Cause
Increase in estrogen and progesterone causes this. Nausea can be felt at any
time of the day or in some from morning to evening woman feels physically
sick, funny taste and a faint feeling. Foods like tea and coffee will make her feel
bad. This prevents woman to eat properly despite her good intention to have an
excellent diet. It disappears by 14 to 16 weeks. Nausea can also be cause of
certain smells, so try to avoid them. Metabolic changes also slower emptying of
stomach, cardiac sphincter relaxation.
Treatment
If she feels worst in the morning, try to eat something plane in the morning
before she gets up from bed like plain biscuit, rice cake, dry toast, herbal tea
which will cleanse and refresh her. Try not to skip meals at work place eat
sandwich, rice cakes spread with a nut butter, a bag of dried fruit, nuts, a piece
of fresh fruit. Ginger tea aid digestion and seems to cleanse the palate.
EDEMA
Cause
Progesterone increase and gravity causes venous engorgement. Slight swelling
of the ankles, feet and fingers is common in pregnancy because of extra-fluid
retained by the body.
Treatment
Try to rest and relax more. Try lying on the back with her feet resting against a
wall. In later pregnancy this position will be uncomfortable, so should not be
for more than five minutes. Stop immediately if she feels any discomfort, avoid
prolonged standing.
PASSING WATER
Cause
Woman regularly passes urine, so woman may feel exhaust and will give up
drink water.
Treatment
Women are advised to take extra-liquid so to avoid constipation and also blood
volume increases. So, before going out carry a bottle of water.
PILES
Causes
Piles are caused during pregnancy by training if a motion is not free and after
the baby is born the chances are there because of pushing into the second stage
of labor.
Treatment
Woman is advised to maintain liquid diet to prevent constipation.
PRE-ECLAMPSIA OR TOXEMIA
Cause
This is less common condition, which occurs towards the end of the pregnancy.
The cause is not known. Kidneys cannot cope with the extra-waste products
from the baby. The symptoms are high blood pressure, edema and protein in the
urine and kidneys could be prematurely damaged.
Treatment
Woman is advised to take rest. So that their blood pressure and urine can be
loosely monitored until the baby is born. After the delivery the signs quickly
disappear.
VAGINAL DISCHARGE
Cause
Almost all the women have vaginal discharge during pregnancy. This is nothing
to worry. If she complains of sore or itching it can be an infection. Discharge
may also contain blood.
Treatment
Eat natural yoghurt, which helps fight the yeast responsible for the infection.
VARICOSE VEINS
Cause
This is caused when the blood flowing back from leg to heart is obstructed for a
prolonged time. The blood then has to find a different route and uses the smaller
veins closer to the surface of the skin. These then swell and show on the legs.
Treatment
Try to avoid standing for long period. Avoid constipation. Regular exercise can
help to prevent the problem. Sit down with feet up for a short-time in a day.
VULVAL VARICOSITIES
Cause
Increase in progesterone and estrogen, increase in blood volume and pressure
of uterus on pelvic veins.
Treatment
Sanitary pad for support should be used avoid prolonged standing, squatting,
constipation and straining with defecation.
GESTATIONAL DIABETES
Cause
Diabetes related solely to pregnancy occurs when the body does not produce
enough insulin to cope with the raised blood sugar levels of pregnancy caused
by placental hormones.
Treatment
Eating well and avoiding excessive weight gaining are the best ways to reduce
the odds of developing gestational diabetes. If developed, a healthy diet is crucial
for keeping it within the safe limits and monitoring blood glucose levels and
baby’s growth will be checked carefully. Eat regularly and avoid sugary snacks.
Insulin use may be requiring.
HEMORRHOIDS
Cause
Constipation, increased uterine weight cause pressing on bowel and pelvic
veins.
Treatment
Increase fiber and fluids, defecation retaining.
BACKACHE
Cause
Relaxin hormone causes softening of ligaments which results in joint laxity.
There will be increase in thoracic and lumbar curves.
Treatment
Teach postural awareness, ergonomic advice should be given, lumbosacral
support belt is advised, stability exercises are taught, strengthening exercises of
back are taught and rest is advised.
TENDER BREAST
Cause
Estrogen and progesterone cause an increase in growth.
Treatment
Firm bra should be worn, warmth is given, physiotherapy treatment for
associated thoracic pain.
CARPAL TUNNEL SYNDROME

Cause
The compression of median and ulnar nerve cause swelling in hand and wrist.
Treatment
Physiotherapy treatment is of very much useful. Use of resting splints is advised,
contrast bathing should be taken which helps in increasing circulation and
reduces pain and edema. Ice, elevation when resting and muscle pump exercise
are done.
INSOMNIA
Cause
The pregnancy discomfort increases as months proceed is one of the major
cause, vivid dreams and anxiety.
Treatment
Relaxation techniques are practiced before going to bed, take rest if cannot
sleep, physiotherapy positions regarding sleeping position, visualization and
stress management techniques are taught and practiced regularly.
CHAPTER
15
Identification of
High Risk Woman
IDENTIFICATION OF HIGH RISK WOMAN

Pregnancy is a dynamic state that needs continuous supervision and adjustment
of management plans. Early identification and management of risk factors is
essential and will put woman and fetus out of risk.
CAUSES FOR HIGH RISK OF PREGNANCY

1. Hypertensive disorder of pregnancy
2. Pulmonary embolism
3. Uterine hemorrhage
4. Sepsis
5. Addiction
Tobacco
It causes spontaneous abortion, fetal death, respiratory illness, and low birth
weight, bleeding during pregnancy, reduction in the supply of the breast milk.
Drugs
It causes intrauterine growth retardation, congenital anomalies, infection
associated with unsterile injections especially hepatitis and HIV (human
immunodeficiency virus infection), malnutrition and premature delivery.
Identification of High Risk Woman 83
6. Chronic Hypertension
The blood pressure of 140/90 mm of Hg or higher, it develops with pre-
eclampsia, abruptio placentae, perineal loss, maternal mortality, myocardial
infection, uteroplacental insufficiency, cerebrovascular accident.
7. Cardiac Disease
It has both maternal and fetal implications, e.g. Eisenmenger’s syndrome,
primary pulmonary hypertension, Marfan’s syndrome, mitral stenosis. Fetal
growth and development are dependent on an adequate supply of the well-
oxygenated blood, if this is limited it cause cardiac lesions then the fetus is at
risk for abnormal development and even death.
8. Pulmonary Disease
Maternal respiratory function and gas exchange are affected.
9. Renal Disease
Renal disease may occur because in the normal pregnancy the renal system
undergoes certain physiological, anatomical and functional changes that may
stress the renal system, so continuous assessment is necessary.
10. Diabetes
It causes maternal mortality, fetal mortality, congenital anomalies, chronic
hypertension, pre-eclampsia, maternal edema, maternal pyelonephritis,
intrauterine fetal death, neonatal mortality (congenital anomalies), neonatal
morbidity, respiratory distress syndrome, macrosomia, hypoglycemia,
hyperbilirubinemia, hypocalcemia.
11. Thyroid Disease

Untreated hypothyroidism, hyperthyroidism may profoundly alter the
pregnancy outcome. Treatment during pregnancy poses a very complicated
situation. Since the fetal thyroid responds to the same pharmaceutical agents
as closes the maternal throid.
12. Rheumatic Disease

Many rheumatic diseases are common in woman often during the reproductive
years, there is an increased risk of abortion, premature labors and intrauterine
fetal death and pharmaceutical agents used in the treatment of the disease may
affect the fetus adversely.
13. Hematological Disorders

Anemia secondary to iron and folic acid deficiency, disorders of blood
coagulation and platelets affects antepartum management, intrapartum,
delivery, postpartum management because of possibility of hemorrhage.
14. Genetic Disorders

A genetic disorder of the mouth must be evaluated prior to the pregnancy or it
may threaten to her health.
Consanguinity
Marriage between the close relations results in a large pool of identical genes
there by increasing the possibility of sharing similar mutant genes resulting in:
i. An increase risk of miscarriage
ii. An increase risk of rare recessive genetic disease in offspring. So genetic
counseling should be undertaken to ascertain risk, carrier testing and
early prenatal diagnosis, if possible by chronic villi sampling or
amniocentesis. Such testing can lead to wise reproduction planning or
relief of anxiety in high-risk couples.
15. Pituitary Disorders

It is uncommon because it is necessary for conception.
16. Liver Disease

Liver undergoes drastic changes and if a pregnant woman has liver disease it
affects fetus by causing viral hepatitis.
17. Venous Thromboembolic

Pregnant postpartum woman are at frequent high-risk of thromboembolism
that becomes life-threatening.
18. Infectious Disease

Infectious disease like rubella, syphilis, gonorrhea must regularly screened
because viral parasitic infectious agents are capable of crossing the placenta
and producing the serious problem for the fetus and newborn. Some virus
which causes mortality are cytomegalovirus, herpes simplex virus, hepatitis B,
toxoplasmosis, provirus, HIV.
Identification of High Risk Woman 85
19. Family History

Maternal hypertension, multiple birth, diabetes, hemoglobinopathy, uterine
fibroids, eclampsia, maternal or paternal mental retardation, congenital
anomalies, congenital hearing loss, allergies and medication.
CHAPTER
16
Labor and Delivery
DEFINITION
Giving birth to the baby is called labor. In the first pregnancy, the baby’s head
may engage in the upper part of the pelvic cavity two to four weeks before
delivery or it may not engage till labor starts as the labor progresses, the head
descends further into the pelvis.
It is difficult to guess exactly when labor starts. Some women labor begins to
happen quite quickly and they move from one stage to the next. But for others
first indication is that labor in beginning may be spread over a couple of weeks.
Some experience to loose weight of 1 to 1.5 kg and some experience high fatigue.
THE SHOW
The show is the release of mucous plug that seals the opening of the cervic. In
some woman it comes out in the form of pinkish jelly, in others it will be a series
of small pieces. The release is the indication of cervix is going to stretch a little
and is in the preparation of labor. In many it may take time gap of several days
to an hour or anything between. A show accompanied with slight vaginal
bleeding may be the sign of early labor.
THE WATERS
Another sign of labor onset is the rupture of the membranes that form the bag or
amniotic sac of fluid inside the uterus. When the membranes rupture, amniotic
fluid may escape. This can happen in a rush, which will feel as a sudden push
of liquid down the legs and will trickle out. If the baby’s head is engaged in the
pelvis there is no room for large quantities to leak out at once.
Labor and Delivery 87
Sometimes a trickle slows the ceases which may indicate that the rupture
was not complete and do not rupture until labor is well-established. If fluid
continue to escape and would not go into labor within a few hours if the
membranes rupture and labor does not start within a day or so, the baby is
vulnerable to infection. If the baby’s head is not engaged when the woman’s
waters break, the rush of fluid can bring the cord with it, compression of the
cord can affect baby’s oxygen supply.
CONTRACTIONS
Contractions are a sign of labor, if they increase in frequency and strength over
a period of an hour or two and last longer or 40 seconds each. Woman will have
tightening sensation across abdomen and back, beginning gently, building-up
to a peak and then fading away. Labor contractions are indicated by
intensification of pain. Contraction are caused because of the muscles of the
uterus will get shorten exerting and upward pull on the cervix and downward
pressure at the top of the uterus. The muscle lengthens again as the contraction
dies away. Each contraction causes muscle to shorten a little more causing the
cervix slightly open a pushing the baby a little down. Stomach will be upset.
SIGNS OF FALSE LABOR

A show that is brownish. Either intercourse or a vaginal examination can
dislodge the mucous plug.
THE FIRST STAGE

This is the longest stage of labor; cervix will slowly open to allow the baby into
the birth canal. Once the labor starts it will be for 10 to 12 hours with the first
baby and will be shorter for the second baby. Labor starts under the influence of
the hormones. At term the function of the placenta is reduced slightly, so that
baby’s pituitary gland releases oxytocin which crosses the placenta into the
blood stream. Oxytocin stimulates contraction when the baby’s adrenal gland
is matured, it secretes hormone cortisol. This crosses into the blood stream and
alters the levels of estrogen and progesterone which produce hormone-like
chemicals like prostaglandins, which soften the cervix and stimulates the uterus
to start contracting.
Each contraction has two effects. First, it restricts the space in the uterus for
the baby forcing her into the area where there is least resistance, area called
softened cervix. Second, each contraction shorten the muscle fibers attached to
the cervix and pulls them upward, away from the opening called as effacement
and measured in percentages. Woman will be 100 percent effaced by the end of
the first stage. Muscles around the cervix will also widen the opening called
dilatation. With each contraction the baby is forced further down towards the
enlarged opening. The hardening of the abdomen each contraction comes
gradually rising to a peak, then fading away experiences contractions.
Contractions may feel like intense period pains. Some women experiences them
as a sharper pains or a rush of energy.
Pain is felt at the peak of contraction and be able to relax before and after and
during the first stage of labor. The uterus contracts at increasingly shorter
intervals, while the contraction gradually becomes longer. At the start there
will be one contraction of 40 to 50 seconds every 10 minutes. At the end each
contraction will last longer than a minute and there will be a gap of not more
than a minute between each one, giving very little time to rest between them
every single contraction helps the cervix to open up and pull back. By the end of
the first stage the cervix is completely effaced and fully-dilated ready for birth of
the baby. Labor often progresses at the first. There will be several hours where
nothing seems to happen contraction are felt will get longer and stronger. But
will dilate not more than half a centimeter. This is normal once it is 7 or 8 cm
baby’s head will descend further.
Baby
During first stage of labor the baby continues to receive oxygen and nutrient
across the placenta. Baby will be experiencing contractions in the uterus. Some
babies can not find the difference in contractions in the beginning of the first
stage. Some babies will sleep, as there is increase in the intensity, the baby will
feel the uterine walls pressing against baby’s body and the pressure of the
cervix on the bones of the head.
The baby’s effect can be seen when observed in the monitor. When uterus is
contracting the blood flow through the placenta is slowed down. It becomes
normal as contraction passes. In response to the lower blood volume, the baby’s
heartbeat may be slow and average heartbeat in the first stage of labor is usually
120 to 160 beats per minute.
This shows that heart is functioning well. There may be slight variation too.
Contraction can be painful. In between contractions no pain will be felt so as
contraction comes woman should try to relax and should release tension of
shoulders, face and hands or it may transmit through the body to all muscles
including uterus and increases pain. So, relaxation plays a vital role.
Concentrate on breathing is also very important. As the contraction begins,
breathe deeply and slowly. This delivers oxygen to all parts of the body across
the placenta to baby. With each exhalation woman will be expelling tension. As
a contraction goes to peak, woman should take shallower breaths in and out
through mouth. As it decreases go back to deep breathing. Woman should not

try to stop the contraction it causes increase in the intensity, reaches its peak
and will be painful, later it comes down, so in between contractions woman
should relax.
This will help to conserve energy when contraction comes close together.
She can use the energy to push baby out. Woman is advised to take frequent
sips of water or fruit juice, crushed ice. This causes some women refreshing.
Urinate frequently or full bladder is very uncomfortable during contractions
usually sometimes backache is experienced, so partners can help massaging
back woman to get relief and woman should maintain her contraction on the
contraction.
STAYING UP RIGHT
Women who stay upright tend to have shorter labor, since keeping the pressure
of the uterus on the cervix can speed dilatation. Some woman find it comfortable.
Woman can stand leaning against a wall or partner and he should take all the
weight, if required.
THE BABY’S POSITION

If baby’s position is occiput posterior, backache may be severe. Lie on side to
relieve pressure on the back and ask partner to massage back vigorously. If
baby’s head faces mother’s back, i.e. occiput anterior, her body is well-aligned
for delivery. Squatting will help open up mother’s pelvis for a smoother exit. In
a breech presentation it is important that the head is born in a controlled gentle
way. Helpers will assist in choosing a comfortable position that minimizes the
possibility.
INDUCTION
It is the process where if the delivery has not started by 41st or 42nd week, the
start of labor is induced. It is done in any of the three ways:
1. Introduction of vaginal prostaglandin hormone like substances that soften
and ripen the cervix and induces labor by stimulating the uterus to contract.
2. By ARM—artificial rupture of membranes.
3. By means of a hormone drip.
Second and third are used if first alone do not induce strong enough
contraction. ARM may be attempted if labor is still not progressing a drip will
be set up. ARM is also known as breaking the waters. The membranes are
loosened slightly with the fingers called a membrane sweep and the sac is
pierced with a small hook.
The amniotic fluid then leaks out. This releases further prostaglandin that
starts the labor process. The use of prostaglandin followed by ARM is the most
common method of induction and supplemented with a hormone drip called
syntocinon—a synthetic form of hormone which plays a role in triggering labor
enters the blood stream directly. A catheter attached to a drip stand with a
solution of hormone in it is inserted into a vein. The drip administers the hormone
and the dosage can be increased or reduced as required.
The reason for inducing the labor. If pregnancy is continued for more than
40 weeks it leads to aging of the placenta and the problem of postmaturity that
causes failure to nourish the baby adequately. Induction is done 10 to 15 days
overdue period. A baby is monitored regularly to check if showing no signs of
distress (Lack of oxygen) or poor growth.
The amniotic fluid level may also be assessed. Twins are induced after 38
weeks because by then the babies are mature enough and allowing them to
continue growing in the womb may cause problems and discomfort. Ultrasound
scan taken at 37 or 38 weeks shows that baby is very large, so induction is
avoided, a cesarean is done later.
The same is recommended in case of pre-eclampsia, high blood pressure,
diabetes or it may affect the mother and the baby if pregnancy is continued. Rhesus
disease and the heart conditions need treatment prior to induction of labor.
NATURAL PAIN RELIEF

Labor and birth involve pain. Planning and preparing can lessen this before
hands and learning breathing techniques and relaxation, use of complementary
therapies. All these give natural pain relief. The main aim is to reduce the
severity and intensity of the pain. It also helps in speeding up the recovery after
birth; mother will feel energetic, can sleep better and move naturally.
The benefits for baby are no artificial reaches him/her, baby born without
any secondary affects of pharmacological pain relievers, baby will be alert,
baby can look with wide open eye because he is not sleepy. The first breastfeed
goes better since the sucking and swallowing instincts are not masked by drugs.
The following are most commonly recommended forms of natural pain relief:
Breathing
The breathing exercises practice throughout pregnancy become useful.
Try:
• Level-1: Breathing in early labor when contractions are mild and short.
• Level-2: As labor progresses.
• Level-3: In the final stages when contractions are long and intense.
Never tense shoulders face and hands.
Relaxation
Relaxing the body and mind during pregnancy creates a sense of well-being,
allows physical recovery and helps to prevent the tension that can lead to high
blood pressure. It also gives rest to the back, legs, abdomen from extra-weight
and effort of holding baby upright because it sharpens mental ability and
releases natural pain killers, it can be particular help in managing the labor.
The body is relaxes the mind will be relaxed. Stress and worry manifest as
headache or backache while physical pain increases strain or stress.
Relaxation is practiced for 15 to 20 minutes. Shoulder should be contracted
and released, fingers and hands are clenched and unclenched talk softly and in
a slower voice this is called quick relaxation technique very much useful during
labor birth, and in the early weeks of motherhood. Relaxation technique plays
an important part in preparing for labor. Tension in one part of the body indicates
that there is tension elsewhere. The above can be worked in different positions
like lying, sitting, squatting, standing, kneeling.
TENS
Transcutaneous electrical nerve stimulation. It works through a small power

box with electrodes, which is placed on back. By adjusting the control on the
box, controlling the emission of a low level electrical current, which overloads
the nerves thereby blocking the pain signal from the uterus. TENS produces no
side effects.
PHARMACOLOGICAL PAIN RELIEF
A number of commonly used drugs can safely and effectively ease the pain of
childbirth.
Pethidine
It is a powerful synthetic analgesic. This is administered only after labor is

well-established. It takes 20 minutes to start taking effect. It is administered by
intramuscular injection into the thigh or buttock and repeat after two or four
hours.
Effect on Mother
It gives drowsy, woozy, nausea, vomiting, feeling of depression, drop in blood
pressure, or others it will be normal and would not interfere with the contraction.
Effect on Baby
Near the birth the dose is given the greater will be the effect on the baby and the
baby will be drowsy and have difficulty in sucking. The baby may need
additional oxygen for a few hours to help her to breathe.
Entonox
It is also called gas and air. Entonox is a mixture of oxygen and nitrous oxide
that can be breath through mouthpiece or facemask. Entonox does not take
away all the pain, but makes it easier to bear and manage pain better and it
takes only about 15 seconds to start taking effect.
Effect on Mother
There is no side effects. Woman feel drowsy and once stopped start to feel
normal again.
Effect on Baby
No side effects on the baby too.
Epidural Anesthesia
This is popular form of pain relief and local anesthetic drug is injected into the
epidural space at the side of the spinal cord. A catheter is left in at the injection
site so that more anesthetic can be given if required. Woman is given IV infusion
of fluid that prevents blood pressure from falling too low then asked to lie on
side while anesthetist inserts the epidural. Now-a-days low doses of the local
anesthetic together with small doses of an analgesic. This works more quickly
than anesthesia alone and allows to feel the urge to push and retain the ability
to do so. Such is called walking epidurals for pain relief an active participation
of delivery.
Effect on Mother
A standard epidural offers total pain relief to most women. Woman will have
no feeling from the waist down which depends on dose and timing which
makes harder or to push in the second stage of labor. There is likelihood of
forceps delivery.
Effect on Baby
On rare occasion slows down baby heartbeat, so baby will be monitored
continuously. Babies born after an epidural are more likely to be drowsy. The
baby may require a forceps or vacuum extraction.
FETAL MONITORING
Electronic fetal monitoring (EFM) allows continuous monitoring of the baby.
This is important, if the baby is at risk the monitor will signal the beginning and
end of the contraction helping her to maximize her efforts. It also alerts the
medical teams if the baby is becoming distressed so that immediately go for
assisted delivery or cesarean section.
TRANSITION
Transition is a labor milestone. The end of the first stage is exhausting and
emotionally draining. Transition marks 2 to 3 cm of dilatation. It can last from 15
minutes to one hour. Woman may be physically hot one minute and too cold the
next, legs may tremble and have cramps, feeling of nausea and vomiting. The
baby’s head is down and presses on rectum making to feel the need to cope bowels
contraction will be strong upto 90 minutes long and coming every two minutes.
Woman may loose the ability to concentrate and will be focusing concentration on
next contraction. Woman becomes impatient, tired, angry, frustrated, and irritable.
Some women starts to have doubt about their ability to deliver her baby or not so.
Transition is a psychological state as well as physical state.
THE SECOND STAGE

The second stage of labor is easy for most of the women to handle than the first
stage because they can have more control over what is happening. Once cervix
is fully-dilated, the baby’s head can start to descend through the birth canal.
This marks the beginning of the second stage of labor and will end with the
birth of the baby’s epidural is not given mother will be knowing when she has
reached the second stage by the feeling of push with the effect of epidural,
depending on the dose and timing and will know that she is fully-dilated.
Midwife will be telling when a woman is fully-dilated and when to push,
woman and partner can feel the contraction by placing a hand on abdomen or
by watching the printout from the fetal monitor. At the start of the second stage
the baby’s head may be visible during a contraction. Each contraction and each
push helps to move more further own the vagina. At first it disappears when
contraction ends, pushed back by the resistance of the pelvic floor mucles. It
moves further down with each contraction when the top of the head becomes
completely visible at the vulva, the head is said to be crowning. The contraction
of the first stage is different from the first stage part of the contraction is urge to
bear down or push.
The baby’s head will be pushed against the back or pelvis and on the bowel
and will defecate if anything in bladder or rectum. The head descends the birth
canal and the pressure diminishes and will feel pressure on the perineum and
vulva as they stretch. There will be burning sensation as the skin of the perineum
is stretched thin. The midwife will tell the woman if pushing is not required as.
There is risk of tearing the perineum she will suggest breath deeply and
push more gently. A warm compressor held against the perineum will encourage
the tissues to expand and may help to avoid tear. If tear is going to occur the
episiotomy is given. With the next one or two contractions the baby’s head
glides out in front, allowing the widest part pass through pelvis. The head and
neck extend around the pubic bone and the head crowns. The baby’s head is
compressed by her descent down the birth canal, the edges of her soft
cartilaginous skull bones slide under and over each other to ease the journey.
This process is called moulding and with the first baby the second stage of
labor lasts an hour subsequent babies, may come after one or two pushes in a
single contraction. Prolonged second stage lasting more than two hours is
exhausting for mother and stress for the baby. If baby is doing well and mother
is able to cope with the process and is continued if mother is tired and baby
shows the signs of distress mother may be helped out with forceps or vacuum
extraction or a cesarean.
EPISIOTOMY
Episiotomy is a cut made in the perineum, i.e. the area between the vagina and
the anus, extending through the underlying muscles into the vagina. It makes
the exit point wider for the baby and allows the head to be born more quickly
and easily. If necessary it will be done when the baby’s head is crowing. Two
types of incision are common, the first is called the midline runs directly back
towards the anus, the second a mediolateral cut. Starts like the midline cut, then
goes to one side to avoid the anus. If forceps are necessary, episiotomy is first.
Tears that do not involve several layers of muscles heal more quickly and with
fewer problems than episiotomies.
Larger ragged tears are more difficult to stitch well. Injection of local
anesthetic is given the cut is made. Stitching up or suturing is done after the
third stage of the delivery of placenta and it can be painful. She will be give an
injection of local anesthetic. Stitching can take 10 to 20 minutes. And stitch is
done through vaginal skin, muscle, and external skin of the perineum. The
stitching is done layer-to-layer. Her legs are likely to be in stirrups to have good
view for the doctor. Try to relax mother’s head, shoulders with the help of
pillows. Stitches will be uncomfortable and painful in the first week.
Painkiller can be taken but traces of it will get into mother’s breast milk and
will make baby drowsy. If stitches are sore it is better to checked once. Sometimes
knot in the stitch will hurt mother or stitches are too tight then knot can be
snipped off and can be restitched. If mother is very tired she will find stitches
ache so try to take rest (Fig. 16.1).
Fig. 16.1: Episiotomy
An icepack will help to relieve discomfort, wrap a bag of frozen vegetables

in a clean, nonfluffy cloth and apply this to the stitches or a foaming cream that
should ease discomfort, lavender essential oil (add 10 drops to bath water) is
reputed to heal stitched and bruised tissue, also try salt baths or arnica tablets.
Sitting down is usually a little uncomfortable at first. Once she is seated she
should be fine. Sit squarely to avoid pulling on the stitches. Get in and get out of
chairs slowly and carefully. Many women worry that they will burst stitches
when moving bowels. Try to avoid constipation by drinking plenty of fluids
and eating fiber rich food is concerned, lubricate the anus with vegetable oil
before a bowel movement.
Pelvic floor exercises will improve the blood flow to the perineum which
will promote healing. If woman finds uncomfortable to dry the area with a
towel. Use a hair dryer on a warm setting this can also be very soothing.
Everything should be back to normal after four or five weeks. Most episiotomies
heal without any problem.
The stitches dissolve and do not need to be taken out. The skin knits together
leaving the same as she is before. But after a year or so she will be able to show
the mark of the scar mothers do suffer from after effects, usually due to infection
or poor suturing. Very rarely, a stitch may become infected and this can be
painful. Poor suturing can mean she was sewn up so tight that the healing
process leaves her perineum and vagina much less-elastic than it should be.
Sexual intercourse can be uncomfortable or even impossible. Woman can
massage the perineum throughout. Pregnancy to keep it supple and stretchy.
Squat, lubricate one or two fingers with vegetable oil and insert them into the
vagina then press down on the perineum. This is advised everyday from about
six-month on gradually increasing both the downward pressure and the number
of fingers. It can also increase the elasticity of the perineum by inserting both
index finger and gently stretching. Giving birth in an upright or semi-upright
position also helps by putting less pressure on the perineum. If woman squats
the muscles of the perineum relax and tear or cut less likely one.
ASSISTED DELIVERY
Some babies and their mothers do not handle the second stage of labor well. In
several situations a little help may be a good idea. These cases fall into one of
the two categories (Figs 16.2A and B).
1. Birth seems to go on too long to deal with.
2. Baby showing the signs if distress when the baby is short of oxygen.
A B
Figs 16.2A and B: A. Forceps delivery; B. Vacuum extraction
A diagnosis of fetal distress is made when the baby’s heart rate slows in
response to contraction but does speed again as it should. Another sign is that
baby opens his bowels and pass meconium (the contents of the rectum) which
will strain the amniotic fluid which is greenish in color. Blood oxygen level
from the scalp can also be evaluated to help in the diagnosis of fetal distress
may be caused by a poorly-functioning placenta, along tiring labor, contraction
that are too strong or too frequent or prolapse of the umbilical cord which can be
compressed by the baby’s body, thus preventing sufficient oxygen from reaching
him the baby’s exit may be obstructed or hampered because he is in a poor
position such as face up (occiput-posterior) or because his mother’s pelvis is
not able to open wide enough.
Sometimes, the contraction of the second stage are simply not strong enough
to help push the baby out, oxygen drip is tried to increase the strength of the
contraction then forceps or vacuum extraction is suggested. In other case, the
mother may be too exhaused to help the contractions along by pushing when
they are strong. The use of forceps is common in women who had an epidural. If
the mother has health problems such as high blood pressure, forceps or vacuum
extraction is suggested. During an assisted delivery, anesthetic is given if epidural

is already given more anesthetic will be administered or a local anesthetic will be
administered in the perineum. Bladder may be emptied with a catheter. Probably
need an episiotomy to allow room for the instrument to be inserted.
She will lie down on her back and her legs will be raised with the ankle
supported in stirrups so that she is in lithotomy position. Each forceps is made-
up of two separate halves that lock on to each other. Each half has a handle at
one end and a scoop like blade at the other. The forceps are inserted into the
birth canal one blade at a time. Each blade goes around the baby’s head, cupping
it at each side and the handle lock together. As woman feels each contraction
coming she will be told to push just as was doing before. Doctor will gently ease
the baby toward delivery. This process usually take’s just two or three
contractions and baby will be born. Vacuum extraction can also be used to turn
and deliver the baby. The instruction known as a ventouse has a tube with a
cup at one end. The other end is attached to a vacuum bottle and then to a small
pump. The cup is applied to the babys head and pump creates negative pressure
that fixes. As the mother pushes with each contraction, the doctor help with
gentle traction on the cup. The baby is usually born with in two or three
contractions. Episiotomy is not required with vacuum extraction.
A CESAREAN BIRTH
A cesarean birth is a surgical procedure performed under general anesthetic or
an epidural. If local anesthetic is given woman will be fully conscious throughout.
If the general anesthetic is appropriate to delivere the baby immediately because
epidural takes about 20 minute to start taking effect. Where as a general anesthetic
will put the mother to sleep in a matter of seconds (Fig. 16.3).
Fig. 16.3: TENS application

Lower abdomen will be shaved and catheter will be inserted through the
woman urethra into the bladder to keep it drained of urine. Abdomen will be
washed with an antiseptic solution. If woman is going to be awake a screen will
be placed over her abdomen so that she would not see the cut being made. Her
partner can sit between her head and shoulders and hold her hand. Once
anesthetic has taken effect, doctor will make a horizontal incision along her
pubic hair line which minimizes bleeding and means less pain and faster heeling.
The surgeon will then cut through the lower part of her uterus again, cutting
here minimizes bleeding and the risk of scar rupture in a subsequent labor.
She may be aware of the cuts being made but they will not cause pain. The
amniotic fluid will be drained if membrane have not already ruptured and will
hear as a giggling sound then the baby may be lifted out by hand or with a pair
of forceps. To deliver the baby will take 5 to 10 minutes. The baby’s cord is cut
and clamped. If everything is well baby will be given to mother to hold. The
placenta and membranes are delivered and then the process of stitching up
takes place. The layers of uterine wall and abdominal skin are stitched one by
one. This will take about 30 minutes. The stitches used usually dissolved, if not
dissolvable they will probably be removed before woman leaves hospital. The
first few days after cesarean section, woman will feel tired more than after a
vaginal birth and the area around scar will be tender, she may suffer from
intestinal wind which is common after any abdominal operation. Laughing or
coughing will be painful because they pull on her abdominal muscles. She will
be shown how to support scar to avoid undue pressure. Scar will be checked
regularly to make sure that it is healing well. Painkillers to help with the
discomfort or injection will be given. She will have an intravenous drip in her
arm for about 24 hours to replace lost fluids. In the beginning she need to use
catheter in place or be helped to use a bed pan. She will be encouraged to move
around as much and as early as possible to help her breathing, improving
healing and prevent blood clot from forming. Breastfeeding the baby may need
little more patience. She will need help to position her baby comfortably and get
herself into a position that does not cause pressure or discomfort on her
abdomen. Try raising baby on a pillow across her lap or feeding him as she lies
on her side. At home it is vital, no heavy household tasks are done and to avoid
lifting anything heavy or surgery may trigger an infection which can be treated
with antibiotics (Fig. 16.4).
THE THIRD STAGE

The last part of the labor begins after the delivery of the baby and ends with the
delivery of the placenta and membranes. It usually takes less than five minutes,
but she will have to start in the delivery room which any tears or an episiotomy
Fig. 16.4: The cesarean birth
are stitched. The process is speeding up mainly to avoid hemorrhage caused by

a retained placenta when baby is about to be born usually when the first shoulder
is emerging she will be given an injection of oxytocin in thigh or buttock or
through intravenous drip. After baby is born the umbilical cord is clamped and
cut. It is usual to wait until the baby is breathing well and the cord has stopped
pulsating an indication that the baby’s oxygen supply is no longer dependent
on the placenta painful. Oxytocin stimulates the uterus to contract strongly.
The uterus becomes smaller, harder and tighter. This results in the placenta
peeling itself off the inner wall of the uterus. The expulsive force of the contraction
helps push the placenta down and out. She will be asked to give a push or two
to help it along. The doctor may also speed the delivery of the placenta by a
maneuver called controlled cord traction that is by pressing on the uterus with
one hand while holding the cord taut in a small pair of forceps with the other.
At the same time that the placenta comes away.
The blood vessels that were connected to the placenta close off under the
force of the contraction. This prevents excessive bleeding. She may feel the
placenta slide down and out between her legs followed by the membranes.
They are usually delivered into a bowl so that the doctor can check that it is all
there and open or torn vessels on the placenta will indicate that a section may
have been retained. It must be removed immediately, if pieces of placenta are left
in uterus, mother may suffer from infection or heavy bleeding. Then the mother
is shifted to the general ward.
CHAPTER
17
Breastfeeding
Breastfeeding is the best food for the baby. It has everything the baby needs to
grow stronger and healthier. Breast milk contains antibodies that give the baby
protection from infections such as cough, cold and childhood disease. The
breastfed babies are less likely to get diarrhea, constipation or stomach upsets.
As baby grows the nature of mother’s milk changes so it is always exactly right
for the baby.
Once mother has mastered the art of the
breastfeeding there are many practical advantages.
It is cheap and convenient, because does not have
to know what is in the milk or how is it has been
processed, about bottles, sterilization, nor need to
panic if she ever got struck somewhere with no
food. It is always there. Breasfeeding help mother
during her post-pregnancy tummy go down more
quickly. Breastfeeding is a rewarding experience
some babies may not accept breastfeeding (Fig.
17.1). Fig. 17.1: Breastfeeding
GETTING STARTED
Babies know how to suck immediately after birth. This reflux is strong in the
first few hours. It is a good idea to put baby to breast as soon as mothers feel
ready. Many mothers do this as soon as the baby is born or within a few hours
after the birth. He may suck or simply nuzzle for the first three days mother will
Breastfeeding 101
produce a special milk called colostrum. This has a rich creamy consistency
and contains all the nutrients a newborn baby needs as well antibodies to build
up the baby’s resistance to infection. Mother’s milk will come in between the
second and fifth day after birth. When the milk comes breast will be larger, hot,
swollen and hard. This feeling lasts for few days and she will be having a
feeling of fullness before the feed and empty afterwards. Take help from the
midwife or easy breastfeeding techniques because it is not easy in the beginning.
The most important thing is to get the baby positioned correctly on the nipple.
This is one of the key factors in successful breastfeeding. If the baby is not in the
correct position or mother is not comfortable, baby cannot feed as result cause
sore nipples, hungry and frustrated baby. Other problems are also encountered
in the first few days. If the nipple is flat for the baby to suck even the mothers
breasts are full of milk the baby can not suck as a result baby starts crying if
baby is large baby wont get satisfied when mother’s milk may not come through
quickly enough, baby will be disappointed, mothers become tired and constant
sucking makes breast sore. So, if all the above happens mothers should rule out
the possibility of mistake and should correct it at the earliest a must give the
baby best possible start, at the same time mothers should be confident and
experienced so that problems get eased.
The mother’s should be comfortable using pillows or cushions in sitting or
lying down, wrap the baby around. The baby’s mouth should be just opposite to
the mothers breast. And lift the baby towards the breast support the baby well
throughout the feeding see to that the baby gets both the nipples and the surrounding
area into his mouth then baby will be able to suck efficiently. The best sign whether
the baby feeding or not is baby’s ears will be wriggling and baby can breath well
with his nose see to that baby cheeks should not hollow or it means baby is not
latching well. Mother can also hold the baby across mother, or one side and lie with
baby on a pillow held under the same arm as side of the breast.
FEEDING TIMES
The feeding time of the newborn babies in their first few weeks will be for every
two or four hours. As the baby grow the feeding times will get reduced. Each
baby may take different time to feed. Some suggest to feed for 10 minutes on each
side of the breast, some recommend to let the baby feed as long as baby likes to
feed. Mother will get experience whether her baby is satisfied and stomach is
full or not. When mother wants to take of the baby from breast she has to put her
little finger in between baby’s mouth and nipple to release the suction first.
A DIET TO HELP MOTHERS

For a day a baby will be requiring 75 ml milk for every 450 gram of weight.
Example: 3.5 kg or 8 pound boy will need 600 ml or 1 pint. All these are rough
measurement because it is very difficult to calculate and there is no way to

measure how much milk the baby will be drinking. The baby should be gaining
150 to 185 gram per week the bay should look satisfied, have a good muscle
tone and should be hanging about six wet nappies a day. If the above is not
attained then put the baby to the breast more often. The diet of the mother plays
an important role. The mother need to consume approximately 500 extra-calories
per day to help to produce enough milk. It is best to have the extra-calories at the
start of the day when the system can deal with the intake more efficiently mother
should have a good breakfast, have a good meals in the day or milk production
gets reduced there are some natural foods which induce milk they are natural
coconut, paw-paw, aubergines. Fresh coconut can be eaten raw which is a
good exercise for jawline. It can also be added in salads, curried vegetable
mixtures, etc. Mother’s weight may be little more but will return back to normal
weight if the breastfeeding is done.
EQUIPMENT
Very little equipment for the breastfeeding is required. A good bra is essential
for easily assessing and to give good support when breasts are full. Mother
should dress horizontally. Which can be lifted from waist onwards or button
down the front. Breastpads are small-shaped absorbent circles may be necessary
depending on the amount of the milk mother produce. Mother may leak between
feed or if mother hear her baby crying the pas will help protect spoiling of
clothes frequently. It can be worst in the morning where jets of milk spurting
out. Mother’s should go for breast shells if having plenty of milk. It is used in the
cases when the feeding from one side, the mother will drip from the other. The
shell just tucks into the bra and will collect the milk. This milk can be stored for
a day or frozen for upto three months, if mother wants to have spare milk for
emergencies. Shells need to be sterile for storage.
BREASTFEEDING PROBLEMS
There are discomforts with the breastfeeding that mother might experience like
swollen or leaking milk. So, the remedy is to express a little milk by hand to ease
the pressure. Alternatively have warm bath which causes some milk will flow
out. Do not express too much milk or the problem worse as body will assume
that the baby is taking more milk and will produce more. As the baby feeding
pattern become established the problem should ease still leaving have a good
supply of breast pads handy.
Sore or Cracked Nipples

This is the worse problem. It will be painful as she feeds her baby. And the
cause or this is baby being not latched properly onto the breast when feeding.
Breastfeeding 103
The midwife can be helpful. She has to leave herself exposed in between feeding
and the body is very quick at healing breast milk helps in healing process. After
woman feeds the baby rub the part with a few drop of milk and let it dry. Nipple
creams can also be very helpful made of chamomile. They give soothing effect.
The advantage of this cream is mother’s need to wash in between the feeds. But
mother has to take care that the creams she is using should not contain comfrey
nor lanolin. Soreness will be decreased only when mother positions baby
correctly.
If the mother is sorer and have a cracked or bleeding nipple, nipple shield
may help. This is made of latex which is put over the nipple and surrounding
area. The disadvantage is that the baby has to suck quite hard to get the milk.
This may lessen the stimulation and mother supply goes down. But will give
her the protection.
Blocked ducts
Missing or rushing a feed or pressure from restrictive clothing can cause the
blockage. Mother can find a red patch on the breast or feel a lump. So, treatment,
mother has to continue feeding as this helps her to clear block. Expressing milk
by hand or having a warm bath to get the milk flowing can also help.
Mastitis
It is an infection which will make the mother feel painul. Antibiotics are given,
this would not prevent mother from feeding but care to be taken baby would not
get diarrhea. If mother’s position is good and still mother feel very sore it could
be a case of Candida or thrush.
BOTTLEFEEDING
The 98 percent of woman are capable of successful breastfeeding. This is not
possible for some woman because of hormonal imbalance or woman is on
specific medication and women with flat or inverted nipples. Such woman
prefer bottlefeeding the milk used can be either buffalo milk, cow milk and if the
child is allergic to cow’s milk products or has lactogen intolerance then nondairy
formula.
Bottlefeeding Equipment
Mother requires six bottles and teats so that she can keep two bottles ready,
cleaned and sterilized. To sterilize specially designed sterilized equipment is
available or a large saucepan can be used. A bottlebrush is also required bottles,
standard of hygiene is useful. Many babies suffer from gastroenteritis after
three months. Steam sterilizer is best. Powdered milk is also preferable.
COLIC
Colic causes pain and wind as they pass down the gut. Baby will be constantly
worrying, screaming in agony, bright red in face with a tense and rigid body. An
attack may last on and off for a whole evening colic can start at any time from first
week to ten days and last upto three months. Mother should cuddle the baby very
tightly and used rhythmic rocking motions either sitting down or walking round
the room. Being put on mothers lap soothes some babies, face down, so their
tummy is across mothers knees. Then gently rub their back. Another position that
can be helpful is to hold the baby face up. Gently bring each of his legs up across
his stomach bending at the knee. Do this only at a time.
This is similar to a yoga position that is supposed to relieve wind. A warm hot
water bottle, well-wrapped on the tummy may also help. Take out baby’s nappy
off also works. The remedies are try out herbal teas made with boiling water left to
cool can be tried. Chamomile and fennel are thought to be effective. Only give two
or three teaspoonful on a sterilized spoon. Mother may also be able to soother the
baby for feeding at the breast. The old remedy was grape water.
Assessment and Handling of Newborn 105
CHAPTER
18
Assessment and
Handling of Newborn
The baby will be taking few minutes to get used to life outside the womb and the
carers will be watching as baby becomes accustomed to his new environment.
The carers will assess his well-being. Baby’s mouth, nose will be cleared of
excess mucus and eyes are wiped with swaps.
APGAR SCORE (TABLE 18.1)

The Apgar score is given by taking one or two normal assessments and most
commonly taken about a minute to five minutes after the birth. The Apgar sore
is used primarily to help staff to recognize those babies who need immediate
specialist care. The scores of 0, 1, or 2 are given on various aspects of the baby’s
appearance and health and then made up. Few babies achieve a score of a
maximum of 10 because it takes time for the circulation of even the healthiest
and most alert babies to reach all the extremities. A score of 7 is good, babies
scoring between 4 to 6 need help such as suctioning of the airways and
administering of oxygen.
Table 18.1: Apgar score
S.No Sign Score-2 Score-1 Score-0
1 Color Pink for white baby Pale or blue Pale or blue
Brown for a black baby extremities all over
2 Pulse or heartbeat Over 100 per minute Less than 100 Not discernible
3 Response to Strong Makes a face No response
stimulation
4 Muscle tone Moves strongly Limbs are flexed Limbs are weak
and floppy
5 Respiration Strong Slow or irregular Absent
MEASURING THE BABY

Baby length, head, circumference and birth weight are recorded which will be
useful baselines against which his future growth can be compared. More than
95 percent of babies born at term weigh from 2,500 to 4,250 gram or five and half
to nine pound with the average being 3,400 gram or seven and half pound. Boys
on average weigh 250 gram half pound more than girls. The baby’s length is
measured from crown to heel, and will in between 46 and 56 cm, 18 and 22 inch,
the average is 51 cm or 20 inch. Baby’s head circumference will be between 33
and 37 cm or 13 and 14 ½ inch, the average is 35 cm or 13 ¾ inch. A finger is put
in the mouth of the baby to feel. Examine and to check for cleft palate.
The doctor will be listening to the baby’s heart. If there is heart disorder can
be known by irregularity of heartbeat or by the sound of the blood going in and
out of the chambers of the heart. Heart murmurs are very common, many as 50
percent of babies have them in the first week and in later weeks they disappear.
To prevent hemorrhagic disease of the newborn in which blood fails to clot
vitamin K supplements is given soon after birth either orally or by injection to
prevent the above rare disease. The baby’s heart beats around 120 times a minute.
The pediatrician checks the heartbeat, will also feel the chest to check that the
lungs are expanding, as they should.
LATER CHECKS
In the first week of baby’s life, several more checks are done on everyday in the
first week. A sample of blood will be taken by pricking his heel. The blood will
be tested for phenylalanine, high levels of which indicate a very rare metabolic
disorder that affects 1 in 15,000 babies that leads to severe brain damage.
Treatment involves placing affected children on a restricted diet until puberty,
so by that time the body gets acquired and will have the ability to handle the
amino acid.
Baby will also be tested for an under active thyroid, which could slow brain
development. Doctor will check the soft spots on the baby’s skull, the bones of
the arms and legs and the neck and shoulders for any abnormalities.
The baby’s abdomen is felt to check his internal organs. The genitals will be
examined to make sure that there is no sign of hernia. Hip joint is checked for
clicking hip. The doctor will manipulate each hip joint to check that the head of
the femur (thigh bone) moves well within its socket and that it does not slip out.
If it is dislocated it slips out easily or unstable which means that it is liable to
become dislocated later, treatment involves using a splint or plaster to hold the
femur in place as the baby grows.
After a couple of days the baby’s skin has a yellow tinge. In the early days of
the life the liver does not always function well. Bilirubin is one of the products
of the breakdown of red blood cells in the liver may spill into the bloodstream
and build up there. This usually clears up after the fourth day but if it persist, a
blood sample will be taken to check the level of bilirubin. If levels continue to
rise, the baby will be given phototherapy treatment with ultraviolet light.
Phototherapy treatment for jaundice alters bilirubin so that it can bypass
the liver and can be extracted by the kidneys instead. The majority of babies
sleep through the treatment. Bilirubin lights can also be prescribed for home
use. Baby’s heart will be listened to again before leaving hospital and every
time he has a check up. At least until school age. This is a precautionary measure
in case a abnormality has been missed and because some heart disorders become
apparent only when the baby is older. Most problems can be treated if caught
early (Fig. 18.1).
Fig. 18.1: Phototherapy treatment for jaundice
COMMON MUSCULOSKELETAL DISORDERS

Congenital Dislocation of Hip
It is posterior dislocation of the femoral head in the acetabulum that cause
abnormal relationship.
Treatment
Immobilization of reduced hip in flexion, abduction position for a period of 6 to
12 weeks, Vonrosen splint, pelvic harness or Denis Brown harness splints are
used.
Physiotherapy Treatment
During mobilization period side lying, sitting and prone position should be
used.
Talipes Equinovarus
This is the condition where there is adduction, inversion and plantar flexion of
the foot.
Exercises and electrical stimulation are given. Exercises to dorsiflexors, everters
are done. Massage should be done. Passive mobilization or lengthening of
short soft tissues in direction of movement in abduction, eversion and
dorsiflexion at the midtarsal, subtarsal and talocrural joints. The corrected
position is maintained for 20 seconds. It is performed 5 times daily.
Strapping
Strapping with tape is done to maintain the foot in a corrected position.
Metatarsus Adductus
This deformity consists of adduction of the forefoot and varus of the midfoot.
Passive movements are given by stabilizing the calcaneum and cuboid with
one hand, hip and knee flexed with other hand. Thumb should be moved along
the medial border of the forefoot and lateral pressure applied slowly and
gradually. The therapist aim to increase the distance between the stabilized
hind foot and the forefoot. The corrected position is held for 20 seconds and
repeated 2 to 3 times.
Talipes Calcaneus Valgus

It is a postural deformity where the foot is held in dorsiflexion. The foot is
moved to plantar flexion and inversion for 20 seconds, massage with oil and
passive movements should be firm and gentle.
Brachial Plexus Injury

It involves Erb’s palsy, Klumpke’s palsy and total brachial plexus lesion.
Initially, the baby is left and only given pain relief, use of peanut pillow during
nappy change, to prevent soft tissue contractures, passive movements should
not be attempted in the first few days, mild injury will recover in a few days and
most brachial plexus injuries have fully recovered by 12 months. Peanut pillow
is used to maintain midline orientation, gentle passive movements are performed,
shoulder abduction, elevation, elbow flexion, wrist extension, forearm supinated,
finger extension and thumb abduction must be combined and repeated slowly.
Sternocleidomastoid Tumor
It is a hard lump occurring in the sternocleidomastiod muscle at about the level
of the angle of the jaw and will be felt when the baby is at two weeks old.
CHAPTER
19
Exercise Therapy
Regime
The physiotherapy plays very important role during this period for healthier
pregnancy, easier childbirth and regain the shape back to the normal. So effective
practice for physiotherapist is based on a sound knowledge and understanding
of anatomy and physiology and of the social and psychological aspects of the
each stage of child bearing year
AIMS OF OBSTETRIC PHYSIOTHERAPY

1. To promote good health, price and sense of well-being during pregnancy
and encourage preventive medicine.
2. To give women the opportunity to discuss their fears and expectations in a
relaxed and sympathetic atmosphere and to acquire positive and accurate
information about pregnancy and labor.
3. To offer instructors in skills to conserve energy, raise pain tolerance levels
and maintain control during labor.
4. To alleviate stress and strain of the pregnancy.
5. To rehabilitate women during the puerperium to full physical activity and
mental well-being.
The exercise regime of pregnancy is called Pilates. Pilates are defined as the
mild or moderate exercise method to be used in the months of pregnancy, after
birth and to regain shape back to normal. The exercise designed to strengthen
the back, pelvic floor, to maintain tone of the abdominals and achieve the longer,
leaner and stronger body.
Exercise Therapy Regime 111
PRINCIPLES
The Concentration
Concentration is fundamental aspect of exercise required or correct performance
of technique or diversion may occur on the concerns, anxieties that will have
affect future mother and fetus.
The Breath
Breathing plays a vital role. There are two breathing exercises in the warm-up
session. This helps the woman to breath deeply, rhythmically and to the full
capacity. When exercising she has to breathe in and breathe out with effort, this
helps the woman to relax a movement. If vice versa happens, i.e. if she breathes
in for the effort she will get tensed up.
The Girdle of Strength

The girdle of strength is essential for all exercises. It includes three areas. They
are the upper back, the abdomen and the buttock.
The Back
The upper limb exercises are very important in relieving the tension and can be
the major seat of tension. So, woman has to perform the upper limb exercises
correctly from the midline of the back so that she will be free of tension.
Abdomen
All the exercises begin by drawing the navel gently towards the spine. This
strengthens the transverse abdominis muscle to regain a flat stomach and protect
the back against undue strain during the exercise.
Buttock
Buttock muscle movements and squeezing during the exercise will tone the
muscles and also bring the body into the perfect alignment thereby improves
the posture and protects the back from strain or injury.
Relaxation
Relaxation plays a vital role in the exercise session. The warm up should be
done whenever exercises are performed. This helps in reducing the tension in
the body. Breathing control is also important by slowing down the breathing
and followed by the relaxation at the end of exercise session.
IMPORTANCE OF EXERCISE SESSION

1. The increase in hormones relaxes the ligaments and muscles make pregnant
woman’s body supple than normal woman, so body will be loose. Stretching
exercises should be avoided.
2. All the joints become unstable, so the pregnant woman should maintain the
tone of the abdominal muscles or the back may get strained.
3. The posture should be checked regularly. In the 1st trimester utmost care
must be taken to prevent damage to her back. Because when the weight of
the body changes, the center of gravity tends to induce a sway back in her
stance.
4. Women breast also enlarge rapidly from the beginning of pregnancy, the
extra-weight puts strain on the neck, shoulders, upper back as well as
shoulders become rounded resulting in postural problem. So, a woman has
to perform regular shoulder, neck exercises, should know posture correction.
This will release tension in the area, increases mobility. Woman should also
wear a well-fitting bra that will give her support at each stage of her pregnancy
5. The extra-blood is produced, waste disposal system increases, amniotic
fluid surrounding her baby and the fluid to all of her body tissues in the
pregnant woman body will increase, so regular exercises must be done to
keep the fluid moving and to prevent edema which is retention and swelling
of the area, woman also has to drink plenty of water.
6. Pelvic floor exercises play an important role because this will help to reduce
the risk of varicose veins as the effect of relaxin causes the wall of the women’s
blood vessels to relax which leads to varicose veins as well varicosities in
the vulva or anus called hemorrhoids or piles.
7. The digestive system is also affected with morning sickness and leads to
nausea or actual vomiting. This usually disappears after the third month of
pregnancy. Digestion slows down during pregnancy and will result in
heartburn or constipation. Exercise helps women’s metabolism speed up
gradually and risks are reduced.
8. After the birth of baby, body starts to return to its pre-pregnant state, reducing
output and fluid balance immediately. Breastfeeding will speed up this
process. Women body will be back in shape, so women should take time to
recover, relax, rest into mother’s new role.
EXERCISE PROGRAM
Exercise is important during pregnancy on a number of levels. Pregnancy is
time to focus of stretching, relaxing and general toning.
AIMS OF PHYSIOTHERAPY
1. To provide maximum possible physical independence.
2. To give relief of symptoms.
3. To improve functions of the body.
4. To increase functional capacity.
GUIDELINES FOR EXERCISE DURING PREGNANCY

1. Exercise thrice a week.
2. Maximum heart rate should not exceed 140 to 150 beats per minute.
3. Maintain adequate fluid intake to avoid dehydration.
4. Proper diet to be taken to meet the exercise needs.
5. Avoid exercise during illness.
6. Avoid exercising in supine position after end of the fourth month.
CONTRAINDICATIONS
1. Gestational diabetes.
2. History of miscarriage, premature labor.
3. Vaginal fluid loss.
4. Hypertension.
5. Multiple pregnancies.
6. Abnormal placental function or position.
7. Anemia.
8. Decreased fetal movement.
EFFECTS AND USES OF EXERCISES

1. Helps to improve posture.
2. Aids to reduce stress and anxiety.
3. Maintains cardiovascular fitness.
4. Reduces backache.
5. Aids in preparation for labor.
6. Maintains muscle flexibility and length.
7. Helps in control of weight.
8. Improves body awareness.
9. Improves blood circulation.
10. Reinforces relaxation.
11. Decreases fatigue.
12. Reduces stress and anxiety.
13. Increases endurance and stamina.
14. Provides social interaction. Assist postnatal recovery.
15. Helps in shaping up back to normal.
AIMS AND PLANS DURING PREGNANCY

1. Aim: To teach knowledge of awareness and control of posture.
Plan: Postural awareness training, strengthening and stretching postural
muscles.
2. Aim: To learn safe body mechanics.
Plan: Body mechanics in sitting, standing, lifting lying, moving from one
position to another, during labor and delivery.
3. Aim: To prepare the lower limbs for weight-bearing and prevent circulatory
problems.
Plan: Stretching exercises, resistance exercises to the muscles of lower limb,
use of elastic stockings or edema control.
4. Aim: To teach the importance of the exercise and control of the pelvic floor
muscles.
Plan: Awareness of pelvic floor contraction and relaxation. Train
strengthening and muscle control.
5. Aim: To maintain abdominal function and prevent diastasis recti
pathology.
6. Aim: To promote safe cardiovascular fitness.
Plan: Aerobic exercises.
7. Aim: To have knowledge about pregnancy and childbirth.
Plan: Women should attend antenatal physiotherapy classes arranged at
the hospital.
8. Aim: To teach relaxation method.
Plan: Women should make a habit of practicing relaxation techniques.
9. Aim: To prevent impairments associated with pregnancy like low
backache, pelvic floor weakness, and decreased circulation.
Plan: Women should attend classes to know about problems of pregnancy,
preventive techniques and appropriate exercises.
10. Aim: To mentally prepare woman for labor and delivery.
Plan: Women should have knowledge about of signs of starting of labor.
11. Aim: To develop awareness of the pelvic floor dysfunction.
Plan: Pelvic floor exercises strengthening during pregnancy, after birth
should be taught.
First Trimester
In the first trimester strenuous exercise should be avoided as it may lead to
miscarriages, concentrate on improving posture, strengthening the pelvic floor,
relaxation, and breathing techniques.
Posture Awareness
This helps in release of tension, improves the blood supply, improves the
functions of the autonomic nervous system which in turn improves the
functioning of the reproductive organs, it reduces the strain of muscles, joints
and ligaments.
Standing posture:
• Head and neck: Head should be relaxed and balanced on the top of the spine
with neck straight.
• Shoulders and arms: The arms hang comfortably by the sides without tension
looking straight at the mirror; check the shoulders are at an even height.
Turn sideways to the mirror and check that the shoulders are neither pulled
back, which distorts neither neck nor slouched forward.
• Back and stomach: Stand sideways on to the mirror to check your back. Let your
spine lengthen out. Draw the navel gently towards the spine and gently pull
up the pelvic floor muscles, so doing like this prevents strain to the back.
• Buttocks: The navel and back are in the correct placement, pelvis will be
lightly upward. So lowest muscle in the buttocks must be squeezed for correct
alignment.
• Legs and feet: The feet should be a hip foot apart with the toes facing forwards
weight should be taken equally on both the feet.
Pelvic Floor
Pelvic floor strengthening is important because the muscles support the baby
and extra-weight of the uterus, prevent incontinence, hemorrhoids and prolapse
of the uterus.
Position of patient: Standing up, sitting down, squatting on heels with knees
apart. If women has problems like hemorrhoids and varicose veins then prefer
sitting on a chair.
Contract and release: slowly contract pelvic floor muscles in long upward
movements towards the uterus. Abdomen and buttocks should be relaxed. Hold
and slowly release. Perform ten repetitions.
The lift: Contract pelvic floor muscles and pause three times.
Pulses: Contract all the pelvic muscles and then release rapidly, so do this
repeatedly in time within pulse time.
Breathing Exercises (Fig. 19.1)

Relaxation and stretching are done with treath in a movement and effort takes
place in treath out.
Fig. 19.1: Breathing exercise
Breathe awareness: Lie on the back with a small cushion below head and feet
should be on the chair so that knee will be right angle. See to that back is straight
and no tension in the shoulders or neck. Place the hands on abdomen so that
the fingers touch each other. As woman breathes in the inhalation should reach
the abdomen and indicated by separation of the fingers, as she breathes out the
fingers should meet again. Do not exaggerate the movement and repeat for 10
breaths.
Rib Awareness (Fig. 19.2)

Sit on a ball or chair with feet on the floor with hip width apart, toes pointing
forward. The back should be straight with no tension in the neck and shoulders
wrap a long scarf around back at rib level, cross it in front and hold one end in
each hand breathe in and feel the expansion of ribs and breathe out and feel the
ribs contact. Repeat for 10 breaths.
Fig. 19.2: Rib awareness

Head Roll and Head Tilt (Figs 19.3A and B)

These exercises relieve tension in the shoulder and neck and keep the spine in
proper alignment.
1. Sit with both the feet flat on the floor with a long, straight back. Draw the
navel gently to the spine and pull up the pelvic floor. Check there is no
tension in the shoulders, neck or face particularly in jaw, forehead and
around the eyes. Take a few long deep breaths and let women relax.
2. Drop your chin down to your chest, without moving or tensing the shoulders.
Roll the head around towards the right, center, left and return to the central
position and lift the head, repeat for 4 to 5 times.
3. Turn the head and look to the right shoulder. Chin should be slightly tucked
in and turn to the left side and return to the center.
A B
Figs 19.3A and B: Head roll and head tilt
Shoulder Lifts and Circles (Figs 19.4A to D)

This exercise relieves tension in the upper back. Keep the backbone straight.
1. Lift the shoulders as high as can reach towards your ears, letting the arms
hang loosely at your sides. Drop them heavily. Repeat each shoulder for 5
times.
2. Draw the shoulder forwards so that she can close up the front of the chest
and take them backwards to touch the shoulder blades. Repeat for five times.
Arm Stretches (Figs 19.5A to C)

This helps in toning up the arms:
1. Sit on a chair with feet flat on the floor with backbone straight. Draw the
navel gently to the spine and pull up the pelvic floor. See to that there should
be no tension. Take a few long deep breaths and relax.
A B C D
Figs 19.4A to D: Shoulder lifts and circles
2. As she breathes out lift the arm straight to the shoulders level a breathe in put
the hands down. This causes stretch in the shoulders. Repeat 5 to 10 times.
3. Drop the arms down to your sides, take the arms straight behind you. Bring
back to normal position, repeat the same for five times. This gives downward
stretch effect.
4. Sit with the arms bent at the elbows and fingers pointing to the sides and
keep the elbows tuck into sides. Breathe out return to normal position. Repeat
for five times.
A B C
Figs 19.5A to C: Arm stretches
Side Stretch (Fig. 19.6)

This gives side stretch
1. Sit sideways on an armless chair with feet on the floor and left hand holding
the chair back. Backbone should be straight. Draw the navel gently to the
spine and pull up the pelvic floor. Slowly breathe in and breathe out.
2. Place right hand behind your head. Breathe out turn your head to look away
from the chair back a pull through the ribs. Now, stretch gently away from
the chair back feeling the lower ribs stretching up.
Fig. 19.6: Side stretch
3. Breathe in to return to the starting position and repeat 5 to 10 times. Repeat

on the other side.
Forward Bend (Fig. 19.7)

1. Stand facing a window ledge or heavy table or chair and arms length away.
Feet should be firmly on the floor; hip-width part keep the backbone straight.
Draw the navel gently to the spine and pull up the pelvic floor. Raise your
arms above your head without raising your shoulders.
2. Breathe in and while breathe out slowly bend forward. Let the fingers rest
on the support and feel a long stretch through the arms, neck a back. Hold
this position for a minute and breathe naturally.
3. Now, continue to bend forwards and drop the head towards the floor, if
strain is felt bend the knees slightly.
4. Breathes in and breathe out slowly roll up back to the straight standing
position. Repeat this for five times.
Pillow Squeeze (Fig. 19.8)

This causes exercise to pelvic floor, inner thigh, postural awareness and relaxing
the lower back.
Position of woman is supine lying with a pillow below her head.
1. Lie on your back with the knees bent and feet flat on the floor. Gently hold
the pillows between knees. Place the arms by side of the body with palms
down. Whole body should be relaxed. Breathe in pull up the pelvic floor
muscles.
Fig. 19.7: Forward bend
Fig. 19.8: Pillow squeeze
2. Breathe out squeeze the pillows with your knees.

3. Breathe in to release the cushion comes back to the starting position and
repeat the same for 10 times.
Relaxation: After exercising it is important to relax. This should be for 10 to 15
minutes. This relieves stress levels, feeling of tiredness, ability to cope and
overall health will be fine.
Relaxation Sequence (Fig. 19.9)

Lie down on the floor with the spine straight, arms close to sides, palms
uppermost because it causes upper back and shoulders down, comfortable on
the floor close your eyes and relax total body and slowly roll the head from side-
to-side to check the tension in the neck. Practice the relaxation techniques, i.e.
Yoga-nidra.
Fig. 19.9: Relaxation sequence
Alternating the Breath

Alternate nostril breathing should be practiced after relaxation because it
improves oxygen intake, purification and circulation of the blood and lymph.
Oxygen flow is increased to every cell in the body, improves alertness,
concentration and a good exercise or lungs and respiratory muscles.
1. Keep your backbone straight, sit on the floor with crossed legs or in the
chair. Breathe in and breathe out with force.
2. Close the right nostril with the help of right thumb and breathe in and
breathe out with force through left nostril.
3. Close the left nostril with right hand little finger and breathe in an breathe
out with the left nostril.
4. Alternately close the right and left nostril and breath alternately with force.
Second Trimester
In the second trimester: All signs of nausea disappear. Women feel extremely well
both physically and emotionally. So, exercises to protect against strain and
injury, to boost the circulation of both blood and lymph, to keep muscles tone
and sense of well-being.
Curl-ups
This exercise causes increase mobility in the spine strengthens pelvic floor and
abdominal muscles.
1. Lie on your back with knees bent, feet slightly apart and flat on the floor.
Shoulders and neck are relaxed and arms by the side of the body. Place a
rolled towel between the knees and slowly lengthen the spine along the
floor, tuck the chin in and lengthen the neck.
2. Slowly breathe in and as you breathe out draw the navel gently towards the
spine. Lift the buttocks and back slightly up so that shoulder blade should
touch the floor. This causes mobility of the spine.
3. When the body is lifted up, breathe in and breathe out, lower the back down
slowly and place it on the floor. Repeat for 5 to 10 times.
Knee to Chest
This exercise helps in improving posture, releasing the tension in the lower
back and neck.
1. Lie on your back with knees bent and feet flat on the floor, the spine, neck,
and head straight. Lift the knees up and feel the whole spine in contacts
floor. Place your hands just below the knees, holding them apart to fit around
the bump. Draw the navel gently back towards the spine throughout the
exercise.
2. Breathe out draw your right knee towards the chest, breathe in release the
knee, neck and shoulders should be relaxed.
3. On the next out breath, draw the left knee to the chest in the same way.
4. Breathe out draw both the knees to the chest. Repeat the whole sequence 5 to
10 times.
Opposite Arm and Leg Stretch

This exercise helps in stretching out and relaxing the body.
1. Lie on your back with your knees bent, feet flat on the floor and arms beside
you. As you breathe out slide your left leg away from you on to the floor
simultaneously lifting your right arm up above your head to lie flat on the
floor.
2. Breathe in and breathe out return your arm and leg to the starting position.
3. On the next breathe out; repeat with the left arm and right leg. Alternate 5 to
10 times.
Arm Reaches
This exercise is useful for releasing tension in the shoulders, back and neck.
1. Lying on your back, place your feet on the floor, slightly apart with knees
bent. Reach your arms straight, so those finger tips are pointing at the ceiling.
2. Breathe out take your arms in the opposite directions, so one goes above the
head closely to the floor and other goes down to your side. Breathe out come
back to the starting position
3. Breathe out repeat the same in opposite direction. Perform alternatively for
10 times.
Hip Rolls
This exercise is designed to release the tension from the back and neck and
helps for relaxation.
1. Lie on your back with your feet together and knees raised and slowly breathe
in and breathe out.
2. Breathe out roll the knees gently to one side keeping them together. Breathe
in return to the center.
3. Breathe out repeat the same on the opposite side. Repeat the whole sequence
10 times on each side.
Knee Drops to Side

This exercise relaxes pelvic area.
1. Lie on your back with knees waist and feet flat on the floor slowly breathe in
and breathe out.
2. Breathe out slowly drop one knee to the side without lifting the hip or moving
the pelvis, breathe in and return to the starting position.
3. Breathe out drop the other knee to the side and return back to the starting
position, and repeat the same for five times on each side.
Leg Slides
This exercise maintain good alignment and posture, mobilizes and stretches
the joint of the leg.
1. Lie on the floor with knees raised and feet together on the floor and slowly
breathe in and breathe out.
2. Breathe out straighten one bent knee along the floor and breathe in return
back to the starting position.
3. Repeat the same with the other leg and perform the same alternately five
times on both sides.
Hamstring Stretch
This is the stretch for hamstring muscles, this also release the feeling of heaviness
in the legs, edema.
1. Lie on your back with both the knees bent, feet flat on the floor, the shoulder
should be relaxed, wrap a long scarf or belt along the foot and slowly bring
the left knee up towards the chest and slowly breathe out straighten the leg
up towards the ceiling. The knee should be facing the woman try to feel the
stretch for a count of ten to twenty.
2. Breathe in bent the leg slowly and relax for a moment and repeat the same
on the other side.
Leg Stretchers
This is the exercise that reduced the edema and strengthen the abdominals.
1. Lie on your back with both the feet together flat on the floor and knees raised
now take your feet off the floor. Keeping the knees apart to make a V shape
towards your toes.
2. Breathe in and bring one knee up towards your chest and breathe out and
stretch of the second leg.
3. Breathe out change the legs, so that second leg is drawn towards the chest
and first is stretch up and repeat the same five to ten times on each side.
Leg Lift
This exercise help to reduce edema and keep the muscles strong.
1. Lie on your side against a wall. Place a big cushion below the upper leg and
rolled up towels to support the waist, now stretch out your lower arms
parallel to your spine and place a small cushion between head and arm,
bent your lower leg and flex the foot of your upper leg on the cushions place
your upper hand on your upper hip.
2. Breathe out slowly lift your whole upper leg slightly upwards, breathe in
slowly bring back to starting position.
3. Breathe out perform the same on the other side by same arrangement of the
pillows.
Posture Awareness
This exercise done in front of the mirror to check the position to know how
spine does works and to improve the posture.
1. Sit on a chair or a ball and keep your backbone straight in front of the mirror
with both arms folded and few inches in front of the chest only rest your
hands against your arms and slowly breathe in and breathe out.
2. Breathe out slowly turn your spine to the right side, breathe in return to the
starting position.
3. Breathe out turn to the left side and repeat the same alternately five times on
each side.
Squatting Against a Wall

This exercise helps to maintain the mobility of the pelvic and hip joint.
1. Put a big cushion on the floor next to wall stand against the wall with feet
hip width apart and slowly breathe in and breathe out.
2. Breathe out slowly begin to bent your knees and slowly slide your lower
back down the wall keep your heels flat on the floor. Stay in this position for
a minute or two.
3. Slowly breathe in and breathe out slide slowly up back the wall.
The Quadruped Position (Figs 19.10A to C)

This exercise stretches and relaxes the back
1. Position yourself on your hand and knees with hip width apart in front of
the mirror and check shoulders hips and knees are all in alignment and
slowly breathe in and breathe out.
2. Breathe out slowly draw the naval back towards spine so that back arches
up and head drops down between the arms. Breathe in and return to the
starting position.
3. Breathe out and arch your back so that it hollows out and raised your head.
Breathe in and return to back to the starting position. Repeat the both for five
to ten times.
A B C
Figs 19.10A to C: The quadruped position
Pillow Squeeze
This exercise is to strengthen the pelvic floor and tones up the inner thigh.
1. Lie on your back with knees flexed with a harder pillow in between knees
and thighs and feet slightly apart and flat on the floor. Slowly breathe in
and breathe out.
2. Breathe out pull the muscles of buttocks and thighs and squeeze the pillows
to the count of ten breathe in slowly relax. Repeat the same for five to ten
times.
Relaxation Sequence
Finish this whole exercise session with the relaxation sequence.
Third Trimester
In the third trimester women feel the extra weight unbearable. So exercise plays
an important role in reducing the edema, correcting the postural imbalance. So
the relaxation and the breathing technique are the best.
Foot Arching
This exercise decreases the risk of edema. Whenever possible keep the feet raised
with a pillow, feet if lying on the bed.
1. Keep backbone straight and sit near the edge of a chair, with feet slightly
apart, flat on the floor and slowly breathe in and breathe out.
2. Without moving the heels slowly draw back the toes, so that arch increases.
Go back to the starting position.
3. Stretch the toes upwards as far as they go. Come back to starting position.
4. Raise your inner border of the foot. This is called eversion and come to
starting position then raise your outer border of the foot. This is called
inversion and come back to starting position. Repeat all of the above for five
to ten times.
Ankle Exercises
This is the good exercise for swollen feet.
1. Sit with the backbone straight against the wall, the lower legs are supported
with a pillow. Slowly breathe in and breathe out.
2. Slowly bend your both feet forwards, this is called dorsiflexion. Hold and
count five and come back to starting position.
3. Slowly bend both feet downward this is called plantar flexion, feel the stretch
and count five and come back to the starting position.
4. Slowly circle the ankle for five times clockwise and anticlockwise direction
and come back to the starting position.
Hand and Wrist Exercises

This exercise helps in reducing tension and swelling too.
1. Sit comfortably in the chair and keep your backbone straight, shoulders and
neck should be relaxed. Bring both your hands together so that finger tips of
both the hands should touch each other and press them firmly without any
other parts of the hand touching each other. Hold for a count of ten and
come back to the starting position.
2. Shake your hands loosely in front of the mirror for ten times.
3. Make and fist close them and open them for ten times.
4. Rotate your wrist five times clockwise and anticlockwise direction.
Arm Raises
This exercise helps to improve posture, reduces tension in the necks and
shoulders.
1. Take a long scarf and stand with the feet hip width apart with the long
straight back and neck and slowly breathe in and breathe out and hold the
scarf in front of you, breathe out raise the scarf on to the top of the head. Do
not lift the shoulders and slowly breathe in.
2. Slowly breathe out and lower the scarf again and repeat the same.
Legs Against the Wall

This exercise reduces swelling in the ankles and feet. Need not perform the
second one till you feel comfortable.
1. Keep a cushion below head, position in such a way that bottom touches the
wall and lift your feet till you are comfortable on the wall, straighten the legs
and flex the feet or toes can be pointed with knees bent. Hold this position
for 10 minutes or longer depending on comfort of the woman.
2. If the first position is easy then go for second, this causes stretch of the
innerthighs. Slowly take both the legs outward and feel the stretch. Relax for
five minutes.
3. Bend the knees and roll sideways on to the floor to come out of either position.
Spinal Twist
This exercise relaxes back and stretches hamstring and calf muscles.
1. Sit on the floor with backbone straight with legs stretched straight and
shoulders should be relaxed.
2. Bend your left leg and cross your foot over the right leg and keep by the side
of the right knee in the bent position and hold the left knee with the right
arm. Place the palm of the left hand on the floor behind you and breathe out.
Turn your head to look back and breathe in come to the center and repeat the
same exercise for ten times.
3. Repeat the same on the others side.
Sitting with Legs Wide Apart

This causes stretch of the hamstrings and the inner thighs. Increases mobility of
the hip joints and releases the tension in the back and shoulders. Breathing
exercises can also be done in this position.
1. Sit down with backbone straight supported by the lower back, legs straight
in front and slowly breathe in and breathe out.
2. Slowly open your legs wide apart to feel the stretch breathe deeply in and
relax and come back to the starting position.
Leg Raises with Pillow Support

This exercise helps to maintain the tone of the leg muscles.
1. Sit on the floor with the backbone straight by the wall and legs straight in
front of you. Place a double pillow under your right knee so that it supports
the leg and place the left foot on the floor with the knee bent.
2. Slowly straighten the right leg, point the toe, flex the heel and lower the leg
to the pillow. Repeat this ten times and then change the legs.
Child Pose with Pillow Support

This is the best relaxation position in the late pregnancy. It relieves the pressure
on the lower back and opens up the pelvic area.
1. This needs lot of cushions for comfort. Sit on the top of a cushion or bolster
with your knees as open as possible and feet close to your buttocks. Put a
large cushion in front of you and make sure spine is straight. Close your
eyes and take five deep, slow breathes and feel your whole body relax.
2. Place your hands on the floor and walk your body to the cushions in front of
you, placing your arms and head on top and relaxing into the pose. Keep
your back long and place your head to one side. Slowly breathe in and
breathe out and return to the starting position, sit with your eyes closed and
breathing deeply.
POSTNATAL PERIOD
This is the period lasted from immediately to six months after birth.
Aims and Plans of Physiotherapy

1. Aim: To develop awareness and control of the pelvic floor musculature.
Plan: Pelvic floor muscle contraction and relaxation training and
strengthening program for muscle control and treatment for prolapse,
incontinence or hypertonus.
2. Aim: To bring awareness and control of posture during postnatal period.
Plan: Postural awareness training and strengthening and stretching of the
postural muscles.
3. Aim: To learn safe body mechanics.
Plan: Body mechanics with baby equipment and childcare activities.
4. Aim: To develop upper limb strength to meet demands of infant care.
Plan: Resistive exercises to the appropriate muscles.
5. Aim: To promote increased body awareness and a positive body image.
Plan: Woman should know the importance of body awareness,
proprioception activities and posture reinforcement.
6. Aim: To maintain abdominal function and correct diastasis recti pathology.
Plan: Woman has to perform diastasis recti exercises, abdominal
strengthening exercises with diastasis recti protection.
7. Aim: To encourage for relaxation.
Plan: Woman should practice relaxation techniques regularly.
8. Aim: To provide education on the safe postpartum exercise progression.
Plan: Women should attend the exercise session before delivery to have a
clear idea of the importance of postpartum exercises.
Immediately after the birth it is the feeling of joy and excitement and tiredness.
The exercise session is divided into three sections. They are:
1. First three months
2. Three to six months
3. Six month onwards
First Three Months After the Birth

Soon after the birth start the pelvic floor exercises. Mothers who go for the
breastfeeding should take of shoulders and neck. To relieve tension do exercise
regularly.
Flexing the Feet (Figs 19.11A and B)

The use of this exercise is to maintain tone of the muscles of legs, buttocks and
abdominal muscles and reduce fluid retention in the ankles. Position of the
patient is standing, sitting on the floor, can use the ball to make abdominal
muscles work even harder.
A B
Figs 19.11A and B: Flexing the feet
1. Sit on the floor with the backbone straight and stretch the whole length of
the leg. Shoulders should be dropped with arms outstretched in front at the
shoulder height.
2. Maintain the same position and flex the feet so that the toes pointing up to
the ceiling.
Standing position: Stand holding on to the chair back and perform the same.
Point and flex 10 to 20 times.
Arm Exercisers (Figs 19.12A to C)

This exercise prevents the edema.
1. Sit down with the legs crossed and keep your backbone straight, if felt
uncomfortable, use a small cushion, stretch the arms out making a loose fist,
a few inches off the floor.
2. Spread your fingers and make a fist continuously and take your hands up
above the head and do not raise your shoulders.
3. Repeat the same pattern and bring the arms down and repeat for five times.
4. Stretch the arms outside to the shoulder height.
5. Flex the hands so that the fingers are straight and pointing upwards towards
the ceiling. Stretch is felt all the way along the underside of the arms.
6. Reverse the hands so they drop down, curling the fingers back towards the
body as far as possible. Stretch should be felt along the backside of the
hands, wrist and forearms. Flex and curl 10 to 20 times.
A B C
Figs 19.12 A to C: Arm exercises
Bottom Walking (Fig. 19.13)

This exercise is best for the leg-toning.
1. Sit on the floor with both the legs stretched and backbone straight. Stretch
your arms in front and move them along with legs.
2. Moving from the hip and keeping the back straight, walk the right left forward
so that the right foot is in front of the left. Walk with the left leg in front of the
right. Repeat forwards for ten steps. Walk the left leg in front of the right.
Repeat forward for ten steps, then backwards for another ten steps.
Fig. 19.13: Bottom walking
The Pelvic Floor (Fig. 19.14)

This exercise strengthens pelvic floor.
1. Lie on your back with knees flexed, feet flat on the floor. Back is long both the
hands on either side with palms of hands facing down and whole body
relaxed and slowly breathe in and breathe out.
2. As you breathe out squeeze the pelvic floor and the low buttock muscles and
feel the abdomen hollow. This movement occurs only in the lower body.
Repeat up to ten times. Each time trying to extend the movement.
Fig. 19.14: The pelvic floor
Side Rolls (Fig. 19.15)

This exercise strengthens the spine and oblique abdominal muscles.
1. Lie on your back with knees flexed and feet on the floor, place your arms at
a 45 degrees angle to your body, palms facing upwards and whole body
relaxed and slowly breathe in and breathe out.
2. Breathe out and start rolling your knees slowly in one direction and head in
other direction, and feet turns on to their sides but should not come off the
floor. The back should be straight on the floor, and slowly breathe in.
3. Breathe out come back to the center using the abdominal muscles to roll the
ribs then back and buttocks. Now, repeat the same in the other direction.
Repeat both for ten times.
Fig. 19.15: Side rolls
Buttock Squeeze (Fig. 19.16)

This exercise strengthens the lower abdominal and buttock muscles. Protects
the back from undue strain.
1. Lie down in prone-lying with a pillow under abdomen and other between
thighs and rest your forehead on hands, and turn your head to one side and
shoulders and neck should be relaxed. Slowly breathe in and breathe out.
2. Breathe out squeeze the cushions between the thighs using the muscles at
the base of the buttocks and inner thigh. Hold for a count of 5 to 10 and
release. Relax your body completely and repeat upto five times.
Fig. 19.16: Buttock squeeze
Heel Lifts (Fig. 19.17)

This exercises strengthens the lower abdominal and buttock muscles. Protects
the back from undue strain.
1. Lie down as in the previous exercise. Breathe out squeeze the pelvic floor
and buttock muscle and bend the right leg with a flexed foot towards right
buttock.
2. Move slowly to feel the stretch of the hamstring muscle. While holding
buttock and abdominal muscle firmly. Breathe out and lower the foot and
repeat the same with the correct breathing ten times on each side.
Fig. 19.17: Heel lifts
Arm and Leg Stretches

This exercise helps in stretching the arms and legs.
1. Lie in the prone lying with a pillow under the abdominal muscles, stretch
your arms above your head, palms facing down the floor and place the feet
a hip-width apart. Whole body should be relaxed slowly breathe in and
breathe out.
2. Breathe out squeeze the pelvic floor muscles and stretch the right arm and
the left leg as far as possible and little away from the floor and breathe in
lower to the floor.
3. Breathe out and vice versa. Repeat the whole sequence upto 5 times.
Gluteal Muscles
This exercise tones up gluteal muscle of the buttocks.
1. Lie in the prone lying with the cushion under the abdomen, fold your hands
in front of you and place forehead on top of them and turn face to one side to
be comfortable and slowly breathe in and breathe out. Slowly breathe out
and draw the navel by trying to lift above the cushion and hold this position
for rest of the exercise.
2. Stretch your right leg, pointing the toes, so that it comes off the floor. Now lift
the leg further so that you squeeze the pelvic floor muscle and the buttock,
but without hollowing the lower back or letting any tension creep into the
upper body.
3. Lift ten times on each side and then repeat the whole sequence with a flexed
foot, the toes pointing straight down the floor.
Standing Side Stretch

This exercise stretches the whole upper body and improves posture.
1. Stand side on to a heavy table or chair with hand resting on it. Stand near by
for a gentle stretch and move further away for a greater stretch. Place your
feet hip-feet apart, whole body should be relaxed and slowly breathe in and
breathe out.
2. Take a few deep breaths and try to feel growing taller by lengthening the
spine.
3. Breathe out lift the outer arm in a wide circle up an over the head bending
and body away from the support. Keep facing forwards all the time.
4. Breathe in to return to the starting position. Repeat the same upto 10 times
on each side.
Twist Exercise (Figs 19.18A and B)

This exercise helps in checking the posture and the rotation of the spine.
1. Stand straight with hip width apart, upper body relaxed. Slowly breathe in
and breathe out. Rotate the arms at the sides around the spine by turning
from the waist and letting your arms swing as they follow the movement.
Repeat the same for 10 times.
2. Make the swing looser by bending the knees each time as you come to the
center. Keep the knees and hips facing front all the time. Only upper body
moves. Repeat 10 times on each side.
A B
Figs 19.18A and B: Twist exercise

Feet and Ankle Exercise

This exercises feet and ankles.
1. Stand with both feet together, holding on to a firm support. Stand straight
with whole body relaxed and slowly breathe in and breathe out.
2. Breathe out pull up the pelvic floor muscles and tuck in the buttocks and
very slowly turn the feet out keeping the knees in line with the feet. Start the
movement from the hips and whole leg should rotate.
3. Reverse the movement bringing the feet back to parallel. Repeat 10 times.
Foot Exercise
This exercise tones up the foot muscles.
1. Stand tall with one hand on the support. Upper body should be relaxed and
2. Take your right foot forward with a pointed toe. Now lift and flex the heel.
Put the toe back on to the floor and draw it back to the other leg. Repeat 5 to
10 times and then repeat on the left.
Cushion Squeeze
This gives relaxation and tones up the inner backs.
1. Lie on back with backbone straight. Two pillows are placed one below the
head and other in between thighs with knees flexed and flat on feet. Breathe
out and squeeze the pillow for a count of 10. Repeat 5 to 10 times.
Relaxation Sequence
Practice the general relaxation technique for the whole body.
Three to Six Months After Birth

By this time a new rhythm of your lifestyle begins. Mothers will be having
broken sleep at night, will be anxious to get back into shape do not rush up as
the ligaments are still soft and will get strained easily so continue with the
exercises from the previous section up to the cushion squeeze and follow the
new ones like.
Knee Bends
This exercise helps in toning up the legs.
1. Stand in straight posture with a long straight back the shoulders and neck
should be relaxed, take the support of the chair if required, slowly breathe in
and breathe out.
2. Breathe out and turn the feet into V-shape. Breathe out and bend the knees
without lifting the heels off the floor. Breathe in and come back to the starting
position repeat the same upto 10 times.
3. Take the feet about 18 inches apart and perform the same.
Quadriceps Stretch (Fig. 19.19)

Stand straight with shoulders and neck relaxed hold a chair for additional
balance. Bend the right knee and take the foot behind you, holding the ankle
with one or both the hands. Hold the stretch for a minute and then change legs.
Fig. 19.19: Quadriceps stretch
Hamstring Stretch
1. Sit on the floor with backbone straight, right leg stretched and left foot placed
against the right thigh. Slowly breathe in and breathe out.
2. Breathe out reach forwards along your right leg and take series of deep
breaths each times trying to reach further down the leg. Or use a long scarf
around the foot. Repeat on the other side.
Gluteal Stretch (Fig. 19.20)

Lie on your back with your knees bent and feet flat on the floor. Place your left
ankle over the right knee then lift the right leg so that the left leg presses towards
you. You will feel the stretch at the back of the left thigh and into the buttocks.
Hold for a count of 20 and lower. Repeat on the other leg.
Fig. 19.20: Gluteal stretch
Pelvic Tilts (Figs 19.21A and B)

This exercises pelvic floor.
1. Lie on your back on the floor with your feet on a stable chair. The body
should be relaxed, place the arms on either side of the body with palms
facing down and slowly breathe in and breathe out.
2. Breathe out and slowly raise the pelvis up with the support of the hands
down, breathe in and come back to the starting position, repeat the same
upto 10 times.
A B
Figs 19.21A and B: Pelvic tilts
Single Leg Stretch (Fig. 19.22)

This exercises pelvic floor.
1. Lie on your back with feet flat on the floor and knees raised. Draw your
knees to your chest, keeping them apart to make a V-shape towards your
toes. Back should be flat on the floor and shoulders and neck relaxed.
2. Breathe in and bring one knee up towards your chest and breathe out, pull
up the pelvic floor and stretch out the second leg in front of you with a
pointed toe. The closer the leg is to the floor, the more effort the abdominal
muscles will have to make.
3. Take another long full breathe and as you breathe out, change the leg so the
second leg is drawn in towards the chest as the first is stretched out. Always
keep the whole back on the floor. Alternate 5 to 10 times on each side.
Fig. 19.22: Single leg stretch
Variation
When this is done easily try the same with the head raised towards the knees.
Abominal and Pelvic Floor Exercise

This exercise strengthens the abdominal and lower buttock muscles.
1. Lie face down on the floor with the feet slightly apart and the hands level
with the head, palms and elbows on the floor. Slowly breathe in and breathe
out.
2. Draw the shoulders and the muscles of the upper back down and lift the
head off the floor keeping the chest open. Breathe in and return to the starting
position, repeat upto 10 times.
Inner Thigh Lifts (Fig. 19.23)

This exercise strengthens inner thigh muscles.
1. Lie on your side with your back flat against the wall, the lower leg stretched
straight. Bends your upper leg so that knee forms a right angle and places
the knee on a cushion. Rest your head on the lower arm and place the other
hand in front of you or support and slowly breathe in and breathe out.
2. Breathe out lift the lower leg, keeping the foot extended forwards. Lower
and repeat upto 10 times on each leg.
Fig. 19.23: Inner thigh lifts
Variation: Try with the flexed foot and to make it harder still by adding 2 lb or
1 kg, ankle weight.
Arm Stretching
This exercises tones and strengthens and stretches the arms. Use weights of 2 lb
or 1 kg weights are ideal.
1. Stand about a foot away from the wall with the feet hip-width apart. Slightly
bend the knees and lean against the wall so that spine is in contact with the
wall and slowly breathe in and breathes out.
2. Breathe out and draw down your shoulder blades as you raise your arms
straight out to the sides. Bring them towards the shoulders without lifting
them. Repeat 10 times.
3. Lift your arms 10 times to the front bending at the elbows to raise your
hands to your shoulders.
Windmill Arms (Figs 19.24A and B)

This exercise helps in releasing tension and mobilizing the shoulders.
1. Lie with the knees flexed and feet flat on the floor. Now raise your arms so
that the fingertips point upto the ceiling.
2. Breathe out and take the arms in opposite directions, one above your head,
and palm up, the other down by your side, palm down. Take your arms till
they stretch.
3. Rotate the arms as you breathe in and reverse their positions, so that your
first arm is by your side the second above your head.
4. Breathe out, lift the arms up and repeat the sequence for upto 10 times.
Quadripued with a Leg Stretch (Figs 19.25A and B)

Those who have backache do not attempt these.
1. Kneel down on all four, body should be relaxed and slowly breathe in and
breathe out.
A B
Figs 19.24A and B: Windmill arms
2. Breathe out and raise the right knee up towards the chest, dropping the
head down to meet it.
3. Breathe in and straighten the leg out behind you, raising the head back to
the starting position. Repeat upto 10 times with each leg.
A B C
Figs 19.25A and B: Quadripued with a leg stretch
Stretch to Release Tension (Figs 19.26A and B)

1. Begin the same position of the previous exercise, tuck your toes under,
breathing out and press up from the floor so that the soles of your feet are flat
and make a triangle with your bottom as the apex. Straighten your legs as
much as possible, keeping your back long, the head and neck in line with
the spine. Try to extend the stretch as you take long, deep breaths. Hold up
for a minute.
2. Drop your knees back down to the floor and then sit back on your heels with
your arms stretched out in front of you. Rest your head on the floor on one
side if that is more comfortable. Relax and breathe deeply.
Ankle Circles (Figs 19.27A and B)

This exercise tones up the thigh and buttocks.
1. Sit on the floor with your legs straight out in front of you. The body should
be relaxed and place your hands in front of your body. Point the toes and
A B
Figs 19.26A and B: Stretch to release tension
2. Flex the feet back hard so that your toes and knees are pointing up at the
ceiling. Slowing turn the feet out to a V-shape.
3. Keeping the turnout, point the feet and return to the starting position. Repeat
upto 10 times.
A B
Figs 19.27A and B: Ankle circles
Leg Toning with Weights

This is the same exercise from the second trimester of pregnancy but with the
additional 1 kg or 2 lb ankle weight.
Squeeze
This is pillow squeeze.
Relaxation Sequence
Practice complete body relaxation.
Six Months Plus

The exercises during six months are more strenuous than previous one to regain
shape back, so start with the warm-up followed by the exercises from the
previous section and incorporate the following new exercises:
Sit-ups
This exercise strengthens the abdominal muscles.
1. Lie on your back with your knees raised and your feet flat on the floor. Place
a cushion or a rolled up towel between your knees. Keep body relaxed and
place your hands slightly behind your head and slowly breathe in and
breathe out.
2. Breathe out and curl your head and shoulders of the floor. Breathe in and
roll down to the floor. Repeat upto 10 times.
Oblique Sit-ups
This exercise strengthens abdominal muscles.
1. Lie on your back with your knees raised and your feet flat on the floor. Place
a cushion or a rolled up towel between your knees. Keep body relaxed and
place your hands slightly behind your head an slowly breathe in and breathe
out.
2. Breathe out curl up to bring your left shoulder in the direction of your right
knee. Breathe in and lower to the floor. Repeat upto five times on each side.
Advanced Pelvic Tilts

1. Lie on your back with knees raised with a cushion between them feet flat on
the floor. The body should be relaxed and slowly breathe in and breathe out.
2. Breathe out and start to scoop out the abdomen a curl the spine up from the
floor one by one.
3. Holding the body in diagonal shape, breathe in and raise your arms, lifting
them above your head and placing them on the floor behind your head.
4. Keeping your arms behind you breathe out a curl the spine back down the
floor slowly, you will feel a strong stretch in the arms.
5. Breathe in and make a wide circle with your arms on the floor back down
towards your side. Repeat the same for 10 times.
6. Lift your arms so that they are of the floor, parallel to your body, the fingertips
pointing towards your feet. Breathe out curl the head and shoulders of the
floor.
7. Breathe in and lower slowly back to the floor. Repeat the whole sequence up
to 10 times.
Stretch for Abdominal, Gluteal and Back Muscles (Fig. 19.28)

1. Lie on the floor prone lying with a small cushion under the navel, feet and
hip width apart, the legs and toes stretching away. Stretch your arms above
your head, palms down on the floor, keep a towel underneath the forehead
and slowly breathe in and breathe out.
2. Breathe out pull up the pelvic floor muscles and maintain this throughout
the exercise. On the next breathe out stretch your right arm and left leg so
that they lift two inches off the floor. Breathe in and return to the starting
position.
3. Breathe out return to the starting position and on the next breathe out, lift
the left arm and right leg. Repeat upto 5 times on each side.
4. Lift both the arms and both the legs on the next breathe out. Repeat upto five
times and rest in the child pose.
Fig. 19.28: Stretch for abdominal, gluteal and back muscles
Side Stretches (Fig. 19.29)

1. Lie on your side with the back against a wall, legs stretched out in line with
your back. Place your lower arm on the floor and rest your head on it with
your upper arm on the floor in front of you as support. Your face, hips knees
and shoulders should be facing forwards. Completely relax your body and
2. Breathe out and flex the feet and lift them two or three inches of the floor.
Stretch away with the heels. Breathe in and lower the legs. Repeat upto 10
times.
Fig. 19.29: Side stretch
Triceps Exercise (Fig. 19.30)

1. Sit in front of the chair with your back facing it with knee and feet together,
backbone straight, your hands holding on to the edge of the seat and slowly
2. Breathe out let your bottom drop down a few inches supporting your back
with your arms. Breathe out and rise up a few inches. Repeat upto 10 times.
Fig. 19.30: Triceps exercise
The Abdominal Exercise

1. Lie on your back a draw your knees up to that your thighs form a right angle
to your chest. Keeping them parallel and your feet pointed, your arms
stretched out with pointed fingers, just a few inches from your side. Slowly
2. Breathe out lift your head to look straight towards your thighs and lift your
arms a few inches off the floor. Tap your hands on the floor for 5 times.
3. Breathe in and make another 5 taps. Repeat 5 times on each breathe in and
breathe out working up overall till you reach 100 taps. If tensed up lower
down to ground and relax. Finish the exercise by lowering the head to the
ground and hugging the knees to the chest for a few moments.
Double Leg Stretch

1. Lie on your back and bend the knees up to your chest so that the knees are
apart and the toes are together, your hands resting just below your knees.
Breathe in and breathe out, pull up your pelvic floor muscles curl the head
off the floor so you are looking towards you knees.
2. Breathe out and straighten the legs upwards and reach out with the arms so
that they are parallel to the body with pointed fingers.
3. Breathe in, turn out the legs from the hip sockets and flex the feet–this will
extend the stretch in the legs.
4. Breathe out and bring the arms up towards your face, behind your head
and in a wide circle back to where they started.
5. Breathe in and lower your head to the floor and bend the knees to bring the
legs to their starting position. Relax for a moment repeat this exercise working
upto 10 times.
Roll Downs with a Swing

1. Stand with your feet and hip width apart and backbone straight, shoulders
relaxed lift both arms up above your head in front of the body with the
palms facing you. Bend your knees and begin to curl down and look at the
palms.
2. As you bent your knees look at the floor and let your body roll down on to
the knees.
3. As soon as your chest makes contact with your thighs, start to straighten
your legs as far as they will go without straightening.
4. Slowly uncurl to a standing position bring in your spine up slowly to a tall
position. Lift the arms and repeat five times.
Armside Stretches
1. Stand with the feet hip apart and lightly turned out, with a long, straight
back and relaxed shoulders. Breathe in and breathe out.
2. Let your right hand start to slide down. Reach as far as you can and feel the
stretch up to the left side of the body and bend your head on to the right side.
Breathe in and breathe out, and come back to the starting position, breathe
out and repeat five times on each side.
Variation
1. Stand as before this time with your right hand on your waist. Breathe in and
breathe out. Raise your left arm above your head.
2. Bend the upper body to the right as before taking your left arm with you,
stretching your head. Keep your upper arm close to the side of your face and
taking care to keep facing square to the front.
3. Breathe in and breathe out return to the starting position. Repeat upto 5
times on each side.
Wide Leg Circles (Figs 19.31A to C)

This exercise strengths and tones both the legs and abdominals.
1. Lie on your back with your legs stretched out, parallel with the knees facing
to the ceiling and toes pointing. Check that your shoulders are drawn down
into your back and your arms are relaxed at your side. Breathe in and as you
breathe out.
2. Take another breathe in and raise the left leg to the ceiling and keep your leg
straight and the toe pointed.
3. Lower the leg and repeat upto five times on each side.
4. Keeping it on to the floor move your left leg out to the side.
5. Let the leg continue its circle down the other side of the body. Repeat with
the alternating legs twice on each side.
A B C
Figs 19.31A to C: Wide leg circles
Bridging (Fig. 19.32)

This exercise mobilizes and strengthens the back. Do not do if having backache.
1. Lie on your back with your knees raised, heels close to your bottom arms by
your sides. Slowly breathe in and breathe out and upper body should be
relaxed.
2. Breathe out, lift the buttocks and waist from the floor slowly then hold for
some time.
3. Breathe out and come back to the starting position. Repeat slowly upto 5
times.
Fig. 19.32: Bridging
Sitting Forward Stretch (Fig. 19.33)

This exercise stretches and releases the back muscles.
1. Sit up with a long backbone straight and legs stretched in front of you on the
floor, knees facing the ceiling and toes pointed and slowly breathe in and
breathe out.
2. Breathe out and reach forwards over your legs and try little forward. Repeat
over the next four or five time and each time stretch little further.
Fig. 19.33: Sitting forward stretch
Shoulder Release
This exercise helps in releasing the tension in the shoulders and need a belt or
scarf.
1. Kneel down, keep your backbone straight and slowly breathe in and breathe
out.
2. Take the scarf or belt in your right hand an stretch the right arm up to the
ceiling then bend it at the elbow so the right hand reaches down behind
your neck, the scarf or belt hanging down your back.
3. Reach your left arm behind your back so that left hand catches hold of the
scarf belt as close as it can to the right hand, hold this position till you can if
possible to clasp the fingers together it is best, repeat on the other side.
Pillow Squeeze
Follow the same pattern as explained previously.
Relaxation Sequence
Finish the exercise session with complete body relaxation.
CESAREAN SECTION
The cesarean section is suggested for a woman in case of twins, pelvic outlet is
small. So the preparation for this before hand is necessary. If cesarean section is
done in emergency then woman can follow only postoperative physiotherapy.
Preoperative Physiotherapy
Aims and Plans
1. Aim: To prevent respiratory complications.
Plan: Teach and make woman to practice breathing exercise.
2. Aim: To prevent circulatory complications.
Plan: Women should be taught ankle and foot exercises.
3. Aim: To prevent joint stiffness.
Plan: Woman should be taught mobilization of the joints.
4. Aim: To prevent backache.
Plan: To teach correct lifting and bending technique.
5. Aim: To be aware of the ergonomics.
Plan: Woman has to be taught proper body mechanics and posture
awareness.
Postoperative Physiotherapy
Aims and Plans
1. Aim: To increase the pulmonary function and reduce the risk of infection.
Plan: Breathing instructions, coughing and huffing should be given.
2. Aim: To decrease incisional pain associated with coughing, movement during
breastfeeding.
Plan: Postoperative TENS should be given, support the incision with pillow
when exercising. Education regarding incisional care and risk of injury
should be provided.
3. Aim: To prevent postsurgical vascular complications.
Plan: Active leg exercises and early ambulation should be taught.
4. Aim: To enhance incisional circulation and healing, prevent adhesion
formation.
Plan: Gentle abdominal exercises with incisional support, scar mobilization
and friction massage should be taught.
5. Aim: To decrease postsurgical discomfort from flatulence, itching or catheter.
Plan: Positioning instruction, massage and supportive exercises should be
taught.
6. Aim: To correct posture.
Plan: Women should have a clear idea about posture instruction, its
importance and after effects.
7. Aim: To prevent injury to back and prevent low back pain.
Plan: Instruction should be given regarding incisional splinting and
positioning for activities of daily living, body mechanics instruction.
8. Aim: To prevent pelvic floor dysfunction.
Plan: Pelvic floor exercises should be taught, and education regarding risk
factors, types of pelvic floor dysfunction.
9. Aim: To develop abdominal strengthen.
Plan: Abdominal exercises including corrective exercises for diastasis recti
are taught.
HIGH RISK PREGNANCY

Aims and Plans
1. Aim: To decrease stiffness.
Plan: Instruction should be given regarding the instruction or the positioning,
assess for support, facilitation of the joints, and motion in the available
range.
2. Aim: To maintain muscle length an bulk.
Plan: Stretching and strengthening exercises within limits impose by the
physician.
3. Aim: To maximize the circulation and prevent deep vein thrombosis.
Plan: Teach ankle pumping and range of motion exercises.
4. Aim: To improve proprioception.
Plan: Movement activities for as many body parts as possible.
5. Aim: To improve posture within available limits.
Plan: Posture instruction, bed mobility transfer techniques should be taught
and made to practice.
6. Aim: To relieve boredom.
Plan: Vary activities and positioning for exercises.
7. Aim: To enhance relaxation.
Plan: Relaxation techniques are taught for stress management.
8. Aim: To mentally prepare the woman for the delivery.
Plan: Childbirth education, breathing training and exercises to assist and
prepare for labor.
9. Aim: To enhance postpartum recovery.
Plan: Exercise instruction and home program for postpartum period, body
mechanics instruction should be given.
CHAPTER
20
Electrotherapy
DEFINITION
Electrotherapy is the study of electrotherapy modalities and their effects, and it
renders the treatment to the patients suffering from the diseases related to
obstetric, gynecology and all other branches using physical modalities like
heat therapy, cold therapy in order to alleviate the pain and bodily malfunctions
and to make the patient functionally independent.
THE MODALITIES
Muscle Stimulator
This is also called neuromuscular electrical stimulator. It is the treatment by
faradic galvanic system.
Uses
1. This helps the muscle to maintain its properties like excitability and
contractility.
2. Facilitates conduction of a nerve.
3. Prevents wasting of muscle.
Interferential Therapy (Fig. 20.1)

It is the application of two medium frequency alternating currents giving an
effect of low frequency.
Electrotherapy 151
Fig. 20.1: Interferential therapy machine
Indication
Low back pain, stress incontinence.
Uses
1. Helps to relieve pain.
2. Helps in treatment of stress incontinence.
3. Muscle contraction can be achieved.
Transcutaneous Electrical Nerve Stimulation (Fig. 20.2)

It is a modality with low intensity, short impulses are applied.
Fig. 20.2: TENS machine
Indication
Low back pain, sciatica, pain due to scar tissue, postsurgical pain, e.g.
Episiotomy (third degree), cesarean section.
Uses
1. Aids in tissue healing.
2. Gives pain relief.
3. Muscle stimulation prevents disuse atrophy.

4. Rhythmical muscle contraction and relaxation causes increased blood flow
in muscles.
Microwave Diathermy (Fig. 20.3)

Microwave diathermy is irradiation of the tissues with a wavelength between
infrared and short-wave diathermy radiation.
Fig. 20.3: Microwave diathermy
Indication
Pain relief.
Uses
Causes vasodilatation, increased oxygen, increase in nutrition and removal of
waste products.
Ultrasound Therapy (Fig. 20.4)

Ultrasound is treatment in between frequencies of 500,000 and 300,000 cycles
per second.
Fig. 20.4: Ultrasound machine

Electrotherapy 153
Indication
Hematoma, scar tissue.
Uses
Resolution of inflammation, massaging effect, adherent tissue is loosened,
increase in blood supply due vasodilatation, increase in nutrients and removal
of waste products.
Shortwave Diathermy (Fig. 20.5)

It is the higher frequency alternating current has a frequency of 27,120,000
cycles per second and wavelength of 11 meters.
Fig. 20.5: Shortwave diathermy
Indication
Low back pain.
Contraindications
During pregnancy should not be applied to the abdomen and pelvis.
Uses
Increases blood flow, thereby increase in nutrients, removal of waste products
and pain relief.
Infrared Radiation (Fig. 20.6)

These are electromagnetic waves with wavelength between 4,000 and 7,000 A.
it has non-luminous luminous generator.
Fig. 20.6: Infrared lamp
Indication
1. Pain relief.
2. Muscle relaxation.
3. Treatment of superficial wound and infection.
Uses
1. Relieves pain by mild heating that causes vasodilatation.
2. It relieves muscle spasm associated with inflammation there by muscle
relaxes.
3. Increases blood supply assist for healing in superficial tissue.
Laser Therapy (Fig. 20.7)

Light amplification by stimulated emission of radiation.
Types
Ruby-laser, helium-neon, and diode laser.
Electrotherapy 155
Fig. 20.7: Laser therapy machine
Indication
Low back pain in postpartum period.
Contraindication
Pregnant uterus.
Uses
Causes wound healing and pain relief.
Cold Therapy
It is application of cold to the tissues by ice or frozen gel packs.
Indications
Swelling, acute pain after surgery.
Effects
1. The alternative vasoconstriction and vasodilatation is beneficial for the
treatment of swelling and helps in tissue repair.
2. Decreases the pain.
3. Decrease muscle spasm.
Massage Therapy
The systemic and scientific manipulation of the soft tissue of the body is called
massage.
Indication
1. Backache
2. Scar tissue mobilization
Modalities Used during Antenatal Management

Pain relief:
1. Moist heat: This is the form of hot pack, which is safe, effective, readily
accessible and appropriate for home use. Hot packs can be applied prior to
the manual therapy or exercise for muscle relaxation and reduction of spasm.
The physiological effects of superficial heat on tissues are increase in skin
temperature, vasodilatation, and pain gate mechanism gets activated,
produces sedative effect during and after treatment. Patient’s reports being
able to sleep more easily. There will be increase in joint mobility so women
should rest for 20 minutes following heat application before leaving.
2. Ice therapy: It decreases pain and muscle spasm also.
3. Interferential therapy: This is an option treatment but not clearly proved the
after effects on the fetus. A wave of 4,000Hz is preferable for pain relief co-
planar interferential may be used with 2 or 4 electrodes on either side or all
sides of the painful area. It is option in the treatment of lumbosacral pain
during pregnancy. The physiotherapists should place electrodes for co-
planar application for lumbosacral pain close to the vertebral column, so
that there is no risk of current spread to the abdomen. Large electrodes
ensure greater comfort at higher density is beneficial. If side-lying is used for
comfort, electrodes may need to be secured with velcrostraps. Alternatively
a vacuum suction system can be used if available. This has a massaging
effect by aiding muscle relaxation. Frequency of pain relief between 80 Hz
and 150 Hz. Sweep mode is preferable.
4. TENS: TENS is applied for pain relief. It is by use of rubber electrodes
microtape, Electroconducting gel is place on the electrode surface against
Electrotherapy 157
the skin using micropore tape. Skin checked regularly in the first 4 to 6
hours for any signs of aggravation.
Reduction of the edema: Elevation of limb using pillows below limb. Massage
from foot to thigh, e.g. effleurage.
Carpal Tunnel Syndrome

This is a compression of median nerve due to edema in the carpal tunnel syndrome
formed by carpal bones in the wrist.
Treatment: Rest should be given, elevation, splitting in neutral position,

ultrasound, and contrast bathing is treatment by cold and hot water.
Ultrasound: It gives micromanage effect. Head of the ultrasound is applied on

the wrist with gel as media for ultrasound.
Contraindication: It is contraindicated on pregnant uterus because it damages

fetus.
Interferential therapy: Co-planar application increases circulation and fluid

exchange because of vasodilatation. Frequency of 10 to 15 Hz stimulates and
can increase in blood flow.
Ice: It causes vasodilatation, there by decreases the rate of swelling and alleviates
pain.
Meralgia paraesthetica: This condition is managed by TENS, used to control the
pain associated with irritation of the lateral femoral cutaneous nerve during
second trimester of pregnancy, so TENS was described as a highly successful,
non-invasive, non-neurolytic technique which does not carry fetal risk and is
alternative to pain medication for women who are pregnant and for whom
ingestion of certain medication carry significant risk.
ELETROTHERAPY DURING LABOR

TENS (Fig. 20.8)
TENS is an non-invasive self-controlled form of pain relief. It has been used for
pain relief in labor since the 1970. It is free of side effects on mother or baby. It is
stimulation by low intensity, high frequency stimulation at 100 to 200 Hz.
Electrodes are placed over the site of pain. Four electrodes are used, two at the
level of T10, T11 and L1. This is the area where pain is felt because gives uterine
nerve supply. This is not suitable for all women. This is effective in reducing
pain in the first stage and second stage of labor. Lower set of electrodes placed
over the sacral area if pain persist over S2 to S7. Usually pain is located in the
first stage from T10 to T11 and in the second stage from S2 to S4.
Fig. 20.8: Placement of electrodes for TENS

in labor
Technique
The effective technique is by the use of constant low intensity stimulation in
early in the first stage of labor, with boosted high intensity stimulation during
contraction. Pressing a boost button so patient will have control of the machine
and administration of stimulation herself. Adhesive disposal electrodes can be
used and replaced every 4 to 6 hours with conducting gel. The partner can help
in applying electrodes.
Parameters
The battery is powered by a 9V battery, pulse width range of 0.1 to 0.2 ms,
machine should provide a biphasic pulse, the frequency is usually presented
as RATE on obstetric machine and is controlled by the patient via a dial marked
1 to 10, the range of frequency is 1 to 100 Hz. The patient can choose the dial
frequency of 6 to 8. The lower the frequency is less comfortable. The intensity is
denoted (0-100 ma) is controlled by the patient, boost up button will increase
intensity.
Uses
Hospitals that offer TENS as pain relief in labor run special TENS classes
which enable the physiotherapist to explain the theory and allow the woman to
become familiar with sensation and machine, so physiotherapist advocating
TENS for pain relief have always found it more successful when the patient
was well educated in its use. TENS facilitate the mother’s ability to concentrate
on breathing and relaxation techniques. TENS administration during labor
has no side effects on mother’s and babies. Only disadvantage is interfere with
Electrotherapy 159
fetal monitoring as electrical signal generated by TENS device. So temporarily

lowering the TENS Amplitude or turning the device off while fetal monitoring
is done.
ELECTROTHERAPY DURING POSTNATAL PERIOD

Pain Relief
The obstetric TENS is ideal used in management of after birth pain especially
for multiparae.
Electrode Placement
Suprapubically adjacent to the uterus with frequency between 80 to 120 hz,
intensity according to patient tolerance level. Both low intensity used constantly
or boosted for some time.
Cesarean Section
TENS was effectively in managing postoperative incisional pain following
cesarean sections mother can use. TENS and less pain medication so that they
will be more alert, awake and better able to actively participate in the care and
bonding with their babies. Deep breathing, coughing and early ambulating
were also facilitated. TENS helps mother to nurse her infant soon after delivery
with out transmitting narcotics to the child through her breast milk. So infant,
mother bonding can be facilitated, if the mother is not under the sedative
influences of narcotic medication.
Acute Perineal Trauma

This is because of delivery through vagina and having an episiotomy or tear
involving stitches. There will be swelling, bruising and damage to the pelvic
floor. This causes severe pain, unable to move easily, sit comfortably during
breastfeeding.
Ice: It is applied initially.
Ultrasound (Fig. 20.9)

This gives further pain relief with ultrasound. Position of patient is side lying
with lower leg straight and upper limb bent up. Hygiene is maintained, head
should be sterilized to prevent infection. There are two methods of
administration.
Fig. 20.9: Ultrasound for acute perineal trauma
a. A condom filled with water so that when ultrasound is applied depth is

about 10 mm. Gel is applied on upper and lower side of condom. It is best
over sutures.
b. The head of the ultrasound is covered with a condom gel. It is applied on
inside and outside of the condom and treatment is given directly over the
bruised area.
After treatment is completed condom is disposed, head is washed with
soap and water or soaked in 1 percent glutaraldehyde for 10 minutes if head
has come in to contact with body surface.
Parameters
Pulse mode of ratio: 1:3 or 1:4
Frequency: 1 MHz to 40 mm depth
3 MHz to 25 mm depth
Intensity: 0.5 to 0.75 w/cm2
0.75 to 1 w/cm2
Time: 1 to 2 to maximum 4 to 5.
No of treatment: 2 to 3 (benefit initial healings)
Short-Wave Diathermy
It is another modality used to promote healing of the perineum.
Position of the Patient

Side-lying with the single head monoplode is used and positioned very close to
the perineum. There should be no skin contact.
Electrotherapy 161
Parameters
Frequency: 27 Hz
Pulse rate: 100 pulses/sec
Pulse width: 65 microseconds
Time: 10 minutes
Effects
1. Decreases in swelling and inflammation
2. Reabsorption of hematoma.
3. Increase in rate if fibrin and collagen deposition and organization.
Low Level Laser Therapy (LLLT)

Position of Patient
Side-lying with the perineum exposed. If area is larger it is divided and treated
in section separately.
Technique
The probe should be held as close as possible. To the target tissues without
making contact. Irradiation should occur at 1 cm intervals along the episiotomy
wound. The laser probe tip should be cleaned with alcohol wipes before and
after treatment.
Caution
Both the patient and the therapist should wear goggles to protect their eyes
from accidental exposure to the laser beam.
Dosage
1. Wound healing:
Wavelength: 600 to 750 nm
Dosage per patient: 0.5 to 4 cm2
Pulse frequency: 1000 Hz.
2. Keloid formation/scar tissue:
Wavelength: 750 to 905 nm
Dosage per patient: 4 to 6 cm2
Pulse frequency: >1,000 Hz
3. Pain relief:
Dosage per patient: 0.5 to 4 cm2
Pulse frequency: Maximum.
Effects
It promotes perineal healing, therapeutically used for tissue. Healing and pain
relief. Laser radiation is principally absorbed in the dermal layer, so very small
amount penetrates to subcutaneous tissue. Usually helium -neon or gallium -
aluminium-arsenide is used.
Infrared Radiation
It is commonly used for episiotomy. The therapeutic effects are surface
vasodilatation and increased circulation leads to improved healing to surface
wounds and dry the wound for a short period of time, but it is unlikely to affect
deeper levels.
Cracked Nipples
Infrared radiation is used and the therapeutic effect is surface vasodilatation
and increased circulation leads to improved healing.
Chronic Perineal Healing

This is a chronic pain persisting over weeks or months, particular over the scar
area.
Ultrasound Therapy
Parameters
Frequency: 3 MHz.
Pulsed mode: 1:1.
Intensity: 0.5 w/cm2
Time duration: 5 minute.
Number of session: 8
Effects
Increase the excitability of collagen tissue bands on the surface of a scar tissue.
Pubic Symphysis Diastasis

Some women experience severe pain in the pubic symphysis. This is because of
Electrotherapy 163
softening of ligaments and separation of the joint during pregnancy plus joint
edema and impact of delivery.
Ice Application
Ice packs are prepared by wrapping of ice in damp gauze or a flannel can be
placed over the symphysis pubis for 10 to 15 minutes, every 1 to 2 hour in the
first 24 hours.
Ultrasound
Ultrasound is used if acute injury is obvious.
Parameters
Pulse mode: 1:1
Frequency: 1 MHz to 40 mm (half depth value)
3 MHz : 25 mm
Intensity: for 3 MHz – 0.5 w/cm2
Time: 3 to 4 minutes (10 cm2 of surface covered)
Number of treatment: 2 to 3
Position of patient: Supine-lying
Technique
The ultrasound head can be used directly
over symphysis coated will get. If this is too
painful a water filled condom or other
water filled, if this is too painful a water
filled condom or other water filled plastic
bag could be used with gel on both upper
and lower surface of bag (Fig. 20.10).
Effects and Uses

Following treatment by ultrasound the
patient should be advised to rest for at least
20 minutes. The ultrasound affect may
include increased elasticity of collagenous Fig. 20.10: Ultrasound treatment
tissue that is already softened from the to the pubic symphysis for acute
postnatal pain
effects of relaxin.
Sacroiliac Joint Pain/Coccydynia

Women will be complaining of acute sacroiliac joint pain or coccydinia because
ligaments to damaged (Figs 20.11 and 20.12) .
Ice Application
Ice applied in the first 24 hours for reducing swelling and proving pain relief. In
coccydinia, an ice pack applied over the coccyx for 10 to 15 minutes every 2 to 3
hours needed.
Ultrasound Therapy
Parameters
Pulsed mode: 1:1
Frequency: 1 or 3 MHz
Intensity: 0.5 to 1 w/cm2
Time: 5 minutes
Number of treatment: 3 to 4
Technique
In acute injury close to surface so small penetration is needed.
Fig. 20.1 1: Ultrasound treatment Fig. 20.12: Coccywedge pillow allows

for coccydynia weight transmission through thighs
with no direct pressure on coccys
Breast Engorgement
Breast problems occur at any stage of lactation. Engorgement generally occurs
in the first few days of postpartum. Engorgement is defined as an uncomfortable
swelling of the breast associated with increased milk secretion and occurs
usually from 2nd to 4th day. After the delivery there may be lymphatic, vascular
Electrotherapy 165
congestion, interstitial edema causing swelling and tenderness. This exacerbates

the tension of milk in the ducts and may cause stasis of the milk resulting in
ability of the milk to flow. This swelling hardness may make it difficult for the
babies to attach to the nipple and problems can be further aggravated by nipple
soreness. The inhibition of the letting down reflex can lead to incomplete
emptying and decreased milk supply. Unrelieved pressure on the alveoli can
ultimately cause atrophy of alveoli and basket cells, leading to failure of lactation.
Demand feeding usually relieves engorgement.
Heat Treatment
Heat in the form of heat pads or hot water bags can be used to increase blood
low to help movements of fluids prior to a feed.
Cold Treatment
Use of ice cubes wrapped in towel between the feeds can reduce congestion.
The application of old cabbage leaves to the breast is effective in reducing
swelling.
Ultrasound
Parameter
Mode: Pulse/continuous (thermal /nonthermal)
Frequency: 1 MHz
Intensity: 1 w/cm2. This gives 40 mm depth
Time: Bra cup size was used.
A cup — 10 min
B cup — 12 min
C cup — 14 min
D cup — 15 min.
Application
The patient should be made comfortable in supine-lying with the arms on the
right side behind the head. A pillow should be placed under the knees may be
helpful to relieve any tension on the sutures. The physiotherapist passes the
head of the ultrasound firmly over the breast from the periphery towards the
areola, gradually working around the breast, this action gives a good massage
effect and is very soothing. Ideally, the baby should be breast feed soon after the
treatment within 20 minutes to gain maximum benefit. The improved circulation
and relief of pressure on ducts will allow good milk flow during this feed, 2 to
3 treatment should be enough to break the cycle.
Sterilization
Milk will be often flow during treatment and will mix with the gel, so the
ultrasound head must be carefully sterilized following treatment. Virus a bacteria
exist and can be transmitted via breast milk these virus include cytomegalovirus,
HIV, herpes, staphylococci so ultrasound head should be washed in soap and
water dried well an soaked in glutaraldehyde for 10 minutes following
treatment.
Another method is to place a condom over the sound head during treatment.
Adequate coupling medium needs to be placed on both surfaces of the condom,
i.e. internal and external. After treatment condom should be dispose and the
ultrasound head is washed in soap water.
Effects and Uses

Continuous Mode
This helps in healing occurs quite deeply within the tissues of the breast. The
effects of heating will increase circulation of the venous and lymphatic fluid
and leads to decrease pressure on milk ducts and improved flown. The pain
relief will enhance the let down reflex.
Pulse Mode
This helps to increase the permeability of the cell membrane and promote
movement of fluid at the molecular level and also provides a pleasant massage
effect.
Mastitis
It is another breastfeeding problem. It occurs after the first week of postpartum
period. It is the inflammatory disorder of the breast. The bacteria called
Staphylococcus aureus. It causes cellulites of interlobular connective tissue
resulting in pain, swelling, redness and fever. It is associated with cracked and
fissured nipples, allowing bacteria to enter the breast from the nipples. This
condition becomes peak before the end of the second week postpartum and
again 5 to 6 weeks. Bacteria will be present because the site of infection is
extradural, continuous breastfeeding is recommended.
Electrotherapy 167
Treatment
Includes antibiotics, continuous breastfeeding, pain relief to improve letdown.
There is no record of a baby becoming sick as a result of the mother having
mastitis.
Ultrasound
Has a role in pain relief.
Parameters
Mode:
Pulsed: Blocked ducts: non-thermal effect
Continuous: Breast abscess –thermal effect
Frequency: 1 MHz –half value depth 40 mm – good penetration
Intensity:
Acute condition:
Mastitis –1 wcm square
Chronic condition:
Blocked ducts – 1.5 to 2 w/cm2
Time: 1 to 2 minutes per cm2
Blocked Ducts
Obstruction of ducts can occur at any time in the breastfeeding period. Anything
that disrupts normal breastfeeding drainage can be a risk factor. It occurs as
tender lump and erythema called non-infective mastitis. Some women are prone
to develop the problem in the same area of the breast.
Treatment
Including feeding from the affected breast first, massing the area first the feed,
nursing frequently a positioning the mother during the feed to encourage
drainage from the affected area.
Ultrasound Treatment
Continuous ultrasound would help by the effects of heat and micromanage to
open the ducts and increase circulation, thereby assisting in movement of milk
through the area.
Precaution
The physiotherapist using ultrasound in the case of active infective mastitis
should take care as increase circulation could lead to increase spread of
organism through her breast.
Application
If the smaller area is being treated on the superior, lateral or medial surface, the
patient may be more comfortable in sitting. It is better to give treatment with the
patient in a position that will encourage drainage of breast from the affected
area. The patient should be encouraged to feed her baby in the same position
after treatment. Discussion with a lactation consultant is recommended for
breastfeeding problems. She would be able to advice the physiotherapists about
positioning.
Contraindications
Patients who have had silicone breast implants should not be treated with
ultrasound the effects of ultrasound on silicone are not known and could be
potentially harmful. Patients who have had breast cancer should not be treated
with ultrasound with out consulting with their physician.
PELVIC FLOOR DYSFUNCTION

Aims of Pelvic Floor Dysfunction
1. To stimulate weak muscles
2. To inhibit detrusor instability.
3. To aid cortical awareness of an isolated pelvic floor muscles (PFM)
contraction.
Before stimulating pelvic floor muscles assessment must be one regarding
1. Cause of muscle weakness
2. Degree of the weakness
3. Result of the stimulation.
Causes
Birth trauma, chronic constipation, constant straining at stool, extensive surgical
damage
Type of Nerve Damage

1. Neuropraxia of pudendal or pelvic nerves or some of its branches by pressure
of the fetal head as it passes through the pelvis.
Electrotherapy 169
2. Disruption to the neuromuscular junction leading to partial denervation of

pelvic floor muscles caused by over stretching of muscles as the baby’s head
passes through them. This is because of long second stage of labor over two
hours, a big baby a use of forceps.
Type of Machine
Muscle stimulator which has low frequency currents can be used. The
physiotherapist need to check the parameters set by the machine a devise a
program that will benefit each patient individually.
Frequency: 35 to 40 Hz
ACUTE STIMULATION OR SHORT-TERM BY MAXIMUM INTENSITY

Effects
This builds up bulk in muscle that has been weakend. There will be increase in
the capillary density and levels of oxidative enzymes after 10 to 28 days of
stimulation. For chronic stimulation for one hour or longer everyday for a period
of six months, for acute conditions intensity higher of 60 ma or greater for 20 to
30 minutes, 2 to 3 times per weak for 5 to 6 weeks.
Electrodes
Both internal and external electrodes can be used. Internal electrodes are more
successful is tolerated as the current is delivered in close proximity to the
pubococcygeus muscle. These electrodes are vaginal or anal electrodes that
have both positive and negative nodes. Women find these electrodes acceptable
and comfortable the size of the vagina and the size of the electrode need to
match otherwise discomfort will be cause. So use of anal electrode will overcome
these problems. External electrodes are an alternative, higher intensities can be
used for spread of current from the more superficial perineal muscles to the
deeper pubococcygeus muscle. The electrode may be multiuse single patient
electrodes or covered by disposable covers. Wet chix nappy liners can be used
to cover rubber electrodes. After use the clix covers should be discarded the
rubber electrodes washed in soap and water.
Electrode Placement
Larger electrode placed horizontally across the anus/perineal body and a small
electrode placed vertically just below the pubic bone. There will be concentration
of the current towards smaller electrodes and this follows the line of the
pubococcygeus. Other application is use of two small electrodes paravaginally,
i.e. anterior and posterior to the anus, adhesive gel pads over small rubber
electrodes, are suitable and can be repeatedly used by the patients, patients
need to remove perineal hair in the area of electrode placement.
Care
Physiotherapist care should be taken in treatment as stimulators have negative
or positive effects on the healing muscle. Stimulation at > 60 Hz frequency, > 80
ma intensity will kill denervated muscle fibers, stimulation at lower intensity
can damage the recovery muscle fibers, so physiotherapist usually takes
conservative approach and do not use electrotherapy until damage is healed
and mature muscle cells are formed by at least 8 weeks postpartum.
Contraindications
1. Acute inflammatory of the perineum or vagina.
2. Pregnancy
3. Poor skin condition
4. Immediate postnatal period
5. Inability to understand or tolerate treatment.
Detrusor Instability
Sensory stimulation of sensory afferent fibers of the pudendal nerve and the
other nerve by S3 sensory fibers, sacral reflex center S2, S3, S4 to the detrusor
(bladder) stimulator for muscle strengthening, frequency 5 to 10 Hz,
physiotherapist must be aware as this also stimulates pelvic floor, so short-time
stimulation for 10 to 15 min of 35 to 40 Hz frequency stimulate fast twitch fibers
at S3 dermatome to achieve inhibition via sacral micturition reflex center S2, S3,
S4.
Complications of Pregnancy 205
CHAPTER
21
Complications of Pregnancy
HEMOGLOBIN STATUS
The status of the hemoglobin gets reduced if there is more loss of blood during
delivery or woman might be having the low hemoglobin level during delivery,
due to this aerobic capacity can get enormously effected. Resulting in
breathlessness on walking few steps or climbing stairs, so woman has to wait
till the hemoglobin levels come to normal range before she starts with exercising
again so woman are advised iron therapy and usually takes three to four months
to reach the level of 12 to 14 gram/dl.
PELVIC FLOOR PROBLEMS (FIG. 21.1)

Most perineums should be healed within two weeks of delivery. Some women
experience long-term problems such as stress continence, scar tissue, discomfort
and problems in resuming sexual intercourse. Specialist advice should be sought
immediately and before proceeding with any exercise program. The effect of the
relaxin hormone will be there for three to five months. Postnatally women are
advised to take little or no impact movement. Pelvic floor exercises should be
resumed soon after delivery, the high impact classes can begun from 9 to 12
months period duration.
BACKACHE
Pain due to postural changes of pregnancy, increased ligamentous laxity and
decreased abdominal function. If epidural was given as form of pain relief
inappropriate body position during labor, incorrect technique of breastfeeding
without appropriate support, improper lifting and bending techniques, the
Fig. 21.1: The pelvic floor
symptom of low back pain usually worsen with muscle fatigue from static
posture and symptoms get relieved with rest. Avoid heavy weightlifting for
atleast 12 weeks special attention should be paid to posture and promoting
correct technique of back strengthening exercises and abdominal exercises that
will help to support the back, women should be taught proper bodymechanics,
posture instructions, work place ergonomics. Women should be physically fit
before becoming pregnant so that backache problems get reduced.
SACROILIAC PAIN
This is common in pregnancy because of ligamentous laxity coupled with
postural adaptation and muscle imbalance. The pain is felt to the woman in the
posterior pelvis and will be in the form of stabbing pain deep in the buttocks.
The nerve roots affected are L-5, S-1. The radiation pain will be in to the posterior
thigh or knee. Pain increases with activities like sitting, standing and walking,
climbing stairs, turning in bed, unilateral standing, turning in bed, etc. Pain is
worsened with activity and does not get reduced with rest. Sacroiliac pain is
accompanied with pubic sympysis discomfort subluxation or both.
PUBIC SYMPHYSIS JOINT SUBLUXATION

This occurs in pregnancy or postnatal period. Woman either becomes wheelchair
bound or as to walk with a walking stick. Physiotherapy treatment will be in
form of exercises of the upper body like mobilization, warm-up and exercises in
a seated position.
SACROILIAC JOINT DISCOMFORT

These two are very powerful joints situated at the back of the pelvis. These have
small range of motion and are affected by hormone called relaxin. Most of the
babies produced stress on these joints and the result is in postnatal period in
the form of discomfort, unstable pelvic girdle, if pubic symphysis joint is also
effected need to take special care. Physiotherapy should only be started after the
effect of pregnancy is lost, weightbearing and strenuous exercise program in
totally supported body positions.
SEPARATION OF THE RECTUS ABDOMINIS

(FIG. 21.2)
It is the separation of the rectus abdominis muscle
in the midline at the linea alba. The abdominal
wall continuity is disrupted separation is more
than 2 cm or 2-finger width, it is problematic. The
causes are due to the biomechanical causes of
pregnancy or hormonal effects on the connective
tissue. This can occur at any level above, below or
at the level of the umbilicus’s women before
pregnancy should have good abdominal tone and
will be less common.
This condition is called diastases recti and
leads to the problems like low backache because
of decreased ability of abdominal muscles to Fig. 21.2: Separation of
control the pelvis and the lumbar spine. rectus abdominis
Functional limitation like inability to perform
independent supine to sitting transitions. In severe separation the anterior
segment of the abdominal wall is composed only of skin, fascia, subcutaneous
fat and peritoneum. The lack of abdominal support provides less protection for
the fetus. In the severe cases progresses to herniation of the abdominal viscera
through the separation: in the abdominal wall.
CESAREAN SECTION DELIVERY

Women should have their postnatal check and ensure that the section scar has
healed before taking part in exercise programs again. Any scar tenderness or
discharge should be reported to doctor immediately. Two heals most scars
externally or three weeks postpartum with alternate sutures removed at six
days post-delivery. Specifically designed postnatal exercise classes would be
appropriate from six weeks of delivery.
BREASTFEEDING (FIG. 21.3)

Regular levels will raise prolactin levels, a bonus
for breastfeeding. A well-supported bra should be
worn at all times and especially when exercising
postnatally. Some exercises may be uncomfortable
to perform if breasts are lactating and a feed is due
for instance back extensions from a flat-lying
position. So put a thick bed-sheet and practice.
TIREDNESS Fig. 21.3: Breastfeeding
Most newly-delivered woman feel exhausted in those first few weeks. Mother
has to adapt to the birth process and reversal of physiological system, new
mothers have to come to terms with their role of being a mother and their
responsibility towards child. The baby will be playing havoc with most sleep
routines and most parent feel very tired for a few months. Once the baby has
settled in to a feeding routine a sleep pattern that allows mother regular sleep.
The exercise classes can be started again. Do not participate if the mother is
feeling exhausted as well as prone to injury.
WEIGHT GAIN
The women usually put on 14 to 20 pounds during pregnancy. Cardiovascular
and aerobic work will help to burn up those unwanted pounds and advice
regarding diet to be taken from the dietician during breastfeeding. Dieting has
to be discouraged. A woman has to go for a brisk walk and swimming, which
are best for the recently delivered mother. Who would like to go for an exercise
regime before woman’s postnatal check.
SPINAL PAIN
This is the common problem during the pregnancy women complaints of pain,
in sacral, low back, posterior thigh, leg, pubic, groin and hip area. Cervical,
thoracic and coccygeal pain can be felt. Sciatic pain is due to involvement of
nerve roots L5 and S1, some of the causes can be postural adaptations, increase
joint mobility, collagen volume, fatigue leads to pain, weight gain, pressure
form the growing fetus, poor stability, altered muscles, stretched pelvic and
abdominal muscles, more strenuous work involving bending, twisting, lifting
and sitting, previous history of low backache, decreased fitness level before
pregnancy are the precipitating factors for the spinal and the pelvic pain.
Physiotherapy plays an important role with regard to educating women on
posture awareness, correct bending and lifting techniques, baby care and
handling, breastfeeding, nappy changing, etc., TENS is used postnatally to
decrease pain, sacroiliac and trochanteric belt for pain reduction and can be
used antenatally and postnatally.
NERVE COMPRESSION SYNDROME

In the third trimester fluid retention occurs which leads to nerve compression
syndromes like carpal tunnel syndrome, is compression of medial nerve in the
tunnel formed in between carpal bones of the wrist joint, brachial plexus
compression, compression of the lateral cutaneous nerve of the thigh as it passes
under the inguinal ligament called meralgia paresthetica. Posterior tibial nerve
compression. All these cause tingling and burning, sensations in the area where
nerve supplies. These entrapments are present during pregnancy and will be
resolved postpartum, if not resolved should go for physiotherapy treatment like
wrist splints, ice for carpal tunnel syndrome, postural advice, i.e. positioning of
arm for brachial plexus compression, ice and elevation to reduce edema for
posterior tibial nerve compression.
PAINFUL PERINEUM
A difficult delivery and prolonged, episiotomy with third degree tear results in
a painful, bruised and edematous perineum’s physiotherapy is advanced in
the form of pelvic floor exercises which helps in strengthening of muscles,
increased blood supply and aid healing, ice packs to reduce pain and edema,
teach defecation techniques, usage of pillows under each buttock to prevents
pressure on gluteal region and wound, scar tissue formation cause pain during
sex.
PUERPERAL INFECTION
A local infection can be caused by the bacteria called Escherichia coli, Staphylococci
or Streptococci. The infection causes delay in healing of the placental site and the
patient shows signs of general malaise, a raised temperature. Investigations
should be done for urine, blood, cervical swab to determine type of bacteria
infected. Treatment is with antibiotics prevents spread from the primary site
causing a more serious pelvic infection.
BREAST INFECTION
It is caused by Streptococcus aureus. The entry is through crack in the nipple.
Inflammation of breast is called mastitis. Mastitis with breast care is treated
with antibiotics and analgesics prevents the occurrence of breast abscess.
Symptoms are painful, red, wedge-shaped area of inflammation and enlarged
axillary lymph glands. The patient has a raised temperature and feels generally
ill. Incision and drainage under anesthetic may be necessary the drainage tube
is kept for 48 hours. Antibiotic treatment is given.
VENOUS COMPLICATIONS OR THROMBOPHLEBITIS

It is also called superficial venous thrombosis. It occurs in one percent of the
patients. Inflammation occurs in varicose superficial vein. There will be local
tenderness and vein will be distended which will be visible. Suppoted bandage
or elasticated stocking and encouraged activity for re-absorption of the clot
occurs.
DEEP VEIN THROMBOSIS OR PHELEBOTHROMBOSIS

This is a venous thrombosis occurring in the deep veins of lower limbs. It occurs
in 0.02 percent of puerperal woman. The symptoms will be women will be
having a raised temperature, leg pain and tenderness. Medical treatment is
with anticoagulation and analgesics. The patient is nursed in bed (with the foot
of the bed elevated and a cradle to take the weight of the bed clothes of the leg)
till all the pain and tenderness gets subsided. When the deep pelvic veins are
affected there is a serious risk of the patient developing a pulmonary embolism.
Physiotherapy treatment should be started immediately after cesarean section
with early mobilization to prevent deep vein thrombosis.
INCONTINENCE
Incontinence is the inability to control the passing of urine and feces so that
either or both excretion are passed at inappropriate times or places. So, therapist
must identify incontinence, cured, reduced or managed well and promote
continence and prevent incontinence.
Assessment
1. Register the need to pass urine or feces.
2. Know where the toilet or receptacle is located or able to summon assistance.
3. To able to reach the toilet.
4. Undress adequately.
5. Sit or stand safely.
6. Perform all these activities in time.
Cause
Gradual change or sudden change in a person’s health status or her environment
can precipitate her in to a cycle of events in which incontinence becomes a
dominant and distressing factors. Physiotherapist must assess the condition of
the patient and should be able to distinguish between the various types of
incontinences that effective physiotherapy treatment program can be planned.
Types of Incontinence
• Stress incontinence
• Urge incontinence
• Overflow incontinence
• Reflex incontinence
• Continuous incontinence.
Stress Incontinence
It is involuntary loss of urine on exertion, e.g. coughing or running when patient
is upright.
Genuine Stress Incontinence

It is the involuntary loss of urine when pressure in the bladder exceeds maximal
urethral pressure in the absence of a detrusor contraction. If this is contraction,
if this is accompanied with minor degree of vaginal wall prolapse. Then can be
solved by physiotherapy treatment, i.e. reduction of the pelvic floor muscle, if
not then surgical correction followed by postoperative pelvic floor muscles.
Idiopathis stress incontinence of feces responds well to re-education of the
puborectalis in postpartum period.
Urge Incontinence
This is the involuntary loss of urine associated with a strong desire to void.
It is of two types:
a. Motor urge.
b. Sensory urge.
Motor urge: It is characterized by uninhibited detrusor contraction, i.e. detrusor
instability. It occurs in 30 percent of referral. Treatment is by bladder training.
Sensory urge: Its cause is acute or chronic infection, urinary calculi or bladder
tumor.
Treatment: Treatment is with antibiotics or surgery.
Overflow Incontinence
This is the involuntary loss of residual urine in dribbles or jets (on movement)
when the bladder is unable to empty completely. The conditions is caused by
an obstruction to the overflow of urine, e.g. overstretched atonic bladder,
retroverted gravid uterus, impacted feces.
Reflex Incontinence (Neurogenic)

This is the voluntary loss of urine due to abnormal reflex activity in the spinal
cord in the absence of sensation. Usually associated with the desire to micturate.
It is associated with wide range of disorders that effects the brain and spinal
cord including trauma, e.g. paraplegia.
Continuous Incontinence
This may result from pathological or structural abnormality or be related to
major trauma or surgery, e.g. a fistula.
Frequency
This is usually defined as the passage of urine severe or more times. During a
day walking twice or more at night to void. If present with other types of
incontinence, self-induced frequency is found in patients who make a habit of
voiding regardless of a desire to do so because they are frightened of leaking
urine.
Re-education of Pelvic Floor

The physiotherapist gives advice on the postnatal care and postpartum advice
to combat the effects of childbearing. So, physiotherapist role is important during
pelvic floor laxity and stress incontinence.
Pelvic Floor Laxity

When the pelvic floor muscles are stretched and weak the support for the pelvic
organs is poor and patient complains of heaviness in the perineal area. The
walls of the vaginal and urethra get overstretched and called cystocele, rectocele
and urethrocele and uterine supports (1st, 2nd and 3rd degree uterine prolapse).
If the severity is mild then re-education of the levator ani muscles will relieve
these symptoms if they are mild. If there is cystocele, 2nd or 3rd degree uterine
prolapse surgery is required. Preoperative pelvic floor exercises are advised.
Sexual problems can arise as a result of pelvic floor laxity. The vagina will
feel slack and lacking in squeeze as the weak muscles are unable to compress
the vagina during intercourse. There is also difficulty in retraining a

contraceptive diaphragm or tampon.
Assessment of the Pelvic Floor Muscles

This is an essential part of the treatment. Therapist must use a digital check or
vaginal pressure gauge (perineometer) to monitor the strength of the pelvic
floor muscles and whether the exercises are being performed accurately.
Method
The woman is positioned on a cough in crooklying with her knees and feet
apart and suitable covered. Additional lightening may be required to illuminate
the perineum. Wearing disposable gloves and using the thumb and finger of
her left hand the therapist separates the labia and any sign of inflammation,
discharge or uterovagianl prolapse. Ask the woman to cough twice and strongly
downwards noticing any bulging at the intriotus or leakage of urine. She then
applies vaginal lubricant to her fingers with the phrases “I am going to slide
two fingers in to your birth canal, so make room for my fingers”, she introduces
the index finger and middle finger of her right hand in to the vagina. Vagina
should be visualized and muscles must be relaxed then therapist asks the women
to strain and cough again. Any descent of the base of the bladder, the cervix or
anterior and posterior vaginal walls will be noted. If there is a large degree of
uterovaginal prolapse, the therapist fingers may be pushed out of the vagina.
To assess the strength of the pelvic floor muscles the following are useful:
A. With the fingers open palpating the pubococcygi. Close my fingers.
B. Switch the fingers closed: do not let me pull my fingers out.
C. With fingers closed: squeeze my fingers
D. With fingers palpating posterior vaginal wall: imagine you have diarrhoea,
so close your back passage.
All the woman’s problem related more to poor bowel control it is advisable
to go for assessment. In the side-lying position using new gloves check the
strength of the puborectalis by inserting the index finger through the anus to
the anorectal angle. Close you front and back passages, draw them up inside so
you can feel a squeeze and lift -hold for four seconds and let go slowly. Start
with 2 or 3 second hold, progress to 10 seconds. Assessment is finished.
A vaginal pressure gauge or perineometer is valuable as a teaching aid over
a period of time will demonstrate an improvement in the strength of the muscles
as the reading on the gauge increase, initially it should be used early in the
assessment before the muscles become fatigued. Women are encouraged to check
their own pelvic floor muscles digitally at home.
Explain women that daily routine must be followed for the treatment to be
effective.
Routine for Exercises

Position of sitting or standing with slightly apart is most-effective, as the weight
of the pelvic contents acts as a resistance to the muscles, command should be
given close the back and front passages, draw them up in-side, hold this squeeze
and lift for up to six seconds-let go slowly.
Some women does it closing the basic and front components separately at
first, combining them at a later data. The therapist should check that the women
understand that she should not contract her glutei, abdominal muscles or hold
her breath while practicing pelvic floor contraction. In the beginning exercise
become difficult muscles are weak. So, she has to concentrate her attention on
the central area from her coccyx to symphysis pubis gradually squeeze and lift
in this area alone. As the muscles tire after 5 to 6 contractions, the exercise need
to be repeated frequently eachday. Routine is worked out to suit the persons
everyday activities. Practice every hour, e.g. at sink, having coffee on the lavatory.
Women are advised to brace her pelvic floor (to reduce the downward thrust)
whenever she coughs, sneezes or lifts heavy objects. Stopping and standing a
flow of urine while micturating is a good awareness test and provides an
indication of progress if the stream of urine is stopped more completely, but it
should not replace the exercises. The use of a daily record chart is advisable for
at least the first week of the pelvic floor exercise program as it serves as reminder
to do the exercises until they become part of the daily routine.
Follow-up Appointments
Patients return for assessment three weeks after the first appointment.
Subsequent appointments are at four to six weeks intervals. Those with less
severe symptoms will be ready for discharge after about three months.
Progressions of the exercise program is important so that the muscles re-learn
how to contract reflexly in response to a threat.
Group Therapy
Weekly exercise sessions as a group can be very beneficial. Much can be gained
form contact with others, who have similar.
Exercises
Pelvic floor contraction are practiced in variety of positions like lying, sitting,
standing relating the positions to woman’s daily life. To prevent fatigue of the
pelvic floor muscles, strengthening and mobilizing for the abdominal and back
muscles are interspersed. Posture correction is also taught.
As the pelvic floor muscles increase in strength the contractions can be
made more difficult to sustain by practicing them while skipping, running,
jumping, coughing, sneezing and lifting with the pelvic floor contractions also
must be taught. Overweight women are weighted each week and their weight is
recorded.
Bladder Retaining
Physiotherapist usually teaches in ward or in outpatient department. Each
time the desire to pass urine is felt the pelvic floor is contracted in an effort to
delay micturition. If the delay time is slowly-lengthened an appreciable
improvement in urgency frequency can be obtained in a few weeks.
Pre- and post-treatment bladder function charts should be maintained
regularly.
DIASTASIS RECTI
This is the separation of the rectus abdominis in the midline at the linea alba.
Etiology is unknown. The abdominal wall is disrupted. Any separation larger
than 2 cm or 2 fingerwidths should be taken care. This occurs above, below or at
the level of the umbilicus. Distasis recti test is required. Diastsis recti produce
muscloskeletal complaints such as low backache because of the decreased ability
of the abdominal muscles and to control the pelvic and lumbar spine. Women
will have functional limitations like inability to perform independent supine to
sitting transition. In severe cases the anterior segment of the abdominal wall is
composed of skin, fascia, subcutaneous fat and peritoneum the lack of abdominal
support provides less protection for the fetus.
In severe cases of diastais recti may progress to herniation of the abdominal,
viscera through the separation in the abdominal wall.
Treatment
Woman should be taught the exercises of spine, upper limb back exercises
except abdominal exercises. Regularly should be monitored for decrease of
separation.
Glossary 179
Glossary
Abdomen: The part of the human body comprising the lower portion of the
trunk. This is the lower section of the backbone and the muscles of the back,
and abdominal muscles at the side and front. The diaphragm forms the top of
the cavity and the pelvic basin forms the bottom.
Abdominal Cavity: The abdominal cavity contains several important organs, the
liver in the upper right portion, the stomach and the spleen in the upper left
portion, the small and large intestines in the lower portion, the kidneys one on
each side in the back and the urinary bladder in the pelvic region. There are also
major blood vessels and other smaller organs in the abdominal cavity.
Abortion: The untimely termination of a pregnancy, either by natural or artificial
means.
Amniocentesis: Drawing of a sample of the amniotic fluid from the womb of a
pregnant woman, in order to examine it. The amniotic fluid is the medium in
which the fetus lies and contains some cells from the fetus that can be analyzed
to detect a number of abnormalities.
Anatomy: A study of structure of organisms.
Anemia: A shortage of RBC or a deficiency in hemoglobin, the pigment in RBC
that carries oxygen. The woman suffers from and experiences fatigue, shortness
of breathe, rapid heart rate, headaches, loss of appetite, dizziness and weakness.
Very severe cases of anemia may exhibit swollen ankles, a rapid weak pulse
and pale clammy skin. Anemia can be caused because of deficiency of iron,
vitamin B12, folic acid can inhibit the production of hemoglobin. This is available
in dark green vegetables, egg yolk, meat, sea food or dried beans.
Anesthesia: Anesthesia usually refers to the administering of a drug to produce
a reduced state of sensitivity in order to perform a surgical operation.
Auscultation: Listening with a stethoscope to sounds of heart and lungs within

the body.
Birth Defect: This is an abnormality that is present at birth. A birth defect may be
genetic that is inherited from one or both parents and may be acquired during
pregnancy or at birth.
Blood: A fluid that runs throughout the body by way of the arteries, veins and
capillaries. Blood is composed of serum or plasma, red cells, white cell and
transports nutrients to all tissues then to the organs for excretion. Red cells give
color to the blood and carry oxygen. White cells aid in defending the body
against infection. Platelets are essential to the formation of the blood clots
necessary to stop bleeding.
A loss of blood can cause a state of physical shock that occurs because there
is insufficient blood flowing through the tissues of the body to provide food and
oxygen.
Carpal Tunnel Syndrome: This is the condition with numbness, pain and
weakness associated with the compression of the median nerve at the wrist.
The finger tendons and the median nerve are present in a tunnel formed by the
carpal bone and the membrane that stretched over them. Any swelling of tissues
within the tunnel can put pressure on the median nerves that control the thumb,
index and middle finger. This occurs during pregnancy.
The condition will be worsened by any activity that requires constant or
repetitive twisting of the hand and wrist.
The pain travels up the arm into the shoulder and even the neck. The
symptoms will be in the worse situation are unable to make a fist because the
fingers get weakened and the muscles atrophy. So, the treatment is to alleviate
the pressure on the nerve by removing the cause, in severe cases, surgery may be
necessary, to prevent permanent damage. In extreme cases where treatment has
been delayed full recovery may not be possible.
Cerebral Palsy: Cerebral palsy is caused by nerve or brain damage usually
occurring around the time of birth. Early signs of the condition may be
convulsions, partial paralysis of the face muscles or slow development of motor
functions as sitting, crawling or standing. Later symptoms may range from lack
of co-ordination to the inability to move normally. The damage cause mental
retardation or learning and behavioral disorders.
Chromosomes : The body is made up of genetic material contains in the nucleus
of a cell. The basic unit that makes up all living organisms. Chromosomes carry
the genes that transmit the characteristics of a parents to a child and through
each cell throughout life, the cells in the body are created by division from the
initial fertilized ovum or egg.
Glossary 186
Clubfoot: A birth defect in which the foot is turned inward or twisted. Early
correction may involve manipulation and the use of casts or other devices to
gradually correct the position of the foot. Surgery is required to lengthen the
Achilles tendon or correct the ankle joint.
Coccyx: A small bone that forms the lower extremity of the spinal column.
Congenital: A condition existing from birth.
Diabetes Mellitus: A condition in which the body is not able to satisfactorily
process ingested sugar. Body and brain cells need many different types of
nourishment. The circulatory system carries sugar and transfers it to the cells
with the aid of a chemical substance called the insulin. This is manufactured by
pancreas. When the insulin production sugar production are in balance, the
body functions normally. An individual suffering from a reduction in the
production of insulin is said to have diabetes mellitus. As a result of this
imbalance, the body is adversely affected. This condition in pregnancy is called
gestational diabetes.
Diaphragm: The muscular partition in the body that separates the chest cavity
and the abdominal cavity.
Edema: Swelling caused by the accumulation of fluid in the tissues.
Febrile: It is the body temperature that is above normal.
Gynecology: The branch of medicine concerned with the diagnosis and treatment
of disorders of the female reproductive system.
Hemogloblin: The substance in red blood cells that enables them to carry oxygen
and gives them their color.
Heredity: Transmission of characteristics from parent to offspring.
Hypertension: This is increase or high blood pressure.
Incontinence: Inability to control the passage of urine and stool.
Iron Deficiency Anemia: An inadequate supply of iron in the body, caused by
excessive bleeding. Most iron is stored in the blood and an adequate supply is
maintained from the normal diet that includes meat and dark green leafy
vegetables.
Joint: The junction of two or more bones.
Ligament: Tough fibrous tissue that holds bones together at a joint and supports
body organs.
Mastitis: An inflammation of the breast especially of a nursing mother.

Muscle: Tissue made up of fibers that have the ability to contract. Voluntary
muscles are known as striated muscles controlled by the individual. Involuntary
muscles are known as smooth muscles found in blood vessels, digestive system
and respiratory system. Heart muscles are the striated muscles controlled by
the motor neurons.
Nausea: A feeling that one wants to vomit.
Neuralgia: Any pain occurs along the course of a nerve.
Obstetrics: It is the branch of medicine that deals with condition related to
pregnancy and childbirth.
Pediatrics: The branch of medicine science that deal with the disease and care of
children.
Pelvis: The pelvis is a basin-shaped bony structure at the lower portion of the
trunk. The four bones composed of the pelvis, the two bones of the backbone
and the wing-shaped hip bones on either side. The pelvis forms the floor of the
abdominal cavity and provides deep sockets in which the heals of the thigh
bones fit.
Rh Factor: A specific antigen that is present in some blood. An antigen is a
potentially harmful substance in the body that starts the reaction leading the
body to produce a special antibody to neutralize it. Antigens are commonly
introduced into the body by invading bacteria or other infecting agents.
If Rh-positive blood is introduced into the blood stream of Rh-negative blood,
antibodies are produced when this mixing of the blood of an Rh-negative mother
with that of a child who has inherited Rh-positive blood from the father. The Rh
factor in the Rh-positive blood will cause the Rh-negative system to form
antibodies to trap and destroy the offending Rh factors. Such action causes the
formation of clumps in the blood that can create a stoppage that will result in
death.
As with all allergies the first exposure may not cause a serious reaction
because of the time required for the body to form antibodies. The second
pregnancy, antibodies are already present in the blood and the immune system
is ready to produce more will cause severe complications.
Sciatica: It is severe pain in the lower back extending along the path followed by
the sciatic nerve down the length of the back of the thigh.
Therapeutics: The branch of medicine concerned with the treatment of disease.
Glossary 188
Ultrasound: The technique of using high frequency sound waves to record an

image of internal tissue that cannot be detected by X-rays. It helps for examination
of the fetus during pregnancy, as it produces no harmful emission of radiation.
Urinary Bladder: The organ or sac that receives, holds and discharges urine.
Varicose Veins: A condition characterized by swollen knotted blood vessels
usually in the legs. Varicose veins may be temporary as in the case of pregnancy
when they are caused by the strain of carrying the additional weight.
Wean: To teach a baby to consume foods other than mothers milk or formula.
X-rays: High frequency electromagnetic radiation that is capable of penetrating
some solid objects of destroying tissue by extended exposure and of creating an
image of a photographic plate or a fluorescent screen. This is used to create
image of body parts for study and diagnosis.
Bibliography
1. Anna Selby. Pilates of Pregnancy.

2. CS Dawn. Textbook of Obstetrics and Neonatology.
3. Dutta. Textbook of Obstetrics.
4. Jeffcoate. Principles of Gynecology.
5. Jones. Fundamentals of Obstetrics and Gynecology.
6. Mudaliar and Munnis. Textbook of Clinical Obstetrics.
7. NA Beischwer, EV Mackay. Obstetrics and the Newborn.
8. Patrice A Bownie. Cash Textbook of General Medicine and Surgical Conditions.
9. Praveen Kapadia. Yoga Simplified.
10. R Sapsford. Women’s Health.
11. Sachedeva. Notes on Obstetrics.
12. Shaw. Textbook of Gynecology.
13. Sheela B Korah, Jessy Philip. Handbook of Midwifery.
14. VR Tindall. Principles of Gynecology.
Index
A C
Abdominal muscles 29 Carpal tunnel syndrome 81, 154, 169
pelvic tilt: on bed 29 Cesarean birth 97, 99
Antenatal management, modalities used 154 Cesarean section 147, 156
ice therapy 154 Cesarean section, postoperative
interferential therapy 154 physiotherapy 147
moist heat 154 aims and plans 148
TENS 154 Colic 104
Apgar score 105 Common musculoskeletal disorders 107
Assessment of newborn 105 brachial plexus injury, treatment 108
Apgar score 105 congenital dislocation of hip, treatment
later checks 106 107
measuring the baby 106 metatarsus adductus, treatment 108
talipes equinovarus, treatment 108
B Complications of pregnancy
backache 166
Biomechanical changes 17 breast infection 170
functions of sacral region 19 cesarean section delivery 168
motions at sacroiliac joints 18
hemoglobin status 166
sacral region 18 incontinence 171
Bottlefeeding 103 nerve compression syndrome 169
Breastfeeding 100, 161, 168
painful perineum 170
equipment 102 pelvic floor problems 166
feeding times 101 phlebothrombosis 170
getting started 100
pubic symphysis joint subluxation 167
problems 102
puerperal infection 170
Breathing during labor 53
sacroiliac joint discomfort 167
Breathing techniques
importance of 49 sacroiliac pain 167
technique-1 49 separation of the rectus abdominis 167
technique-2 50 spinal pain 169
technique-3 52 thrombophlebitis 170
D gluteal muscles 133
hamstring stretch 136
Deep vein thrombosis 170
heel lifts 132
Diastasis recti test 43
pelvic tilts 137
quadriceps stretch 136
E roll downs with a swing 145
Edema 78 shoulder release 147
Effleurage 55 side rolls 131
Electrical stimulation side stretches 143
care 164 sitting forward stretch 146
contraindications 165 standing side stretch 134
effects 164 stretch for abdominal, gluteal and back
electrode placement 164 muscles 142
electrodes 164 stretch to release tension 140
Electrotherapy 150 triceps exercise 143
Electrotherapy during labor 155 twist exercise 134
TENS 155 wide leg circles 145
Electrotherapy during postnatal period 156 windmill arms 139
TENS 156 Exercises during pregnancy, aims and plans
Electrotherapy modalities 150 114
cold therapy 153 arm stretches 117
infrared radiation 152 breathing exercises 115
interferential therapy 150 child pose with pillow support 128
laser therapy 153 forward bend 119
massage therapy 153 hamstring stretch 123
muscle stimulator 150 hand and wrist exercises 126
shortwave diathermy 152 head roll and head tilt 117
Embryonic and fetal development 58 knee drops to side 123
Ergonomics 31 knee to chest 122
aims of 32 leg raises with pillow support 127
causes of injury 33 leg slides 123
factors causing risk 32 legs against the wall 127
risky areas 33 opposite arm and leg stretch 122
safety measures 34 pillow squeeze 119
Exercises during postnatal period, aims and posture awareness 115, 124
plan 128 rib awareness 116
abdominal and pelvic floor exercise 138 shoulder lifts and circles 117
advanced pelvic tilts 142 side stretch 118
arm and leg stretches 133 spinal twist 127
arm exercises 130 squatting against a wall 124
bottom walking 130
bridging 146 F
buttock squeeze 132 Female reproductive system 4, 7
double leg stretch 144 estrogen 8
feet and ankle exercise 135 female reproductive cycle 7
flexing the feet 129 hormonal regulation 7
foot exercise 135 inhibin 8
Index 192
mammary glands 6 J
ovaries 5
Jaundice, phototherapy treatment 107
perineum 6
progesterone 8
relaxin 8 K
uterine tube 5 Kinesiology 21
uterus 5 aims of 21
vagina 5 Kneading 55
vulva 6
Female reproductive system, phases of 8 L
menstrual phase 8
postovulatory phase 10 Labor 58, 86, 156
preovulatory phase 9 alimentary tract 59
Forceps delivery 96 assisted delivery 96
baby 88
H baby’s position 89
central nervous system 59
Hemorrhoids 80 cesarean birth 97
High risk of pregnancy, causes for 82, 149 contractions 87
addiction 82 during first trimester 60
cardiac disease 83 during second trimester 66
chronic hypertension 83 during third trimester 69
diabetes 83 episiotomy 94
genetic disorders 84 fetal growth 58
hematological disorders 84 fetal hypoxia 60
infectious disease 84 fetal monitoring 93
liver disease 84 first stage 87
pituitary disorders 84 induction 89
pulmonary disease 83 maternal nutrition 59
pulmonary embolism 82 pharmacological pain relief 91
renal disease 83 placental size and function 58
rheumatic disease 83 placental transfer 59
sepsis 82 renal function 59
thyroid disease 83 respiratory system 59
uterine hemorrhage 82 second stage 93
venous thromboembolism 84 show 86
High risk woman, identification 82 signs of false labor 87
skin physiology 59
I staying up right 89
TENS 91
Ice application 160
third stage 98
Incontinence 171 transition 93
assessment of the pelvic floor muscles waters 86
173 Labor and delivery 86
cause 171 Low level laser therapy 158
exercises 174 Lower body exercises 21
types 171 half squats 22
Infrared radiation 158 hamstring 22
Insomnia 81 heel-raises 25
lying on side 24 role of pelvic floor 30
quadriceps 21 superficial muscle layer 30
side-leg lifts 24 Pelvic floor dysfunction 163
straight leg extension 22 Pelvis, bones and joints 1
toe pull-ups or foot lifts 23 Physiotherapy assessment chart 39
history 39
M investigations 40
objective assessment 41
Massage
previous management and effects 40
classification 54 subjective assessment 40
contraindications 55 Physiotherapy management during 43
indications 55
antenatal period 43
session 56 perinatal period 43
techniques 55 postnatal period 44
self-massage 56
puerperium 43
Methods of infection control for Pilates 110
physiotherapist 177 Pre-eclampsia or toxemia 78
cleaning 178
Pregnancy 58
cleaning vaginal weights and catheter 178 Pregnancy tests 14
decontaminated ultrasound head and amniocentesis 15
interferential
antenatal cardiotocography 16
electrodes 178 chorionic villus sampling 15
handwashing 178 estriol tests 16
perineometer 178
fetal movements recording kick chart 16
protect from infection 177 routine blood test 14
use of gloves 177 routine test 14
vaginal and anal electrodes 178
specific blood tests 15
Mittelschmerz meaning pain 10 ultrasound 15
Muscles urine test 14
abdominal muscles 1
Pregnancy, postural change 20
muscles of pelvic floor 3 Pregnancy, role of physiotherapy 12
oblique muscle 3 creating an awareness of the physical
changes 13
O management of physical discomforts 12
Obstetric physiotherapy, aims of 110 physical coping up skills for labor 12
contraindications 113 preparation for the changes during
effects and uses of exercises 113 pregnancy 12
exercise program 112 prevention of musculoskeletal problems
guidelines for exercise during pregnancy 12
113 promotion of health and healthy lifestyle
importance of exercise session 112 13
principles 111 treatment of musculoskeletal disorders
12
P
R
Pelvic floor 30
exercising the pelvic floor 30 Relaxation 45
pelvic floor muscles 30 techniques 46
Index 194
Relieving pregnancy discomfort 75 posture and balance changes 38
anemia 75 pregnancy weight gain 36
backache 80 pulmonary system 37
bleeding gums 75 thermoregulatory system 38
breathlessness 76 urinary system 37
carpal tunnel syndrome 81 Stop test 42
constipation 76
cramp 76 T
edema 78
TENS 91, 97, 154, 155
gestational diabetes 79
hemorrhoids 80
U
indigestion and heart burn 77
insomnia 81 Ultrasound 157
nausea or morning sickness 77 Upper body exercises 26
passing water 78 lateral pulls 27
piles 78 press-ups 26
pre-eclampsia or toxemia 78 trapezius 28
tender breast 80 triceps 27
vaginal discharge 79
varicose veins 79 V
vulval varicosities 79 Vacuum extraction 96
Varicose veins 79
S Venous complications 170
Sacroiliac joints 18
Short-wave diathermy 157
W
Skeletal changes during pregnancy 36 Whole body relaxation 46
cardiovascular system 37 advantages 47
musculoskeletal system 37 procedure 46
pelvic viscera, fasciae and ligaments 37 training for labor 48

Textbook of Physiotherapy For Obstetric and Gynecological Conditions MASUD PDF

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Textbook of Physiotherapy For Obstetric and Gynecological Conditions MASUD PDF

Încărcat de

Drepturi de autor:

Formate disponibile

Textbook of

Physiotherapy for Obstetric

Textbook of Physiotherapy for Obstetric and Gynecological Conditions

First Edition: 2007

Typeset at JPBMP typesetting unit

Chapter ten covers definition of relaxation, practicing relaxation, relaxation

Chapter twenty is in detail about definition, muscle stimulation, inferential

Textbook of Physiotherapy for Obstetric and Gynecological Conditions is a book that

treatment modalities in the form of electrotherapy for complications after delivery

BONES AND JOINTS

Fig. 1.1: Bones and joints of the pelvis

Action: Compresses abdomen.

Muscles of Pelvic Floor

FEMALE REPRODUCTIVE SYSTEM

Uterine Tube (Fallopian Tube)

FEMALE REPRODUCTIVE SYSTEM

Female Reproductive Cycle

follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the

PHASES OF FEMALE REPRODUCTIVE SYSTEM

Menstrual Phase (Menstruation)

temperature at rest). It is 0.4 to 0.6 degree Fahrenheit. Ovulation occurs about 14

ROUTINE BLOOD TEST

SPECIFIC BLOOD TESTS

CHORIONIC VILLUS SAMPLING

FETAL MOVEMENTS RECORDING KICK CHART

Pregnancy results in an alteration of every organ system with in the woman’s

Fig. 5.1: Biomechanical changes during pregnancy

Fig. 5.2: The sacroiliac joints

MOTIONS AT SACROILIAC JOINTS

Fig. 5.3: Nutation

Fig. 5.4: Counternutation

The change in position of the sacrum during nutation and counternutation

FUNCTIONS OF SACRAL REGION: STABILITY AND MOBILITY

Exercises are categorized into:

Lower Body Exercises

Straight Leg Extension

Toe Pull-ups or Foot Lifts

Upper Body Exercises

The Abdominal Muscles

Static Abdominal Contraction—Pelvic Tilt: On Bed

Position of the patient:

Role of Pelvic Floor

Pelvic Floor Muscles

Superficial Muscle Layer

Exercising the Pelvic Floor

Factors Causing Risk

Lifting and Its Risk

PREGNANCY WEIGHT GAIN

Fig. 8.1: Distribution of weight gain during pregnancy

PELVIC VISCERA, FASCIAE AND LIGAMENTS

in relaxin and progesterone level. Joint becomes hypermobile which leads to

POSTURE AND BALANCE CHANGES

pregnancies. Previous complications as premature labor, miscarriage, type of

PREVIOUS MANAGEMENT AND EFFECTS

Pelvic Floor Muscles

Pelvic Floor Assessment

Perineometers: Air-filled pressure probes is used to register vaginal pressure as

Diastasis Recti Test

PHYSIOTHERAPY MANAGEMENT DURING

Period from the day of pregnancy confirmation to the 20 weeks of pregnancy.

This is the period after puerperium from 8 weeks to 6 months.

is never go waste because it helps woman to take up the responsibility of mother,

WHOLE BODY RELAXATION (FIG. 10.1)