Physical Therapy & Pregnancy

Question 1

Changes to the cardiovascular system due to pregnancy

Answer 1

• blood volume increases progressively from 6-8 weeks gestation & reaches a max at about 32-34 weeks
• increase in plasma volume is relatively greater than that of red cell mass resulting in hemodilution & a decrease in hemoglobin
• cardiac output increases by 30-40% in the first trimester
• the heart is enlarged by both chamber dilation & hypertrophy
• dilation across the tricuspid valve can initiate mild regurgitant flow causing a normal grade I or II systolic murmur
• upward displacement of the diaphragm causes the heart to shift to the left & anteriorly

Question 2

Changes to the respiratory system due to pregnancy

Answer 2

• capillary engorgement & swelling of the lining in the nose, oropharynx, larynx, & trachea
• nasal congestion, voice change, & upper respiratory tract infection
• can be exacerbated by fluid overload or edema associated with pregnancy induced hypertension or pre-eclampsia
• from middle of the 2nd trimester expiratory reserve volume, residual volume, & functional residual volume are progressively decreased by about 20% at term

Question 3

Changes in metabolism due to pregnancy

Answer 3

• all metabolic functions are increased during pregnancy to provide for the demands of fetus, placenta, & uterus

Question 4

Changes in renal physiology due to pregnancy

Answer 4

• renal plasma flow & glomerular filtration rate begin to increase progressively during the 1st trimester
• at term both are 50-60% higher than in the non-pregnant state

Question 5

Physical changes in the 1st trimester

Answer 5

• first 12 weeks after the first day of the last menstrual period
• breast enlargement
• average weight gain of 5 lbs
• may start to see increase lordosis at 10-12 weeks

Question 6

Physical changes in the 2nd trimester

Answer 6

• week 13 to week 27
• average weight gain of 1 lb per week
• uterus will expand to 4x its size from week 12 to 27
• shift in center of gravity due to the increased size of the belly & hyperlordosis
• rectus abdominis increasing in length & diastases rectified may be forming

Question 7

Physical changes in the 3rd trimester

Answer 7

• week 27 to week 40+
• complete core disruption
• increased fatigue
• heart burn
• upper respiratory breathing
• swelling
• hemorrhoids
• varicose veins
• stress incontinence
• shortness of breath

Question 8

Describe a diastasis recti

Answer 8

• associated with support-related pelvic floor dysfunction, stress incontinence, fecal incontinence, & pelvic organ prolapsed
• 66% of individuals with DR had SPFD
• measure 4cm above & below the umbilicus

Question 9

Post partum musculoskeletal changes

Answer 9

• persistant RAD (rectus abdominis diastasis)
• scarring of the perineal or abdominal area interfering with fascial support
• persistent pelvic obliquity
• breastfeeding = increased thoracic spine kyphosis & poor posture
• pelvic floor muscle deficits & weakness

Question 10

What nerve innervates your pelvic floor muscles

Answer 10

• Pudendal nerve

Question 11

Describe posterior pelvic pain (PGP)

Answer 11

• pain experienced between the PSIS & gluteal fold particularly in the region of the SI joint
• may radiate to the posterior thigh
• can occur in conjunction with pain in the pubic synthesis
• endurance capacity for standing, walking, & sitting is diminished
• diagnosis after exclusion of the lumbar spine
• must be reproduced with specific clinical tests

Question 12

Common outcome tools for PGP (posterior pelvic pain)

Answer 12

• Disability Rating Index (DRI)
• Oswestry Disability Index (ODI)
• Pelvic Girdle Questionnaire (PGQ)
• Fear-Avoidance Beliefs Questionnaire (FABQ)
• Pain Catastrophizing Scale (PCS)

Question 13

Examination for PGP (poster pelvic pain)

Answer 13

• high specificity but poor sensitivity
• P4 test (thigh thrust), Patricks Faber, Gaenslens test, & modified trendelenburg test for pain provocation tests
• long dorsal ligament & public synthysis for pain palpation
• active straight leg raise for functional test

Question 14

Test item cluster for SI dysfunction

Answer 14

• Thigh thrust
• Gaenlens
• Distraction
• Compression
• Sacral thrust
• 3 out of 5 to be positive

Question 15

Define pelvic girdle syndrome

Answer 15

• daily pain in all 3 joints (pubic symphysis, right, & left SI joint) with pain provocation tests

Question 16

Define synphysiolysis

Answer 16

• daily pain in synthesis pubis only with positive pain provocation

Question 17

Define one-sided SI syndrome

Answer 17

• daily pain in one SI joint with positive provocation test

Question 18

Define double sided SI syndrome

Answer 18

• daily pain in both SI joints with positive pain provocation tests

Question 19

Define miscellaneous pregnancy related pelvic joint pain classification

Answer 19

• daily pain in one or more pelvic joints with inconsistent objective findings

Question 20

Treatment for pregnancy related pelvic pain

Answer 20

• manual therapy including soft tissue mobilizations & gentle joint mobilizations for pain inhibition only
• diaphragmatic breathing
• exercise for pelvic & lumbar stability
• postural instruction
• body mechanics
• belting

Question 21

What treatments should you avoid for pregnancy related pelvic pain

Answer 21

• intravaginal treatment
• intrarectal only with specific OB clearance
• asymmetrical LE movements
• E-stim or ultrasound for pain control
• watch for diastasis recti

Question 22

What conditions would call for activity limitations to be used

Answer 22

• prevention of preterm birth
• miscarriage
• growth restriction
• hypertension
• bleeding
• multiple gestation

Question 23

Prevention of preterm birth

Answer 23

• advanced cervical dilation (>2cm)
• frequent uterine contractions
• premature labor

Question 24

Degrees of activity limitation in order of least to most limited

Answer 24

1) strenuous activity
2) lifting
3) working in a standing position
4) no working outside of home
5) home confined
6) bed rest (meaning bed pan)

Question 25

Recommendations for activity during pregnancy

Answer 25

• participation in many sports is safe during pregnancy
• avoid activities with high risk of falling or abdominal trauma
• no scuba
• in the absence of complications, 30 minutes of exercise a day is recommended

Question 26

Absolute contraindications to exercise

Answer 26

• significant heart disease (class 2 & beyond)
• restrictive lung disease
• incompetent cervix
• multiple gestation at risk for preterm labor
• persistent 2-3 trimester bleeding
• placenta prevue after 26 weeks gestation
• premature labor in current pregnancy
• ruptured membranes (water broke)
• pre-eclampsia (HTN)

Question 27

Precautions to exercise

Answer 27

• severe anemia
• unelevated maternal arrhythmias
• chronic bronchitis
• poorly controlled type 1 diabetes
• morbid obesity
• extremely underweight (BMI<12)
• IUGR (inter-uterine growth rate) in current pregnancy
• poorly controlled HTN
• poorly controlled seizure disorder
• poorly controlled hyperthyroidism
• heavy smoker

Question 28

Describe the PARmed-X for pregnancy

Answer 28

• previously sedentary women with healthy pregnancies can Strat an exercise program in the 2nd trimester
• women with low risk pregnancies can continue mild-moderate activity throughout pregnancy
• mild-moderate activity in the PARmed-X is considered safe
• muscle conditioning with necessary precautions is safe

Question 29

Post partum pelvic girdle pain

Answer 29

• similar exam to PGP in pregnancy
• if pelvic floor control appears disrupted then add in a pelvic exam
• remember to rule out the lumbar spine/low back pain

Question 30

Clock for perineal injuries

Answer 30

• similar to wound care clock
• 12 o’clock = pubis
• 6 o’clock = coccyx

Question 31

Describe a 1st degree perineal laceration

Answer 31

• vaginal mucosa & perineal skin torn
• no stitches

Question 32

Describe a 2nd degree perineal laceration

Answer 32

• involves muscles of the perineal body without transgressing the anal spincter
• will have been stitched up on the birthing table

Question 33

Describe a 3rd degree perineal laceration

Answer 33

• laceration of anal spincter
• would have received stitches in a surgery room not on the birthing table

Question 34

Describe a 4th degree perineal laceration

Answer 34

• laceration of rectal mucosa
• one opening instead of two
• probably won’t get full continence back

Question 35

Define an episiotomy

Answer 35

• cutting of the perineal muscles instead of allowing them to tear during birth

Question 36

Describe the order in which you have to cut through for a C-section

Answer 36

• skin
• superficial fascia
• rectus sheath
• rectus abdominus
  -fascia & peritoneum
• uterine wall
• amniotic sac