Long-Term Postpartum Physiotherapy Management

Question 1

Post-Partum/Post-Gynaecological Surgery Dyspareunia? Causes?

Answer 1

Dyspareunia can be defined as any pain or soreness that occurs during sexual intercourse (deep pain or superficial/spasm pain).
Causes:
o Can occur following childbirth (physical or psychological) or a combination of both
o Secondary to scar tissue formation
o Poor repair following perineal trauma
o Trauma or vaginal dryness (breastfeeding)

Question 2

Dyspareunia Treatment

Answer 2

o Pelvic floor assessment of increased tone (PV) and down training (relaxations)
o Myofascial trigger point therapy of PFM
o Vaginal dilators
o Endep, Lyrica, Gabapentin, Ovestin cream
o Pudendal nerve blocks/Botox in severe cases of PFM
o Relaxation
o Return to pain-free movement
o Multi-disciplinary approach to treatment is very important

Question 3

Instructions for getting out of bed

Answer 3

• Position in supine, crook lying, bridge closer to the edge of bed
• Crook lying, roll knees to the side, so that knees are at the edge of the bed
• Push up through elbow and then hand into sitting
• Sit for a moment to overcome any postural hypotension
• Shuffle to edge of bed
• Stand up (stand for a moment to overcome any postural hypotension)
• Start walking 


Question 4

Diastasis Rectus Abdominis Muscle (DRAM) Assessment

Answer 4

Expect 53% immediate postpartum, 36% at 6 weeks Assessment (immediate postpartum).
* Position in supine, crook lying (knees up)
* Palpate 2 finger widths above the umbilicus, your fingers in the cephalad direction
* Concerned if can place 4 finger widths or more into the gap
* Test 1 – resting assessment (no movement)
* Test 2 – head lift assessment (to check if/how the abdominals are contracting and whether anything protrudes)

Question 5

Diastasis Rectus Abdominis Muscle (DRAM) treatment

Answer 5

• Could reassure that this is common (53%) and many resolve
• Provide support over abdomen
• SRC (medical company, supportive garments)
• High-waisted support pants from regular stores
• Recommend postnatal physio check-up at 6 weeks (although many will resolve by 6 weeks, it is worth booking in a check so that you can identify those that have a prolonged problem)
• Ergonomic advice - avoid activities that will increase intra-abdominal pressure (i.e. lifting, gym 
weights) 


Question 6

Diastasis Rectus Abdominis Muscle (DRAM) Long teerm management

Answer 6

• 6-week check-up - reassess DRAM and PFM function
• If the separation is >3cm at 6 weeks, then need a physio program
• Add gentle exercise - arm, leg and trunk movements (avoid crunches initially), build up to light hand weights 

• Ask if you can pop your hand over the abdomen to check separation during exercise
• Supportive pants/garments
• Some may need surgery if unresolved and very wide

Question 7

Constipation guidelines

Answer 7

Bowel function
Be aware of normal frequency which is anywhere between a few times per day to a few times per week.
Constipation
* Day 2 – BNO (bowels not open) not worried 

* Day 4 – This is a problem as will probably be going home today; not good to hold too long;
* Going to the toilet is a discharge criteria 

* Check fluid intake & diet 

* Check normal frequency (do they have a pre-existing pattern or problem) 


Question 8

Constipation treatments

Answer 8

• Encouraging mobility+++ (get them to walk outside their room – up and down the hallway
• Ask nursing staff about stool softeners (movacol, lactulose, coloxyl with senna)
• Support stitches (perineal pressure) with maternity pad or toilet paper whilst on toilet; do not strain
• Reinforce diet –fruit, vegetables, pear juice 


Question 9

Pain 
potential treatments

Answer 9

• Ice
• Positioning – flat lying, side lying, sitting in chair, bed head at 60 degrees (avoid long periods of upright position in bed as can cause swelling to pool)
• Remove/limit haemorrhoid rings/pillows
• Pain relief – check with nursing/medical staff about ability/timing to take pain relief

Question 10

Postpartum SVD Management (on the Ward) guide?

Answer 10

SVD timeline
Day 0 = Day of the birth 

Day 1 = Morning after the birth 

Day 2 = second morning after the birth 

NB: if had an epidural, then refer to LSCS timeline 
Initial assessment 

1. Introduction & check general wellbeing
2. Pain
3. Bladder function 

4. Bowel function
5. Pelvic floor exercise
6. Diastasis Rectus Abdominis Muscle (DRAM) Assessment
7. Exercise advice 

8. Getting out of bed

Question 11

Additional elements for LSCS 
guide?