Womens Health ILP 2006

WOMEN’S HEALTH
Independent Learning Package
© Division of Physiotherapy
The University of Queensland
2006
University of Queensland, Division of Physiotherapy 1

Women’s Health Independent Learning Package 2006.
Continence & Women’s Health Independent Learning Package
TABLE OF CONTENTS
Page No
1.1 Welcome to the Clinical Unit 4
1.2. Expectations Upon Commencing this Unit 5
1.3 List of Resources 6

a) lectures 6
b) textbooks 6
c) booklets 7
d) journal articles 7
e) websites 8
f) videos 8
g) resource package in facilities 9
1.4 Abbreviations 10
1.5 Glossary of Obstetric terminology 12
1.6 Chart entry example 15
1.7 Aims & Objectives 19
1.8 Start up Test 21
1.9 Part 1 Pelvic Floor Dysfunction

and Management 26
Part 2 Ante-Natal Care 30
Part 3 Post Partum Management 34
Part 4 Exercise in Pregnancy 38
Part 5 Antenatal Musculoskeletal Conditions 41
Part 6 Labour Ward 46
Part 7 Baby Handling and Massage 49
Part 8 Gynaecology and Gynae/Oncology 52
Part 9 Breast cancer 57
Part 10 lymphoedema 59
Part 11 Osteoporosis 61
1.10 Acknowledgments 65

1.1
WELCOME TO
THE CONTINENCE AND WOMEN’S HEALTH
CLINICAL UNIT
This Independent Learning Package (ILP) has been designed to be completed over
your Women’s Health clinical placement. It is designed to help prepare you for
clinical practice and achieve competence in the area of Women’s Health.
As you will appreciate, this unit covers a very wide range of clinical situations. The
ILP is broken up into sections, which include the eleven areas of Women’s Health
students will be working in. Each clinical setting may not have all of these
experiences. It is envisaged that by working through each section this will prepare the
student for clinical scenarios in the future.
This ILP which has been developed to provide information and additional learning
activities that will enhance and extend your knowledge in the area of Continence and
Women’s Health. The answers to clinical questions within the ILP are guidelines only
and your aim should be to understand the clinical reasoning to assessment and
treatment planning rather than the rote learning of protocols.
The ILP has a suggested timeframe for completion of tasks. This includes completing
sections 1.9 parts 1-4 during the first week, 1.9 parts 5-8 in the second week and 1.9
part 9-11 during the third week. This will allow you to consolidate your knowledge
and bring all areas together by the fourth week. You should allow approximately 1
hour for each section. The order of sections to be completed may vary from facility to
facility. Please discuss this with your Clinical Educator in order to maximise your
learning opportunities.

1.2 EXPECTATIONS UPON COMMENCING THIS UNIT
Before commencement, you need to complete the “Start-Up Test” – section 1.8. It is
strongly advised that you attempt these exercises without referring to the answers
initially. The test has been designed to reflect a reasonable level of preparedness prior
to commencing the unit and subsequently, if your answers vary significantly from the
suggested answers, then this should guide some urgent revision.
You should review the relevant pre-clinical lecture material. Lectures are listed in the
“resource “section of this ILP.
You are advised to consult the student Web page for individual facility contacts and
additional information.

1.3 RESOURCES
A)Lectures
PHTY2230 PHTY7823
No. Topic
L1 Menarche: Sport, diet, and osteoporosis in adolescence
L2 Ante-natal care; Essential medical care and intervention with
common problems on admission & effect of drugs.
L3. Parturition- Labor and delivery, physiology of labor , types of labor,
medical management, monitoring, interventions, & postnatal
complications.
L4. Exercise in the child bearing years
Pr 1-2 Exercise in the child bearing years
L5. Physiotherapy antenatal education and management during
pregnancy.
Pr 3-4 Physiotherapy antenatal classes.
L6 Post-natal physiotherapy management.
L7 Pharmacological pain management in pregnanc y and labor
Pr 5-6 Post-natal physiotherapy
L8 Osteoporosis – Prevention and management.
L9 Physiotherapy in the management of osteoporosis
Pr 7 Physiotherapy in relation to osteoporosis.
L10- Physiotherapy management of incontinence.
12
Pr 8-9 Physiotherapy for the pelvic floor
B) Textbooks
• R. Sapsford, J. Bullock Saxton and S. Markwell (1998) “Women’s Health – A

Text book for Physiotherapists.” - WB Sanders Co Ltd
• Collins, M (Ed) (1987) “Women’s Health through Lifestages” – The

Physiotherapists Contribution” A.P.A. (NSW Branch)
• Polden M and Mantle J (1990) “Physiotherapy in Obstetrics and Gynaecology”

Butterworth Heinemann Ltd
• Kitzinger S (1977) Ëducation and Counselling for Childbirth” Cox and Wyman
Ltd
• Chiarelli Pauline (1992) “Women’s Waterworks- Curing Incontinence” Health

Books
• Chiarelli Pauline and Markwell Sue (1992) “Lets Get Things Moving,
Overcoming Constipation”

• Sutton Jean and Scott Pauline “Understanding and Teaching Optimal foetal
Positioning” Birth Concepts
• Childbirth Graphics / Birth Atlas
C) Booklets
• “Breast Screening Qld” Workbook - Contact Women’s Cancer Screening

Services for a copy of workbook to be sent
• All About Early Breast Cancer 1996 – NHMRC National Breast Cancer Centre
• After Breast Cancer Surgery – “Looking Ahead” - The Cancer Council Australia
D)Journal Articles
• Julie A Hides PhD MphtySt Bphty

“The deep stabilising muscles of the lumbo-pelvic region: personal observations of
the pre and post partum periods”
National Cont inence and Women’s Health Group, Vol17, 1998.
• Alastair H. MacLennan, Anne W. Taylor, David H. Wilson, Don Wilson

“The prevalence of pelvic floor disorders and their relationship to gender, age parity
and mode of delivery”.
British Journal of Obstetrics and Gynaecology December 2000, Vol 107,pp. 1460-
1470
• R.R. Sapsford, P.W. Hodges, C.A. Richardson, D.H. Cooper, S.J. Markwell,
G.A. Jull
“Co-activation of the Abdominal and Pelvic Floor Muscles during Voluntary
Exercises.
Neurology and Urodynamics 20:31-42 (2001)
• Katrina Horsley, B. Phty, MBA

“Exercise in Pregnancy”
Continuing Education Articles, Women’s Health Group Queensland
• Sue Croft
“Pre-Operative Pelvic Floor Education Class”.
Journal – National Women’s Health Group Vol 14, 1995

E) Websites
• Dr Chris Maher
http://urogynaecology.com.au
• Royal Australian College of Obstetricians and Gynaecologists -

www.ranzcop.edu.au
• The Pregnancy Centre - www.thepregnacycentre.com
• www.lymphoedema.com.au
F) Videos
• “Labour and Delivery”

• “The Birth of Sally’s Baby”
• “Birthing my way”
• “Positions for Childbirth”
• All round work out – Lisa Westlake
• Back in Action - Lisa Westlake
• Roll up to Unwind - Lisa Westlake
• Advanced Fitball - Lisa Westlake www.physicalbest.com
• “Handling your baby”
• “Massaging your baby”
• “Understanding Breast Cancer”
• “Osteofit Australia”
• “Lisa Curry’s Pregnancy Exercise Workout”
• “Pregnant and in Perfect Shape”
• “Pregnancy Exercise Workout” – Julie Sundin
• “Great Expectations” – Lisa Westlake www.physicalbest.com
• “Understanding Bladder Control”
• “Back in Focus”

• “Caring for your back whilst caring for your baby”
• “Back to normal”
• “Positions for labour”
• “Special Delivery”
G) Resource package in Clinical facilities- A resource package has been compiled

containing several of the components listed in this section. This will vary between
facilities. Please consult with your clinical educator for further information and access
to these resources.

1.4 Abbreviations
ACH After – Coming Head
APH Ante-Partum Haemorrhage
ARM Artificial Rupture of Membranes
ATSP Asked to see patient
BBA Born Before Arrival (at Hospital)
BF Breast Feeding
BR Breech
CPD Cephalo Pelvic Disproportion
CTSP Called to See Patient
DCGD Diet-controlled gestational diabetes
EBL Estimated blood Loss
EDC Expected/Estimated Date of Confinement
EDD Expected/Estimated Date of Delivery
EPIS Episiotomy
FD Foetal Distress
FTP Failure To Progress
G,P,M,T Gravida, Parity, Miscarriage, Termination
GTT Glucose Tolerance Test
IDGD Insulin dependent gestational diabetes
IHD Ischaemic Heart Disease
INT Intact Perineum
INUFD Intra Uterine Foetal Death

IUFD or
IUGR Intrauterine growth retardation
KR Keiland’s Rotation

LF Laute Forceps
LNMP Last Normal Menstrual Period
LSCS Lower Segment Caesarean Section
MR Manual Removal (of Placenta)
NB Neville-Barnes Forceps
OA Occipito Anterior
OP Occipito Posterior
PET Pre-Eclamptic Toxaemia
PID Pelvic Inflammatory Disease
PN Premature Nursery
POP Persistent Occipito Posterior
PPH Post-Partum Haemorrhage
PR Per Rectum
PUO Pyrexia Unknown Origin
PVE Per Vagina Examination
RAS Remove Alternative Sutures
RI Rooming In
RIB Rest in Bed
SOBOE Short of Breath on Examination
SVD Spontaneous Vaginal Delivery
TIT2 Twin 1 and 2
TL Tubal Ligation
TPO Toilet Privileges Only
UKO Unknown Origin
UO Urinary Oestriols

URTI Upper Respiratory Tract Infection
USCS Upper Segment Caesarean Section
UTI Urinary Tract Infection
VDRL Venereal Disease Research Laboratories
WLO Wrighley’s Lift Out (Forceps)
1.5 Glossary of Obstetric terminology
Abortion expulsion of products of conception before viability
Abrupto placentae premature separation of the placenta
Amenorrhoea absence of menstruation
Amniocentesis Aspiration of amniotic fluid by inserting needle into the uterus

through the abdominal wall. Analysis of cells and other
constituents may detect foetal abnormalities and maturity.
Amniotomy Artificial rupture of the membranes to induce labour.
Analgesia Pain relief. Various methods are used during labour including
inhaling nitrous oxide and injections of pethidine.
Antenatal period Conception to onset of labour
Anteparum Before labour
Apgar Score Index of a baby’s condition at birth. Scored out of 10 on pulse,

respiration of foetal parts to one another
Attitude Relationship of foetal parts to one another
Augmentation of Acceleration or enhancement of spontaneous labour by using

Labour oxytocics.
Birth Asphyxia A condition in which the baby is deprived of oxygen at birth.
Braxton Hick’s Spontaneous uterine contractions

Contracitons
Breech Extraction Method of delivering foetus by pulling down the legs. Now only
performed in emergencies.
Cephalhaemotoma Bruised skull. Sometimes found in babies who had difficult

deliveries.
Cephalo-Pelvic Small or distorted maternal pelvis which proves difficult for the
Disproportion foetal head to negotiate. Similar problems occur with a large head
n a normal pelvis
Colporrhaphy Surgical tightening of vaginal walls
Foetal Distress Deprivation of oxygen from the foetus during labour. Usually
assessed by changes in foetal heart rate and/or abnormal
appearance of the amniotic fluid.
Foetoscopy Passing a telescopic instrument into the uterus during pregnancy

to examine the placenta and foetus
.
Forceps Delivery Birth achieved by traction or rotation of the foetal head with metal
instruments.
Grande Multipara Woman who has had five or more pregnancies extending beyond
20 weeks.
Haemloytic Disease Destruction of foetal red blood cells leading to neonatal jaundice
of the Newborn and anaemia, or stillbirth in severe cases.
Hyaline Membrane See the respiratory Distress Syndrome

Disease
Hyperbilirubinaemia See Neonatal Jaundice.
Hypothermia Body temperature lower than normal. Pretrerm babies are

particularly susceptible to the harmful effects.
Hypotonic Uternine Infrequent or weal uterine contractions during labour.

Action
Hysterectomy Removal of the uterus
Induction of Labour Artificial commencement of labour after 20 weeks gestation.

Usually performed by Amniotomy with or without the use of
oxytocics.
Intrpartum Foetal Shortage of oxygen to the foetus in labour. Often suspected from
Hypoxia signs of foetal distress. Confirmed by foetal scalp blood sampling
Labour Process of expulsion of the foetus through the vagina
Lie Relationship of the long axis of the foetus to the long axis of the
uterus
Lightening The presenting part enters the pelvis

Precipitive labour Labour less than 4 hours duration
Premature Born before 37th week
Primigravid First time pregnant
Presentation Part of the foetus occupying lower pole of uterus (vertex,

shoulder, breech etc.)
Primpara Given birth to a viable infant
Procedentia Third degree prolapse uterus outside vagina
Prolapse Abnorma l protrusion of uterus through pelvic floor
Puerperium The six weeks following labour
Quickening Woman first aware of foetal movements
Rectocoele Herniation of rectum in the vaginal wall
Retroversion Long axis of the body of the uterus is directed posteriorly
Station Level of presenting part in the pelvis in relationship to the ischial

spine
Stillbirth Infant failing to show signs of life, after viable age
Stress Incontinence Involuntary leakage of urine occurring during raised intra-

abdominal pressure
Term Physiological maturity of human foetus 280 days, 40 weeks, 9

calendar months and 7 days, 10 lunar months from conception
Trimester A period of 3 months
Urge Incontinence Urgent desire to void immediately
Version Turning of the foetus in utero
Viable Capable of independent existence, such a foetus may be stillborn

(20 weeks plus is considered viable)

1.6 Chart entry
These notes should reflect a clear account of background, assessment, treatment,

outcome and plan as it has applied to this patient at this time. Different clinical
placements may or may not require chart entries to be made, + / – documentation in
the Clinical Pathway. Whether it is required or not, the process described is
invaluable for improvement of problem solving skills. You are advised to use these
guidelines for treatment planning and execution, whether or not an actual chart entry
is made.
*******************
• The chart entry must be individualised (reflecting an individual patient focus)

• These notes are used for other members of the team to understand what the
priorities and treatment goals according to physiotherapy are, and so to support us
in achieving them
• On reading the notes in, perhaps, 2 years time, a picture of this patients progress
could be made if the notes are individualised, not generic
• All treatment should be working towards achieving agreed goals – the chart entry
must reflect this
• Notes should use most of the available writing space on the page, but do NOT
need to be written strictly column to column, as with Nursing Staff
• Ensure that
o The layout is logical: - background→assessment→prioritised problem list
→treatment→outcome→plan . The treatment may, in fact, have been
interspersed with parts of assessment, but the chart entry does not need to
reflect the exact order of treatment, but the clinical problem solving path that
has been followed
o Treatment must reflect something found in assessment or listed in prioritized
problem list – it cannot just “appear” for no reason
o “Minimalist”: - phrases rather than full sentences can be used, without
repeating the patient’s name, etc. Stick to the facts – those that are important
in the Physiotherapy perspective. Use abbreviations sparingly – some Obs and
Gynae and general English abbreviations are widely understood, but detailed
Physiotherapy abbreviations should NOT be used
o Easy to read: - legible handwriting or consistent printing is important, check
spelling, especially of Physiotherapy terminology
o Include point form where appropriate: - look at the layout, separate points
should start on separate lines
• Chart entry should not take more than ½ page in most cases
• All entries must be signed, and should be written close to the time of intervention
• Review treatments should reflect cha nges, progressions, responses or any new
information since the last treatment. The full entry does not need to be repeated.

Example Example
Initial C/O Mary feeling and moving well Day 2 Rowena feeling v.
statement post SVD (2nd degree tear) - 1st baby uncomfortable and tired
including Day 2 post C/S – 4th baby
Day.... (6 and 4 yr old SVD, 2yr
post…? old by C/S)
Baby…
other
children….
Previous >No problems with bladder control or >Problems with

history incontinence before or during incontinence since 1st
(long-term, pregnancy, child (some SUI + Urge
before >Some minor symptoms of incont), has managed by
pregnancy constipation/straining in 2nd trimester using pads (constant
or during (used dietary ? and _ water), otherwise throughout this
pregnancy) fine pregnancy). Patient very
– bladder, >Long history of back pain since MVA concerned that problem
bowel, back 12years ago. Back pain _at beginning is worsening
of pregnancy, then constant throughout >No problems with
2nd and 3rd trimester. Accessed PT with constipation/straining
v good results before or during
>Abdominal tone usually good – leads pregnancy
very active lifestyle, enjoys swimming >Has been told she has a
and cycling (not during preg) slight “prolapse” but is
not really sure what that
means
>Back usually OK,
though generally tired/
achy during this
pregnancy
>Abdomen never quite
recovers after pregnancy
– usually too busy to
worry about exercises.
Finds running after
children is all she has
time for.

Currently >Perineum sore and sl swollen (using >Abdominal incision site
ice 4th hourly) very p’ful
>Has not yet moved bowels >IDC just removed, IV
>Tailbone and low back sl painful (is and PCA in situ
sitting in bed to feed) >Has not yet passed wind
>Upper torso feeling “stiff” >Back sore at epidural
site
>R) shoulder and neck in
“spasm”
O/E >Static posture sitting - generally flexed, >Abdominal distended
(These are flat lumbar curve/ post pelvic tilt, _ and fairly tight (wind++)
any thoracic curve >Has not been out of bed
objective >Abdominal tone fair, able to activate – using bedring for assist
measures muscles easily bed mobility (_
that you can >Nil Rectus Diastasis shoulder/neck strain)
state, not the >Moves well – good postural tone and >Abdominal bulging++
patient’s awareness, no breath holding with all _ in IAP
opinion)
NB - do
NOT test
for Rectus
Diastasis
until at least
Day 4 post
C/S
Prioritized >Perineal pain/swelling, no bowel >Wind pain and bloating
Problem movement with history of constipation >Poor movements
List >Tailbone and low back pain – sitting patterns - _ IAP, breath
(This need and feeding postures holding, using bed ring
not be >Upper torso/shoulder girdle stiffness >_awareness of
recorded in >Long-term back problem importance of long-term
chart, but >Change of lifestyle fitness -? Motivation
must be >Pelvic floor muscle
used by dysfunction
student to
show
clinical
problem
solving
process)
Rx >Commenced pelvic floor program – >Commenced strategies
(this needs gentle P.fl. contractions // improved to assist wind movement
to be patient comfort • Abdominal massage
centered, >Activation deep abdominal stability (_ rt, _ top, _lt) //
using active, muscles // good contraction, well _muscle tension, felt
involved isolated, minimal overflow, fair softer
verbs – endurance • Gentle activation
NOT taught, >Functional bracing through all deep abdominals
showed, movements and ? positions // good /p.floor // difficult at
demonstrate within bed and in/out of bed through first (pain inhib), but

d… - but sidelying, some _abdominal stability in fair contraction w
what did the standing practice
PATIENT >Practised position for defecation// well • Lumbar postural
do?) positioned, though feet on stool might stretches++ // felt
assist – also using manual support immediate relief
// All >Practised in/out bed through sidelying • Understands forward
intervention to _ strain on back and perineum // fine lean in stand and
s must state >Postural stretches++ for lumbar and defecation position to
an outcome thoracic spines, pelvic rocking, shoulder use to assist // will
girdle stretches // felt great improvement use when out of bed
>Improved sitting postures - _ >Functional bracing –
awareness of neutral tilt, lumbar before any movement of
support, to use chair with one foot on legs in bed // _ stability
footstool, not bed // __ discomfort of abdom corset (less
bulging)
>Practised roll to side,
sitting up to edge of bed
through sidelying //
improving, min breath-
holding, _pain
>Thoracic spine and sh
girdle stretches in sitting
// felt great
>Discussed sitting in
chair to feed, general
patterns of better
movement
Plan (plan >To use above program approp and >To practise program at
of program regularly, postural stretches after each least hourly today
– from feed (massage, bracing,
patient’s >To use ice, rest and gentle P.fl. stretches, mvt patterns)
view) contractions 20mins each hour for today >For progression of
> d/w M/W re stool bulking +/-softener) stability and pelvic floor
>For R/V tomorrow, further planning re program when wind has
long-term program and management of settled
back problem >To work with patient to
develop realistic plan for
post D/C followup and
long-term fitness
program (incl goal-
setting)
Plan (incl >Keen to commence graduated walking
D/C) program, swimming >6/52.
>To attend Physio postnatal review at
MMH (2nd May), then likely O/P apptmt
after that
>To contact me if any problems before
then

1.7 AIMS AND OBJECTIVES
There are sixteen specific objectives of this unit. Often, one experience will relate
to a number of these objectives. It is therefore important that you peruse these
objectives prior to attending the first day of the unit so that when relevant information
presents itself you will be aware of it.
1. To understand the anatomy, basic physiology, basic pathology and pharmacology

relevant to physiotherapy in Continence and Women’s Health.
2. To understand biomechanical and physiological changes occurring during

pregnancy and the puerperium that may benefit from physiotherapy management.
3. To develop strong clinical problem solving skills – using assessment to identify

problems, planning and implementing appropriate treatment programs, re-
evaluating to gauge the outcome of the treatment
4. To gain practical experience in identifying, preventing, minimising and treating

problems which may arise as the result of these changes.
5. To understand the routine management and common tests of pregnancy and the
routine care and the active management of the woman in labour.
6. To explore and use different teaching strategies that may assist adult learning
7. To effectively teach physiotherapy skills of stress management as they apply in

antenatal, perinatal, postnatal and long-term situations.
8. To use and teach positive baby handling strategies.
9. To gain practical experience in the optimal management of post-operative

gynaecological and caesarian patients
10. To become aware of the physiotherapy management of osteoporosis, predisposing

factors and the influence of hormone replacement therapy.
11. To become aware of the implications of breast cancer for physiotherapy

management:
lymphoedema treatment
stretch and scar tissue mobilisation
12. To acquire clinical skills to assess and manage dysfunctions of the pelvic floor,
recognising that the focus of management may vary in different lifestages -
ante-natal, post-natal, menopause, etc.
13. Apply current research finding to clinical practice, particularly within the area of
pelvic floor/abdominal/multifidus interaction.

14. To become evidence-based and outcome oriented in physiotherapy practice,
understanding the need to value the role of physiotherapy in these areas of
management.
15. To demonstrate the ability to communicate effectively with patients, other

members of the team and peers.
16. To act in accordance with the Department of Physiotherapy Behavioural

Objectives for Clinical Practice.

1.8 – Start-Up Test
1. What are the two most common types of urinary incontinence in females?
2. List the interventions that you would provide for each of these cond itions.
3. List 5 biomechanical +/- hormonal changes occurring in pregnancy which need to

be taken into account during Ax and Rx of a patient who is pregnant
4. A woman who is 29 weeks pregnant is suffering from “pelvic instability” and is

referred to you in an Outpatients clinic. Outline the basic physiotherapy
management
5. What are the basics of “comfort” positioning in pregnancy (i.e. optimal

positioning of the pelvis, hips and spine)?
6. Design two stretching and two strengthening exercises to incorporate into a

pregnancy exercise class
7. List 5 safety guidelines for exercising during pregnancy
8. Describe how you would teach abdominal exercises to a pregnant woman to do as

a home program. How might you change or progress this exercise when you see
her postnatally?
9. A first-time mother who has attended Antenatal Physiotherapy Education

sessions, has had her baby 24hrs ago. What skills might you expect her to be
using to assist her, because of this previous education?
10. List six options of treatment that may assist an early post-natal patient with
back pain
11. What is a Diastasis Rectus and when is it of concern?
12. List 5 strategies used in bladder retraining
13. A 43 year old woman has had a total abdominal hysterectomy and bilateral
salpingo-oophorectomy. What long term goals are important for her well being?
14. You are giving discharge advice to a woman who has had a vulvectomy and
groin lymph node dissection. She informs you that she will be flying to the
Whitsundays and having long walks on the beach to help recover from the
surgery. What specific advice should she be given in relation to lymphoedema
precaution?.
15. Outline the advice you would give to a woman undergoing a pelvic floor repair
who suffers from constipation.

1.8 Start Up Test – Answers
1. Urge Incontinence – the complaint of an involuntary loss of urine accompanied

by or immediately preceded by urgency (a sudden compelling desire to pass urine
which is difficult to defer).
• Stress Urinary Incontinence – the complaint of involuntary leakage on effort or
exertion or on coughing or sneezing If observed during filling cystometry, it is
defined as the involuntary leakage of urine during raised intra- abdominal
pressure, in the absence of a detruser contraction. This is called Urodynamic
Stress Incontinence and is the preferred term to Genuine Stress Incontinence
(GSI).
2.Urge -
• PC muscle endurance training, either TrA or Pelvic floor
• urge control techniques
• bladder retraining – e.g. deferring to ?capacity
Stress –
• PC muscle endurance training – either via TrA or PF
• PF or TrA holds for sneeze and cough etc
• Defecation position and pattern
3. Biomechanical changes occurring in pregnancy include

• production of relaxin (softening effect)
• change in centre of gravity
• change in postural curves
• presence of ?fatigue/anxiety
• risk of instability
• ?efficiency of muscular corset of Lumbar spine
• ?weight of breasts
• work areas for computers/secretarial are getting further away
4. Management of pelvic instability in pregnancy includes

• Correct assessment
• Education re background anatomy/hormonal changes
• Reassurance re approp treatment leads to best outcome
• Optimal Positioning – no rotation, symmetry, hips flexed/abducted, ,pelvis neutral
• Activation and strengthening of deep stability muscles – p. fl., deep abdoms, gluts
• Functional bracing – applied through ALL movements
• Ergonomics – combining functional bracing with lifestyle
• Problem-solving
• Limiting aggravating behaviours – weight relief as required External support/
biofeedback via SIJ belt or PS strap
• Passive mobs if / when required

5. “Comfort” positioning refers to ensuring that the body is in optimal alignment so
that vulnerable of painful areas might “rest” effectively, either when in bed, sitting
down or in upright postures
• symmetry
• minimal weight on back (NO flat supine)
• lean forward position
• minimal rotation
• support of body weight (pillows, bed, passive supports)
• hips abducted and flexed to mid range
• neutral pelvic tilt
• alignment of postural curves
• let go of tension/relaxation
6. Stretches designed for muscle groups which tend to get tight during pregnancy e.g.
hamstrings, hip flexors, calves, piriformis, pectorals, lumbar extensors.
Strengthening exercises – deep abdominals (stability), pelvic floor, scapular
retractors, gluteals
7. Any of the guidelines listed in the Royal Australian College of Obstetricians &
Gynaecologists brochure or website www.ranzcog.edu.au (updated Aug 99)
8. This should include transversus abdominus (deep abdominal) contraction in

suitable positions – NOT supine, e.g. 4pt kneel, standing, sidelying, sit on ball during
pregnancy. Functional use also included. Postnatally, diastasis rectus should be
checked, then continuing transversus, including supine lying, further reinforcement of
dynamic bracing perhaps with leg raises, and adding curl ups when there is good
underlying stability.
9. Skills learnt during Physiotherapy Antenatal Education that can be optimally

applied post-natally include
• Strategies to ↓perineal pain and swelling – ice, rest, gentle p.fl. contractions
• Gentle pelvic floor/deep abdominal stability activation
• Functional bracing during all movements
• Getting in/out of bed through sidelying
• Avoiding all lifts (espec toddlers) and other activities that will strain
• Ensuring soft consistency of stool
• Using optimal defecation position
• Using pelvic rocking, thoracic extension, shoulder retraction
• Good postural awareness
• Good ergonomics – feeding positions, changing baby
• Breathing well – especially through pain, moving after C/S, when breast feeing or
stressed
• Massage/stroking – mother and baby
• Comfort positioning
10. Strategies that may assist post-natal back pain include

• Activation of pelvic floor/deep abdominals (this is a MUST)
• Functional bracing – stability muscles support and protect during all movements
and changes of positions

• Postural stretches
• Heat
• Massage
• Improved ergonomics
• Comfort positioning with adequate support
• TENS
• Passive mobilisations
• Ultrasound, other electrotherapy
11. Rectus Diastasis is the separation of the two muscle bellies of Rectus Abdominus
that occurs during pregnancy. A passive strain is placed on Linea Alba by the
growing baby, and by ↑ in intra-abdominal pressure. The degree of separation is
normally checked at 2 inches above the umbilicus, with the patient in crook lying,
lifting her head and shoulders off the bed, in order to touch the top of her knees with
her hands. A separation of 0-2cms is considered normal – i.e. no diastasis. If >2cm,
it is a diastasis, but the degree of instability or bulging with ↑IAP is really what is
important. The function of the abdominal muscular corset is to provide stability to
the lumbar spine. If there is a weakness or bulging in this wall, then the lumbar spine
(and pelvic organs) becomes vulnerable.
A Rectus Diastasis is significant when it is >2cm and also bulging or unstable with
↑IAP
12.
• Decrease caffeine intake to less than 4 cups/day and avoid excessive alcohol
§ Avoid ‘just in case’ visits to the toilet. Only go to the toilet when the bladder is
full. When there is an urge, defer the urge for as long as possible.
§ Control the urge - sit or stand still and don’t rush
- apply perineal pressure using hands, firm chair, rolled up towel
- curl toes, strong ankle dorsiflexion, mental distraction
§ Pelvic floor and transversus abdominis exercises – tonic rather than phasic
§ Complete a bladder chart for 24 hours recording fluid input, output and any
episodes of incontinence. This provides an objective assessment and basis for
determining effectiveness of intervention.
13.
§ Light lifting (<3-4kg) in the first 4-6 weeks post-operatively. Care with heavier
lifting after the 6 week period. Patient should be taught principles of correct
lifting especially activating PF and TA.
§ Advice on ADL and household tasks eg avoid bending twisting activities such as
vacuuming and mopping in the first 4-6 weeks.
§ Postural advice as appropriate.
§ Advice on good bowel and bladder habits as appropriate.
§ Consider patient’s employment and tasks involved. Advise accordingly.
§ Educate patient re osteoporosis prevention. This is particularly important in
view of surgically induced menopause. Advise on return to general
exercise/encourage to commence a regular general exercise program that
involves weight bearing exercise. Discuss important of calcium intake and refer
to dietitian as appropriate. Discuss hormone replacement therapy and refer to
medical officer.

14.
§ Explain condition of lymphoedema, risk factors, incidence, treatment strategies,

importance of self monitoring and early detection.
§ Measure for and supply with (depending on hospital policy) compression
stockings for the flight.
§ Encourage activities that will enhance circulation eg ankle pumps, regular
general exercise (walking) without over tiring the limb at risk.
§ Avoid prolonged standing and wearing of high heels.
§ Avoid infection/inflammation in at risk limb eg wear shoes at all times, care with
cutting toenails, moisturise limbs, use electric shaver, avoid sunburn, avoid
cuts/bumps/bruises, no injections.
§ Seek medical attention if infection present.
§ Teach patient to measures legs for self monitoring.
§ Notify Physiotherapy Department if any signs of swelling
15.
• Encourage adequate fluid intake eg 2-3litres of water/day (providing no co-
existing medical conditions contraindicate this)
§ Encourage adequate fibre intake especially fruit and vegetables
§ Seek advice of dietitian if appropriate
§ Encourage general activity eg walking, swimming
§ Correct position for defaecation – knees higher than hips (a footstool may be
necessary), lean forward with forearms resting on thighs (maintain lumbar
lordosis)
§ Correct pattern for defaecation – brace (make the waist wide) and bulge (the
lower abdomen)
§ Avoid straining

1.9 Part 1 Pelvic Floor Dysfunction and Management
1. Describe the main functions of the pelvic floor?

2. What is the levator ani and which muscles is it composed of?
3. List the possible causes of a weakened pelvic floor.
4 What is the recommended daily fluid intake?
5. What is the average frequency of voiding for a healthy, middle aged woman?
6. What is the average bladder capacity for a healthy, middle aged woman?
7. What is the average frequency of defaecation?
8. A woman is referred to you because she voids 15 times per day. What additional
questions might you ask her and what might your initial advice include?
9. Which nerve supplies the pelvic floor muscles?
10. Explain the difference between urgency and stress incontinence?
11. Name a treatment option you would use with urge incontinence that you probably
wouldn’t use with pure stress incontinence?
12. A woman is having great difficulty understanding how to activate her pelvic floor
and transversus abdominus. Describe a variety of ways you may facilitate this.
Included verbal cues and different positions for activation.

1.9 Part 1 Pelvic Floor Dysfunction and Management Answers
1. Main functions of the pelvic floor

w Provides support for the pelvic organs
w Assists in maintaining urethral closure especially during increases in intra-
abdominal pressure
w Reduces urgency by bladder inhibition
w Maintains the anorectal angle facilitating faecal continence
w Coordinated activation provides rectal support during defaecation
w Provides lumbo-pelvic stability via co-activation with transversus abdominus
w Contributes to sexual function
Refer to “Women’s Health – A Textbook for Physiotherapists” for further detail
2. Levator Ani
w Is the deep layer of pelvic floor muscles. This group of muscles provides the
primary pelvic organ support, maintain faecal continence and provide rectal
support during defaecation.
w Include
– puborectalis
- pubococcygeus
- iliococcygeus
- ischiococcygeus
Refer to “Women’s Health – A Textbook for Physiotherapists” for further detail
w Puborectalis and pubococcygeus together play an integral role in the
defaecation pattern. Contraction of pubococcygeus provides support for the
rectum during defaecation while relaxation of puborectalis lessens the
anorectal angle to facilitate rectal emptying.
3. Causes of a Weakened Pelvic Floor

w Pregnancy and child birth (pain/reflex inhibition, neuropathy)
w Straining at stool
w Strenuous work or heavy lifting
w Chronic cough (eg asthma, bronchitis) or hayfever
w Obesity or weight gain
w Following menopause due to the reduction of oestrogen
w Genetic inheritance – weaker connective tissue
w Following gynaecological surgery
w Inactivity
4. Daily fluid intake

w 1.5 – 2 litres fluid per day
w excludes caffeinated products (coffee, tea, cocoa, cola) and alcohol
w best to spread the consumption of fluid over the course of the day
5. Average frequency of voiding

w During the day – 5 – 7 voids/day
w During the night – 0 – 1 void/night
w Frequency can be expected to increase during pregnancy and urinary tract
infections

w A woman over 70 years can be expected to void twice per night
6. Average bladder capacity for a middle aged woman

w 250ml for first sensation to void
w 500ml maximum bladder capacity
7. Average frequency of defaecation

w Highly variable
w Dependent on many factors including individual metabolism, dietary intake
and exercise levels
w “Normal” can be anything from 3 times / day to once every 3 days
8. Woman with frequency 15 day voids

w Assessment (this list is by no means comprehensive)
- how much fluid does she drink per day?
- what type of fluid (water, tea, coffee?)
- approximately how much urine is voided? (if large volumes –
consider aetiology may be polyuria, diabetes, excessive fluid
intake)
- is the desire to void accompanied by urgency?
- does she void because she has the urge each time or sometimes is it
“just in case”?
- how often does she go to the toilet at night?
- medical history and medications?
w Advice on good bladder habits
- recommended daily fluid intake
- effect of caffeine products on the bladder (results in detrusor
contraction)
- spread fluid intake out across the day
- avoid just in case visits
- ensure when voiding you relax on the toilet and avoid hovering
- avoid straining to empty the bladder or bowel
9. The pudendal nerve which consists of anterior divisions of S2, S3, S4 spinal cord
segments supplies the pelvic floor muscles
10. See page 22 section 1.8 (answers 1 and 2).
11. Treatment of Urge incontinence

w Bladder retraining and urge control would be essential to teach to give the
patient methods of reducing the urgency and shifting her focus away from her
responding to her bladder. Tips may include encouraging the patient to stop
moving when the urge is felt, apply pressure to the perineum (eg. by sitting on
the edge of a chair or rolled towel, crossing thighs, tightening pelvic floor),
distracting the mind (eg. counting backwards).

12. Facilitation of pelvic floor and transversus abdominus
Positioning
w Side lying, crook lying, sitting with anterior pelvic tilt, standing
Verbal cues
w Gently draw your lower abdomen inwards
w Draw your lower tummy gently inwards without letting the upper tummy move
(with/without self palpation)
w Think about a band tightening around your lower abdomen
w (With fingers palpating TA) Gently pull away from my fingers
w Gently draw your front passages in (ie urethra and vagina)
w Imagine the pelvic floor are a circus tent – think about drawing up the centre
of the circus tent
w Pretend you are trying to stop the flow of urine

1.9 Part 2 Antenatal Care
You are running a Physiotherapy Antenatal Class for women in their second trimester
of pregnancy.
• What core topics would you like to cover?
• What new skills and practices would you like the women to leave the class with?
• How might you check that your goals have been reached?
You are running an afternoon Antenatal Class and your clients have spent all morning
at another class and are looking a little worn out.
• What strategies might you use to optimise learning in your session?
• How might you increase the probability of them applying their new knowledge
and skills in their day-to-day life?
A woman with a hearing impairment arrives at your Physiotherapy Department and

indicates that she would like to attend your Antenatal Class. The following week,
you have a client on the ward who wishes to receive postnatal physiotherapy but is
of non-English speaking background and has poor command of English.
• How would you adjust your regular routine and modify your delivery for these
clients?
You receive a phone call from a woman who lives in the rural region of your district
wanting advice on exercise during pregnancy. What advice and services could you
offer?

1.9 part 2 Antenatal Care Answers
1. Core topics
• Posture
• Deep Abdominal Muscle Function
• Pelvic Floor Muscle Function
• Good Bladder and Bowel Habits
• Back Care
• Positions of Comfort
• Defaecation Position
• Exercise in Pregnancy
• Ergonomics
• Baby Handling and Positioning including Tummy Time
Skills
• Deep Abdominal Activation in various positions, especially weight-bearing, and
functional program
• Pelvic Floor Muscle Activation and functional program
• Techniques for Postural Correction
• Appropriate posture with lifting and other manual work
• Ability to manage minor postural back pain (positions of comfort, stretches,
mobilising exercises, core stability and short term pain relief options including
heat)
• Ability to avoid straining at stool
Have Goals Been Reached?

• Objective assessment
• Feedback via Questionnaires requiring information to be delivered
• Follow-up of clients on the ward after birth of baby
• Follow-up of clients in postnatal class
2. Strategies to Optimise Learning in Adults

• Ensure comfort: temperature, positioning, access to toilets and drinking facilities
• Establish good rapport and give plenty of positive feedback; remember to couch a
correction between two positive statements
• Be enthusiastic and know your topic well
• Use humour
• Provide information in “short bursts” broken up by practical sessions
• Focus on “doing” ie high proportion of practical
• Make use of all styles of learning: auditory, visual, kinesthetic
• Use of multimedia
• Visual: video, demonstration, charts, OHPs, models (eg spine, pelvis)
• Auditory: varied use of voice (pitch, tone, volume, pace), use of analogy,
relate to person’s own experience

•Kinesthetic: plenty of prac and “practise what you preach” eg get everyone to
change positions or stretch at regular intervals
• Encourage contribution: open ended questions, request demonstration, ask for
feedback on how concepts are personally relevant
• Work in pairs or groups in answering questions or demonstrating concepts to
provide “support”
• Remember the “primacy and recency effect”: the first and last things are the most
clearly remembered
• “Tag” important concepts ie tell the class in advance that it is a key concept or an
important skill
• Remember the concepts of memory and learning:
• Input
• Storage
• Retrieval
All three steps are crucial to effective learning.
Rehearsal aids effective input and storage, therefore repeat key concepts and
practise numerous times eg practise deep abdominals in varying positions
• Encourage “deep learning” as opposed to “surface learning”: use examples to
increase relevance to person’s life, present as concepts rather than facts, active
learning ie practical, use problem-solving to consolidate concepts
Application to day-to-day life (all of the above is important)
• Encourage clients to use a reward system for the behaviours you are teaching
• Encourage clients to take notes
• Provide handouts
• Refer to the handouts you provide
• Make suggestions as to use of handouts eg putting on fridge, sticking diagrams up
• Suggest memory triggers for certain behaviours eg sticking up reminder stickers,
“Post-it Notes”
• Encourage the group to share ideas and suggestions with each other
• Principles of goal setting:
• Encourage clients to write down a set number of behaviours they intend to
change, and share these at the end of the class
• Write these down in the form of goals, stated specifically
• Aim for each individual to be 80% confident of each goal (less than this, the
goal is too hard; more than this, the goal is too easy)
3. NESB Backgrounds and Hearing Impaired

• Formal interpreter may be distracting in a class situation but is the best choice in
a one-on-one appointment
• A hearing-impaired patient may wish to bring a family member who can sign to
enhance their understanding
• Use simple English; if explaining complicated concepts, summarise in a simpler
form after explaining in more detail
• Ensure the client can see you clearly, including your mouth if hearing impaired
• Demonstrate everything
• Lots of practical sessions, use audio-visual aids
• Use and provide pictures
• Learn simple words in their language if possible

• Determine whether client understands, either verbally or non-verbally
4. Advice on Exercise
• Low-impact eg walking, swimming
• Avoid abdominal curl-ups
• Avoid exercise in supine
• Reduce intensity levels later in pregnancy (monitor pulse rate and keep below
140)
• Avoid contact sports and high-impact exercise
• Deep abdominals and pelvic floor exercises: you may describe these over the
phone and give general things to look out for but difficult to teach effectively
without hands-on; you may want to send out information or encourage client to
seek out health care provider in her area, preferably a physiotherapist
• Precautions: overheating (keep well hydrated, avoid hot environments); warm up
and cool down; consult your doctor for advice if you have developed any
condition ie not a routine pregnancy; stop exercising and see your doctor if any
pain, CNS signs, vaginal bleeding, contractions, breaking of waters, reduced
foetal movements. Encourage a common-sense, conservative approach ie see
doctor if any doubts.
• Encourage client to ring the Australian Physiotherapy Association – Continence
and Women’s Health Group to ascertain if there is a physiotherapist with a
special interest in Women’s Health whose expertise she can gain access to
• If client has access to Internet, a helpful website which provides information and a
regular newsletter from a physiotherapist is www.thepregnancycentre.com

1.9 part 3- Post Partum Management
1. You are managing a 30- bed maternity ward as part of your caseload. On this
particular day you only have an hour to spend on maternity and must therefore
prioritise your caseload especially effectively.
Name reasons for and/or against seeing the following clients, including extra
information you might need.
a) 30-year-old multipara, SVD, second baby, intact perineum, second stage 15
minutes, baby 3300g
b) 19-year-old primipara, SVD, intact perineum, second stage 35 minutes, baby
3500g
c) 20-year-old multipara, SVD, fourth baby, intact perineum, other children in
foster care, issues with social services
d) 28-year-old multipara, SVD, neonatal death
e) 23-year-old primipara, SVD, primary vaginal tear, second stage 2.5 hours,
baby 3900g, IDC removed 6 AM
f) 24-year-old multipara, SVD, second baby, second degree tear, postpartum
haemorrage of 1200 ml
g) 45-year-old multipara, SVD, third baby born before arrival (in shower at
home), intact perineum
h) 21-year-old primipara, SVD, baby born 5 AM after 20 hour labour, second
degree perineal tear
i) 30 year-old multipara, third baby elective repeat LSCS (all LSCS), spinal
anaesthetic
j) 25-year-old multipara, second baby elective repeat LSCS, general anaesthetic
k) 23-year-old primipara, SVD, intact perineum, second stage 50 minutes,
Cambodian, no English
2. Consider a 29 year old primipara, emergency LSCS after failed vacuum extraction
for obstructed labour, second stage 1.5 hours.
a) What are the priority areas to address on Day 1 from this information?
b) When you go see this client she is sitting upright in a chair looking cheery and
has had a shower. Her main problem she reports is a sore tailbone. What
strategies might you offer her to assist in this?
3. Name some ways to facilitate activation of the deep abdominals in a postpartum

client who appears to be getting a lot of global abdominal muscle activation.

1.9 part 3- Post Partum Management- Answers
1.
a) 30-year-old multipara, SVD, second baby, intact perineum, second stage 15
minutes, baby 3300g
• No particular risk factors for PFD therefore may be able to wait until tomorrow
• If you decide to wait, ensure she will not be on early discharge resulting in you
missing her
b) 19-year-old primipara, SVD, intact perineum, second stage 35 minutes, baby

3500g
• No particular risk factors for PFD except first delivery
• May have a lot of adjustment to do as a young first-time mum so may be better
avoid seeing her Day 1
• Check not being discharged but it is less common for primaras to go home Day 1
than multiparas
c) 20-year-old multipara, SVD, fourth baby, intact perineum, other children in foster
care, issues with social services
• Check for Social Work review; best not to see until social issues on the way to
resolution
d) 28-year-old multipara, SVD, neonatal death
• Definitely avoid seeing Day 1 and be very sensitive to grieving process and that
this takes priority; family may be around a lot so choose time carefully; be aware
that mother may have dead baby in bed with her during this period
e) 23-year-old primipara, SVD, primary vaginal tear, second stage 2.5 hours, baby
3900g, IDC removed 6 AM
• Risk factor of long second stage; baby almost at the level of documented risk for
PFD (4 kg); long second stage may have caused pudendal traction neuropathy,
which may affect sensation of bladder filling and ability to control PFM;
important to check if has voided +/- any discrepancy between feeling of fullness
and amount voided; advise to void regularly to avoid overdistension of bladder
f) 24-year-old multipara, SVD, second baby, second degree tear, postpartum
haemorrage of 1200 ml
• May be best to leave until tomorrow due to large PPH – see tomorrow when feels
better
• Second-degree tear is important to address early (ie RICE and gentle, regular PF
contractions) but weigh up how she feels as to whether you see her; if asleep,
lying flat, there may be less reason to intervene today
g) 45-year-old multipara, SVD, third baby born before arrival (in shower at home),
intact perineum
• No obvious risk factors unless labour was very quick, but because she delivered at
home, it is unlikely she will be in very long at all; this may be a reason to see her
today
h) 21-year-old primipara, SVD, baby born 5 AM after 20 hour labour, second degree
perineal tear
• Unlikely to take much in today – likely very tired! However, you may pop your
head in and see if she is up to brief advice on acute management of the tear

i) 30 year-old multipara, third baby elective repeat LSCS (all LSCS), spinal
anaesthetic
• Check no postoperative complications
• While you want to give advice early on bed mobility for protection of incision etc,
compared to others with LSCS she may be a lower priority: has been through it
twice before, spinal anaesthetic does not have the risks to the respiratory system
that a GA does, and postnatal patients most often mobilise early to the shower, for
baby cares etc
j) 25-year-old multipara, second baby elective repeat LSCS, general anaesthetic
• Probably prioritised higher than i) due to general anaesthetic
k) 23-year-old primipara, SVD, intact perineum, second stage 50 minutes,
Cambodian, no English
• No particular risk factors except first delivery
• Try to time consultation with presence of family member who can assist with
translation
• May need to simplify concepts, illustrate ALL concepts with lavish gestures and
demonstration – exaggerate to elucidate!
2.
a) What are the priority areas to address on Day 1 from this information?
• Encourage early mobilisation
Pain will probably be main concern at this stage, so:
• Teach mobilisation around and in and out of bed, focus on avoiding pain
• Teach protective activation of deep abdominals through movement, focus on
avoiding pain
• Be aware of increased possibility of pudendal neuropathy due to long second
stage; IDC probably still in, but warn of possible reduced sensation when out, and
advise not to have long gaps between voids of >about 4 hours, especially if
experiences discrepancy between amount of filling sensed and amount voided
b) When you go see this client she is sitting upright in a chair looking cheery and has
had a shower. Her main problem she reports is a sore tailbone. What strategies
might you offer her to assist in this?
• Avoid sitting position (and especially the slumped semi-reclined position in bed
with the bed head up); suggest asking midwives to show how to feed lying on side
• If sitting is unavoidable, recommend a rolled towel placed on the chair in a
“smile shape” to slightly elevate coccyx off chair; also show how to sit down with
anterior pelvic tilt to take pressure through ischial tuberosities
• Teach tonic coactivation of deep abdominals and PFM through movement

3.
• Positioning:ensure normal lumbar spine curve; if no help, try a slightly increased
anterior pelvic tilt. Side lying is effective to reduce overactivity of global
abdominals, but if client has poor position sense in this position, try upright
sitting
• Palpation: encourage self-palpation at lowest area of abdomen
• Emphasise SLOW and GENTLE contraction and abandon any attempt that is too
strong or rapid (“phasic”) and try again with less effort
• Shift focus away from abdominal area and towards pelvic floor
• Demonstrate the idea of a “tonic” pattern of activation by asking her to either
stand or sit up straight. Then ask her to make her tummy “let go”. Often it will
release and she will understand that the muscles were holding automatically just
because of her upright posture.

1.9 Part 4- Exercise in Pregnancy
1. The American College of Obstetricians and Gynaecologists (ACOG) recommend

that during exercise
§ maternal heart rate should not exceed ______beats/min.
§ maternal core temperature should not exceed _______degrees Celsius.
§ strenuous activities should not exceed _______minutes duration.
§ no exercise should be performed in the ________ position after the
________month. Explain why this is so.
2. List 5 absolute contraindications to exercise during pregnancy.
3. List 5 relative contraindications to exercise during pregnancy.
4. List 5 signs and symptoms that would be cause for alarm/immediate cessation of
exercise.
5. Outline the components of an exercise class for pregnant women and the time
frame for each component.
6. List some practical preparation and the room set up for an exercise in pregnancy
class.
7. A client has been attending your exercise class for many weeks and wishes to
continue. However she now reports that she has mild ® SIJ pain. What
advice/modifications to the class can you suggest?
8. In general conversation, a group of class attendants are discussing ‘soreness

between the shoulder blades’ and becoming ‘round sho uldered’ as their pregnancies
progress. Describe 5 exercise that you will incorporate into your class to address this.
9. A client is attending her first exercise class on your recommendation. You saw this
client as an oupatient for management of her varicose veins. What aspects of the class
will benefit this condition?

1.9 Part 4 Exercise in Pregnancy - Answers
1. The American College of Obstetricians and Gynaecologists (ACOG) recommend

that during exercise
§ maternal heart rate should not exceed _140__beats/min.
§ maternal core temperature should not exceed __38___degrees Celsius.
§ strenuous activities should not exceed __15_____minutes duration.
§ no exercise should be performed in the _supine_ position after the
_fourth_month. Explain why this is so. To avoid supine hypotension.
2. Risk of premature labour

Ruptured membranes
Severe pregnancy induced hypertension
Uterine bleeding
Incompetent cervix
3. Diabetes
Essential hypertension
Anaemia and other blood disorders
Thyroid disorders
Breech in last month of pregnancy
.
4. Dizziness and faintness

Decreased foetal movements
Severe, persistent headache
Severe abdominal pain
Vaginal bleeding
5.
Standing 5 mins Warm up
5 min Stretches
15 mins Low impact cardiovascular exercise
2 mins HR check and drink of water
3 mins Quads exercises
Sitting/kneeling/
4 point kneel/side lying 15 mins Postural stretches and toning
Side lying 10 mins Cool down and relaxation
55 mins
6.
Wooden or carpet floor Air circulating – air conditioning + fans
Water jug and cups Clock with minute hand
Mat and 2 pillows/client Name labels and pen
Telephone/ emergency buzzer +/- therapy balls
+/- mirrors

7.
If possible, determine the specific exercise or movement that provokes the pain and
eliminate.
Encourage TA bracing and smaller step length.
Avoid one legged activity.
Sit on a therapy ball for the cardiovascular component of the class.
8.
Any exercise that will strengthen deep neck flexors and scapular stabilisers, and will
mobilise/stretch Tx , pectorals, upper traps eg.
Ø Deep cervical neck flexion during warm up and continually remind class of neck
posture during class.
Ø Scapular stabilisers strengthening – push ups against wall/mirrors emphasising
scapular depression and retraction.
Ø Tx mobility –in standing, hands on shoulders and ‘drawing circles’
backwards
Ø Tx mobility – in sidelying, drawing a large circle on the floor with the uppermost
hand in a backwards direction.
Ø Tx mobility – in 4 point kneeling, ‘cat stretches’
9.
Enhanced circulation due to overall cardiovascular component and muscle pump
action in the lower limbs.
Effects of gravity eliminated during exercises and relaxation in supported sidelying
position.
Care must be taken to avoid over heating.
If vulval varicosities present, pelvic floor exercises will be on benefit. Client advised
to wear supportive, cotton underwear and bike shorts.

1.9 Part 5- Antenatal Musculoskeletal Conditions
1. Explain the concept of form and force closure of the sacroiliac joint.
2. Describe 5 tests you may use during an objective examination of the sacroiliac
joint.
3. Sally presents to the physiotherapy outpatient department for assessment and

treatment of “right buttock pain”. She is 36 weeks pregnant with her first baby
and her main concern is difficulty rolling in bed at night. What practical strategies
could you suggest to help Sally with rolling in bed?
4. Mary presents to the physiotherapy department at 30 weeks pregnant with a

diagnosis of pubic symphysis diastasis following a fall. What activities would
you advise Mary to avoid? What are your treatment strategies?
5. Cathy is 26 weeks pregnant with her third child. She has presented to the
physiotherapy department for treatment of her central low back pain. Your
assessment reveals a marked lumb ar lordosis and anterior pelvic tilt. What
exercises might you prescribe for this problem? What positions of comfort could
you suggest to Cathy for relief of her back pain?
6. Karen presents to the physiotherapy department at 32 weeks pregnant with left le g

varicosities extending from her inner thigh to ankle. What treatment and advice
would you offer?
7. You have prescribed the exercise of posterior pelvic tilting in all fours for
treatment of Julie’s back pain. She complains of pain in her wrist and tingling in
her fingers in this position. What condition could these symptoms be indicative
of? How could you adapt this exercise for Julie? What other advice regarding
this condition could you provide?

1.9 Part 5 Antenatal Musculoskeletal Conditions- Answ ers
1. The concept of form and force closure refers to the means of achieving stability in
the sacroiliac joint.
Form closure
• Refers to the stability achieved through the shapes and surfaces of the bones of the
sacroiliac joint.
• Wedge shape of sacrum aids stability
• Coarse cartilage texture of the iliac surface aids stability
• Ridges and grooves of the interlocking sacrum and innominates aids stability.
Force closure
• Refers to the extrinsic forces (ligaments, fascia and muscles) which compress the
sacroiliac joint.
• Ligaments: Sacrotuberous, long dorsal sacroiliac, interosseous, anterior and
posterior sacroiliac ligaments
• Thoracolumbar fascia: An increase in tension in the fascia increases compression
in the joint. Tension is increased by-
i. Contraction of the muscles attached to the fascia (TA, int obliques, lat dorsi, glut
max, trapezius)
ii. “pump it up” phenomenon – contraction of erector spinae and multifidus can
increase tension via an inflationary effect
• muscles: transversus abdominus, multifidus, pelvic floor, glut max, lat dorsi, int
& ext obliques, piriformus, ITB
Reference: Insufficient lumbopelvic stability: a clinical, anatomical & biomechanical approach to “a-specific” low back pain –
Pool Goudzwaard, Vleeming, Stoeckart, Snijders, Mens 1998
2. SIJ tests –
• Standing Forward Flexion Test
Examiner palpates both PSIS’s as the patient flexes forward. The PSIS that
moves up first indicates a fixed SIJ on that side.
• Gillet’s Test (hip flexion to 90°)
Examiner palpates (L) PSIS with the (L) thumb and the S2 prominence with the 
hand. As the patient flexes the (L) hip to 90° the (L) PSIS moves inferiorly. With
a dysfunctional SIJ the PSIS remains at the S2 Level or may move superiorly.
• Piedallu’s Sign (forward flexion test in sitting)
Patient sitting on hard surface with feet on ground. Examiner palpates both
PSIS’s and the patient flexes forward. The dysfunction is on the side that moves
upward relative to the other.
• Supine long sitting test

Patient supine, examiner checks levels of the malleoli. Patient then long sits and
relative levels of malleoli are reassessed. A positive test occurs when there is
observable change in the relative leg length.
• Squish Test
Patient supine. Place hands in front of the pelvis. Fixate one ASIS while gently
gliding the other innominate, via the ASIS, posteriorly and medially. Feel for
differences from side to side. The dysfunctional side is more limited in
movement.
• SLR Test
Passive test. With SIJ dysfunction, PSLR may be painful, may decrease pain or
may only be painful on lowering. With pure SIJ problems, a bilateral SLR should
not give symptoms.
Active test. Patient supine, and asked to lift on leg. Difficulty to lift, apparent
weakness and pain is noted. Test repeated with light medial force to iliac crests,
noting any change to symptoms.
• Accessory Arthrokinematic Glides (Dianne Lee)
Patient is supine with knees and hips flexed. Therapist palpates sacral sulcus just
medial to PSIS with long and ring finger noting movt between innominate and
sacrum. Index finger palpates L/S junction noting movt between pelvic girdle and
L5.
Test both sides comparing end feel, quality of translation and reproduction of
symptoms.
a. Superioinferior translation.
One hand as above, other on knee of patient. Pressure is applied through the knee
in a cranial direction. The end of range of motion is reached when the pelvic
girdle is felt to laterally bend beneath L5.
b. Anteroposterior translation
One hand as above, other hand on patients iliac crest. Pressure is applied in a
posterior direction. The end of range of motion is reached when tthepelvic girdle
is felt to rotate as a unit beneath L5.
• Provocation Tests
- tests that mechanically stress SIJ structures in order to reproduce patients pain.
• Posterior Shear
Patient supine with hip flexed to 90°. Therapist pushes directly down through axis
of femur.

• Compression Test
With patient sidelying, pressure is directed through the upper iliac crest toward the
lower iliac crest.
• Distraction Test
Patient supine, therapist crosses her arms in front of the pelvis and pushes laterally
and posterially.
• Patrick Fabere Test
Patient supine. Hip on side tested is flexed, abducted and externally rotated, with
foot of that leg resting just above knee of opposite leg
• Gaenslen’s Test
Patient supine lying close to edge of table so one leg can hang free off the edge.
The other leg is maximally flexed and stabilised while the hanging leg is
extended.
3. Practical strategies for rolling in bed:

• Contract TA while rolling
• Keep pillow between legs & press knees together while rolling
• Roll via ‘all fours’
• Suggest trial of different mattress
• If severe, wear trunkal tubigrip and/or SIJ support belt to bed
• Manual pressure over SIJ while rolling.
4. i. Activities to avoid:
• Any unilateral weight bearing activities e.g. standing on one leg to dress or to
shower & dry; standing with weight more to one side,
• Stairs – if unable to avoid, use handrail & take one step at a time
• Sitting cross legged in chair or on floor
• Walking up or down steep hills or on uneven ground
• Heavy lifting
• Vacuming/mopping
• Squatting
• Quick walking or running
• Driving manual car
ii. Treatment strategies:

• Reduce pain: local ice/heat; rest – use pillows between legs and under tummy
when lying on side; SIJ belt; manual therapy techniques; if weight of abdomen is
a contributing factor, try trunkal tubigrip;

• Improve stability of SIJ: teach TA, PF, multifidus and progress to vanety of
positions and functional application; aquatic physiotherapy may be appropriate to
practise stability exercises in reduced weight bearing environment; SIJ belt
• Education on avoiding activities that may exacerbate condition
5. i. Exercises:
• TA
• Pelvic tilt – in standing/forward lean/sidely
• “Cat curl” in all fours
• theraball stability exercises
• Pelvic circling in all fours/standing/ball
• Postural ‘set’
ii. Positions of comfort:

• side ly supported with pillows – between legs, under belly, supporting spine – or
any variation
• lying forward over beanbag
• sitting ‘back the front’ on a chair, leaning forward
• standing leaning forward supported by table or wall
6.
• elevation of legs as often as possible
• full leg support stocking – to be applied before getting out of bed in morning (am)
• avoiding standing or sitting in one position for long periods
• active ankle & leg movements
• regular exercise e.g. swimming (hydrostatic pressure aids venous return), walking
low impact aerobics
• cool showers/baths
7.
i. carpal tunnel syndrome
ii.
• take her weight through her forearms rather than wrists
• perform the exercise in standing, leaning forward over a table or on to a wall
• use a theraball or a chair to take the weight of the upper body
iii.
• avoid carrying heavy objects in hands
• support arms in elevated position rather than leave dangling
• avoid maximal flexion and extension of the wrists
• use of wrist splints to keep wrist in optimal resting position
• alternate cold/warm hand baths
• advice on appropriate breast feeding positions for the post natal period
gentle active circulation exercises for fingers.

1.9 Part 6- Labour
1: What are the different mechanisms for pain in First and Second stages of labour?
2: In what way could you use your skills as a physiotherapist to offer assistance to a
woman in labour and her support people?

1.9 Part 6- Labour- Answers
1: Stage 1 (from when labour starts to full dilation of the cervix)
Pain is primarily due to dilation of the cervix, contraction of the uterus muscle and
pressure of the uterus on surrounding sensitive structures.
Nerves from the Uterus and Cervix enter T11 and T12 (secondarily T10 and L1).
Pain distribution diffused over a large area - mostly over the lower abdomen, hips
and lower back. More severe pain is felt in the lower back if the baby is in an
occipito-posterior position. As labour progresses it becomes more intense and can
include the thigh and perineal area.
Stage 2 (from full dilation of the cervix to the birth of the baby)
Pain is primarily due to stretching of the cervix and pelvic floor region (including
fascia, skin, subcutaneous tissue, muscle) and pressure on the bladder, urethra,
rectum and lumbosacral nerve roots.
Nerves from the cervix and pelvic floor region pass to sacral segments S2, S3, and S4.
Pain is initially distributed intensely over the lower abdomen as the baby’s head
descends through the pelvis and progresses to intense localised perineal pain once the
baby’s head has descended far enough that it is visible at the vulva (uterine pain
decreases).
(see pages 196 – 201 of Women’s Health Text)
2: The following are skills and knowledge all graduate physiotherapists should
possess These skills could be of benefit to a woman and her support people in labour.
These same techniques may be useful in pregnancy and post natal care.
MOIST HEAT – has pain relief and muscle relaxation effects.

Application - Heat packs, warm showers (shower head directed to pain areas), warm
bath (uses additional benefits of buoyancy NB: membranes must be intact and water
comfortably warm NOT hot).
TENS – non invasive, self controlled form of pain relief with no known side effects for
mum or bub. Mechanism of pain relief is via gate control mechanism (low intensity /
high frequency stimulation 100-200Hz) and/or by enhancing the release of the bodies
natural pain inhibitors, endorphins and encephalins (low frequency / high intensity
stimulation 2-10Hz) (More detail page 295-296 Textbook)
Application – place one set of electrodes paravertabrally at about T10-L1 (uterine
pain pathways) and the other set at S2-S4 (to target low back and perineal pain).
Tens is most useful started early in labour with a constant low intensity stimulation
and the addition of high intensity stimulation during contractions (many machines
have a ‘boost’ button).

RELAXATION – allows the body to function efficiently in labour with minimum
effort; energy is conserved and the pain threshold is said to increase and the release
of endorphins is promoted. Panic is reduced and this allows more focus.
Options include physiological relaxation (eg Mitchell method of reciprocal
relaxation), touch relaxation, verbal cues (use words like ‘flop’, ‘let go’ not ‘relax’),
music, heat, movement, massage and breathing awareness. Relaxation is a skill that
requires learning to be practiced at it.
POSITIONING/ MOVEMENT – If all is well then ambulation should be encouraged

and when resting frequent changes in position advocated. Aim for comfort.
Labour is shorter in upright positions (sitting, standing, kneeling or ambulant).
Standing is more effective in dilating the cervix than sitting which is more effective
than supine. Supine positioning can compress the vena-cava and lead to Supine
Hypertension Syndrome (SHS) which can adversely effect mum and bub and delay
labour. Use supports available – bed, chair, beanbag, fitball, birthing stool, pillows,
bench, wall. (see brochure, poster or video on ‘Positions for Labour’ or Before &
After for more ideas). Pushing positions are very dependant on how things are going
in labour and the midwife or Dr will direct appropriately. (pages 198 – 203 of
textbook).
MASSAGE – Stroking, touching, kneading are all mechanisms to help promote

relaxation and reduce tension. Be sensitive to the tactile needs of the mum. Some
people love being touched in labour others don’t.
BREATHING AWARENESS – allows for central focus and reduces panic,

promoting relaxation. Breathe at your own pace, adjust your rate according to your
body’s demands. Leaning forward may make breathing easier.
Focus on the ‘out’ breath and let it take the tension with it. Use key words like ‘sigh
out slowly’ or ‘Let you breath out slowly and easily – feel the body release’.

1.9 Part 7-Baby Massage and Handling
1. A client you are seeing in a maternity ward asks if there are any exercises that her
newborn baby should do to assist his development. What advice, and reasons for the
advice, would you give on positioning, handling and suitable equipment?
2. The Child Health Nurse asks you to demonstrate baby massage to a group of new
mothers. List the practical guidelines you would give and describe the baby massage.
Additional activities to help preparation in this area.
§ Handling Your Baby video (Royal Women’s Hospital)

§ An Educational Seminar on the Benefits of “Touch” video (Johnson and
Johnson)
§ The Touch of Love booklet (Johnson & Johnson)
§ Attend Baby Massage and Handling component of Mother and Baby class
§ Attend Handling Pre-term Infants class or ask the appropriate hospital for
a copy of the Handling Pre-term infant booklets given to parents.

1.9 Part 7 Baby massage and handling - Answers
1. The current SIDS campaign advocates sleeping babies on their back. Some
parents take this information literally and their baby spends little or no time in any
other position but supine. This can lead to the baby developing a preference for
cervical rotation, plagiocephaly and delayed motor milestones such as rolling,
crawling, walking. It is important that babies spend time in a variety of positions to
avoid such problems. By spending play time in a variety of positions, baby will
develop the strength, co-ordination and skills to achieve motor milestones and usually
do not need specific equipment to achieve this. However some equipment is suitable
and fun for baby.
Prone play time is important when the baby is awake and supervised. This can be
achieved on Mum’s/Dad’s chest or lap, or on a rug on the floor. It helps to have a
few bright toys/familiar face as incentive for baby to lift his head up. Progress the
time spent in prone each day.
Nappies on babies can restrict leg movement. Having some ‘no nappy’ time allows
baby to kick his legs freely which facilitates abdominal muscle activity.
Play time in sidelying can facilitate bilateral hand play. Ensure baby spends equal
amounts of time in left and right sidelying.
Supported sitting either on parents lap, propped with pillows, or in a rocker can
promote social interaction and facilitate the development of head control.
It is important for parents’ backs and necks, and for baby’s head control that a
variety of nursing and carrying positions are used. It also helps if parents can
become ambidextrous.
Baby slings are useful for short outings/household tasks and are preferable to
carrying baby around in a capsule. Mum/Dad should stand with ideal posture and
the sling should hold baby to Mum/Dad. Straps on slings should be wide and padded
to prevent cutting into shoulders and a slouched posture. If baby is too low in the
sling, this will not promote good scapular control and abdominal activation.
The use of walkers and jolly jumpers is not recommended as they do not enable baby
to walk any quicker and may encourage poor patterns of movement. There are safety
issues with walkers near stairs and floor cover strips. Once baby is cruising, a push
trolley may be used. Other equipment that is safe and suitable includes an activity
gym that facilitates hand play and lower limb flexion. Once baby has good head
control and can sit independently, a swing with the proper restraints is suitable.
2. Baby massage is a lovely activity for parent and baby that promotes bonding and
incorporates stimulation of all senses – vision, hearing, touch and proprioception.
However, if Mum is tired/overwhelmed/stressed it may be more appropriate for her
and the baby to take a walk in the fresh air. Take care not to induce feelings of guilt
if Mum cannot perform a baby massage. Baby will sense tension in Mum’s hands and
the massage will not be a pleasant experience.

Baby massage should not be performed when baby is irritable, very hungry or just
been fed. Massage should never be used as a last resort to settle baby. It may take
some time for Mum and baby to establish the ideal time of day, the order of massage
and most appropriate techniques to use. The room should be warm, Mum should
remove sharp jewellery, perhaps take the phone off the hook and position herself and
baby comfortably.
Any vegetable oil can be used. Definitely do not use talcum powder.
Warm the oil between Mum’s hands as opposed to applying it directly to baby’s skin.
The whole hand or pads of thumbs/fingers can be used and contact should be firm.
Touch that is too light can be irritating. The hand action can either be symmetrical or
alternating so there is constant contact
.
An example of a baby massage is as follows
Head Establish eye contact and talk to baby so he/she knows what is
happening.
Whole hand action from forehead to top of head and circling around to
temples.
Pads of thumb/fingers in small circular action across forehead and
down to cheeks.
Avoid stimulation to back of head.
Chest Whole hand diagonal strokes across chest and abdomen.
Pads of thumb/fingers in small circular action across chest.
Arms Long strokes from scapular down to fingers
Extremely gentle ‘milking’ action down arms
Ensure both arms are massaged evenly
Facilitate baby giving himself/herself a hug
Abdomen Diagonal strokes
Facilitation of lower abdominals with tickling
Legs Long strokes from buttocks to toes
Extremely gentle ‘milking’ action down legs
‘Bicycling’ action
Knees to chest and gentle rocking side to side
Avoid stimulation to balls of feet
Can facilitate rolling prone at this point.
Back Long strokes from neck to ankles
Pads of thumbs/fingers in small circular action down each side of
spine

1.9 part 8- Gynaecology/ Gynae/Oncology
1. What are some ways your management of a TAH (Total Abdominal

Hysterectomy) inpatient may differ from a LSCS (Lower Segment Caesarean
Section) inpatient?
2. Name some indications for abdominal and vaginal hysterectomies.
3. What may be some advantages of the Tension-Free Vaginal Tape procedure for
stress urinary incontinence over the more common Burch Colposuspension?
4. What is a trial of void, and what is normally the “magic number”?
5. How could you assist a patient to minimise her residual volume with a trial of
void?
6. List aspects of your assessment necessary to prepare a post- gynaecological
surgery patient to prepare for discharge.
7. Practise drawing, for educational purposes, a diagrammatic representation of
- Cystocoele
- Uterine prolapse
- Rectocoele
(Refer to the diagrams on page 337 of “Women’s Health – A Textbook for
Physiotherapists” for guidance.)
8. Practise drawing, for educational purposes, the optimal position for defaecation.
(Refer to the educational leaflets at your centre and “Women’s Health – A
Textbook for Physiotherapists” for inspiration).
9. You are providing a physiotherapy pre-operative service to a woman who is

undergoing a vulvectomy and lymph node dissection for vulval cancer. Ask your
tutor or fellow student to play the part of the woman. Practise:
• Explaining lymphoedema
• Explaining why she is at risk
• Explaining sensible precautions to take.
Write down the main things you’ll need to consider in giving your explanation.
10. What do the following abbreviations stand for? (Check your spelling!)
• CIN
• D&C
• DUB
• PCOD
11. List some oncological and non-oncological causes of dyspareunia.
12. What are the words for the following definitions? Check your spelling, and
practise writing the words without looking until you get it right!
• Painful menstrual bleeding, “normal” cycle length

• Dysfunction of menstruation (eg excessively long or short cycles)
• Increased frequency and water content of stools
• Painful sexual intercourse
• Prolapsed varicose veins of the anus
• A condition where cells of the inner surface of the uterus proliferate in other
areas such as on the ovaries, oviducts, pelvic ligaments, bowel or bladder
• Technical name for vaginal repair
13. What are some complications of Anterior Vaginal Repair and Burch
Colposuspension?
14. You are involved in the treatment of an elderly woman with end-stage cancer who
has had a radical hysterectomy and BSO and pelvic lymph node dissection. She
has developed lymphoedema of her left leg. What would your discharge planning
for this lady include?

1.9 part 8 Gynaecology/ Gynae/Oncology Answers
1. LSCS vs TAH
i) Prevention of circulatory and respiratory complications and

ii) Promoting mobilisation
• Usually spinal/epidural with LSCS vs GA with TAH (though check notes)
therefore possibly lower risks with LSCS (but assess each patient’s case
individually); may need to be more intensive with breathing and
circulation exercises with TAH
• LSCS often mobilise easier and more often – often seem to have less pain
than TAH, and the need to look after the baby may compel them to be up
more; progress rapidly off rollator. TAH often experience more pain and
nausea and mobilisation distance and progression require careful
judgement
• Nursing staff often responsible for getting LSCS up initially; check with
your specific centre
• Teaching bed mobility to LSCS should take into account possibility of baby
being in bed also
iii) Education
• TAH - Pelvic Floor education should include explanation of reason for
importance due to cutting of ligamentous supports and removal of uterus
with its cervix, the “cornerstone” of support for the pelvic floor
• TAH – care should be taken when showing diagram of internal organs to
TAH to avoid inadvertently saying “there’s your uterus” – patient may be
experiencing emotional issues with the loss of their uterus
• LSCS – explanation of muscle function should include information on
hormonal influence on soft tissues and pregnancy-induced stretch
iv) Muscle rehabilitation and functional integration

• Both types of patients should be encouraged to activate the deep
abdominals early and especially as “preparation for movement”, and to
activate the PFM once IDC out. Advice for LSCS on functional integration
should include strongfocus on activities with baby
• Both types of patients should be encouraged to commence a low-impact
exercise program, eg walking, soon after discharge; encourage LSCS to
postpone high-impact exercise for at least three months and longer if
breastfeeding due to softening effects of hormones.
v) Discharge Planning
• TAH often returning to work – careful assessment and advice required.
LSCS often taking longer off work and more specific baby-care advice
should be given.
• TAH should be offered a physio OPD appointment or advised how they
can seek such an appointment if problems with continence experienced;

LSCS often encouraged to attend postnatal class and/or postnatal exercise
class
2. Indications
TAH: menorrhagia and dysmenorrhea/DUB; symptomatic fibroids; endometrial
carcinoma; uterovaginal prolapse (if adhesions or other difficulties with vaginal
approach)
Vaginal Hysterectomy: as above (the usual approach for a uterovaginal prolapse
3. TVT – no GA (spinal anaesthetic) therefore usually a day procedure; more

rapid recovery due to less trauma and less pain; immediate mobility therefore
reduced risk of chest and circulatory complications; more rapid return to work and
activity
4. TOV: Following removal of the IDC and voiding normally, insertion of a

catheter to measure for any residual urine in the bladder (normal bladder should
empty fully or no>10ml residual). The “magic number” for many surgeons is 100ml
(sometimes 150 ml) – if the residual volume is higher than this, the patient is said to
have failed their TOV and it must be tried again, usually the next day.
If the patient fails several times she is usually taught to self-catheterise and
discharged, then returns in a week or so to try the TOV again.
5. Assistance with TOV: Positioning – lean forward on toilet, elevate heels, relax
abdomen completely; reassurance; turn tap on if difficulty initiating flow
6. Consider that she may be very apprehensive about the surgery and dealing
with the shock of a serious illness and therefore her concentration may be low, and
lymphoedema may not rank highly on her list of priorities. This may also be the first
time she has heard about lymphoedema. The challenge is to make enough of an
impact to make her understand the risk and take precautions, but to minimise any
extra anxiety. Emphasise that the precautions are all sensible, common-sense habits.
Provide her with a written list of precautions that she can refer to after the surgery,
and tell her you will discuss it further after her surgery.
10. Cervical Intra-epithelial Neoplasia (CIN); Dilatation and Curettage (D&C);

Dysfunctional Uterine Bleeding (DUB); Polycystic Ovarian Disease (PCOD)
11. Causes of Dyspareunia

- Cervical cancer
- Ovarian cancer
- Scarring due to episiotomy, perineal tear, gynaecological surgery eg posterior
vaginal repair
- Pelvic Organ Prolapse
- Menopausal Changes
- Constipation/Full Bowel
- Inadequate Lubrication
- Ectopic pregnancy
- Pelvic Inflammatory Disease
- Sexually Transmitted Infections
- Endometriosis

- Psychosocial Factors
12. A Five Minute Lesson in Greek
Menorraghia – from Greek: meno(menses) rhegnynai (to burst forth), algia (pain)
• cf antalgic gait, analgesia, haemorrhage
Diarrhoea – from Greek: dia (through) rrhea (flow)
• cf diathermy (heating through)
Dysmenorrhea – from Greek dys (faulty/impaired) rrhea (flow)
Dyspareunia – from Greek dys (faulty/impaired) pareunos (bedfellow)
Haemorrhoids – from Greek haem (blood) rrhoos (flowing) cf haematoma
(oma=tumour)
• cf Rhein River (rhein=to flow)
Endometriosis – from Greek endon (inside) metra (womb) osis (state)
• cf endogenous, endorphine (Morph=God of dreams, ine=basic nitrogenous
compound), endocrine
Colporraphy – from Greek colp (vagina), rhaphe (sewing, suture)
• cf colposcopy (skopein=to examine) Colposuspension
13. Complications
Anterior Vaginal Repair and Burch Colposuspension: rare - UTI, voiding
difficulties requiring self-catheterisation
Anterior Vaginal Repair: new stress urinary incontinence if large cystocoele

repaired
Burch Colposuspension: (rare) – pubic pain, damage to bladder/urinary tract,

blood loss requiring transfusion, wound infection, urgency/urge incontinence,
failure to correct stress incontinence, new vaginal prolapse (last three less rare)
(Source: Dr Chris Maher’s website www.urogynaecology.com)
14. Discharge Planning
Consider:
• Mobility status including aids required
• Home situation: physical set-up
• Home situation: Emotional/psychological support (partner, family, friends)
• Community Social Support: community services, community support
organisations eg Lymphoedema Association Qld; enquire at your centre about
local cancer support groups and lymphoedema support groups)
• Continuation of program at home for mobility, lymphoedema management etc
• Comfort of client is highest priority when treatment is palliative: give
modified, manageable program
• Involve partner/family in care where possible; may need to train before
discharge
• Follow-up physiotherapy where required: determine most appropriate type
(outpatient appointment vs community or domicilliary physiotherapy care)

1.9 Part 9- Breast Cancer
Mrs M is a 50yo shop assistant who has recently been diagnosed with breast cancer.
Treatment to date has included a Modified radical mastectomy 4 weeks ago. She has
returned to outpatients for review today.
1. Describe her surgical procedure ?
2. What would you include in her assessment and treatment today?
3. What advice would you give Mrs M about Lymphoedema precautions and
prevention?

1.9 Part 9 –Breast Cancer Answers
1. Excision of all breast tissue on the effected side, auxillary disection (including
removal of lymph nodes) and pectoralis minor muscle.
(see page 457 of Women’s Health Text for description of other surgical proceedures
and their indications)
2. Remeasure shoulder ROM, assess functional ability and limb size.

Progress exercises and stretches - include sustained stretches (limited by discomfor
not pain) and/or neural techniques if required). Must continue exercise for 3/12.
Advice for functional activity progressions (expect full function by 4-6 weeks post op)
Address postural changes – especially shoulder / thoracic spine
Lymphoedema prevention education – causes, precautions for prevention, signs of
early lymphoedema)
Scar management – massage to scar to facilitate exercise ability.
Address complications
ie seroma, - return to Dr for needle aspiration. Exercises will be limited.
cording, - additional exercises to stretch cords +/- massage to cords
neural disturbances, - reassurance, desensitisation, posture re-education
lymphoedema – refer on for thorough lymphoedema management.
(see pages 460-462 of Women’s Health text for further details)
3. Secondary lymphoedema occurs as a result of compromise to the lymphatic system

(due to surgical removal of lymph nodes, irradiation to auxilla/breast, cancer
blocking lymph system) that is then over loaded (this can happen at any time post
surgery).
Avoid
1. overuse
2. prolonged lifting / carrying heavy objects
3. trauma to the affected limb – avoid where possible, keep all wound clean until
healed, seek medical attention if any signs of infection (red, warm, swollen)
4. wearing tight jewellery or clothing
5. poor skin condition (use moisturiser / avoid excessive sun exposure)
6. blood pressure readings, venepuncture or IV lines in that arm
Do:
1. wear a compression sleeve and move arm frequently when on aircraft flights, long
journeys (car, train or bus)
2. be aware of early signs of lymphoedema such as swelling in the back of the hand,
between knuckles, back of upper arm or auxilla. Some patients also complain of a
heavy feeling in the effected limb.
3. note if rings, watch band, shirt sleeve, bra or waistband become tighter.
SEEK ATTENTION EARLY IF YOU HAVE ANY SIGNS OF LYMPHOEDEMA

1.9 Part 10 Lymphoedema
Answer these questions by circling either T if True or F if False.
1. The lymphatic system is not part of the circulatory system. T F
2. Secondary lymphoedema can not be caused by

radiotherapy. T F
3. The lymphatic system consists of lymph fluid, lymph vessels

and lymph nodes. T F
4. The lymphatic system has a mechanical pump T F
5. Acupuncture is useful in treating lymphoedema T F
6. Lymphoedema is a protein enriched oedema. T F
7. Lymph fluid is composed of watery fluid, protein and a few

RBC. T F
8. Lymphoedema can be congenital. T F
9. Air travel does not contribute to lymphoedema T F
10. Lymph nodes act as filter stations, produce lymphocytes and

some monocytes. T F
11. The incidence of lymphoedema is approximately 1/50

following axillary dissection. T F
12. Lymphoedema is never painful T F
13. Axillary nodes are sometimes removed/irradiated in the

management of breast cancer T F
14. If managed well, lymphoedema is curable T F
15. Rapid, repetitive exercises stimulate lymphatic flow T F
16. Oedema can be caused by inadequate lymph flow T F
17. Blood pressure readings should not be taken on ‘at risk’ limbs T F
18. Lymphoedema will not occur within 3 years of surgery T F
19. Stage 1 lymphoedema is sometimes called “Elephantiasis” T F
20. Treatment of vulval cancer may involve removal of or

radiotherapy to groin nodes
T F

1.8 Part 10 Lymphoedema – Answers
1. F
2. F
3. T
4. F
5. F (It is advisable to avoid infections/ risk of infections)
6. T
7. F (Watery fliud, protein and a few WBC)
8. T
9. F
10. T
11. F (Reported incidence is between 1/5 and 1/20)
12. F
13. T
14. F
15. F (Slow, ryhthmical exercises stimulate lymphatic flow)
16. T
17. T
18. F (Lymphoedema can occur any time after surgery. The reported
average time of onset is 3 years)
19. F ( stage 3 not stage 1)
20. ?

1.8 part 11 Osteoporosis
1. Answer these questions by circling either T if True or F if False.
a) Osteoporosis is a condition in which the skeleton becomes so porous

that there is a major loss of bone tissue, and subsequent risk of
fracture. T F
b) Osteoporosis bone is painful

T F
c) Osteoporosis increases the risk of bone fractures

T F
d) Women have a higher peak bone mass that men

T F
e) Obtaining maximum potential peak bone mass may help to reduce

the risk of osteoporosis in later life.
T F
f) After menopause, women lose bone at a faster rate than men in the
same age group, because bone loss is increased as a result of low
Oestrogen levels (female hormone).
T F
2. Which of these are not risk factors for osteoporosis?
a) Gender, race and age

b) Family history
c) Low calcium intake
d) Low body weight
e) Early menopause / delayed puberty
f) Chronic liver disease
g) Loss of menstruation induced by anorexia
h) Loss of menstruation induced by exercise
i) Overactive thyroid
j) Low physical activity levels and immobilisation
k) High alcohol or caffeine intake
3. Osteoporosis affects 1 in …….. women over 60 years of age and 1 in ……..

men over 60.
……….% of fractured neck of femurs or total hip replacements never return
home.

Recommended daily calcium intake for women over 54 years is …………..
For men …………...
4. Does an Xray indicate Bone Density accurately? ……………..
What is the preferred method of measuring Bone Density accurately?

……………………………..
5. Prevention is better that treatment and client education and reduction of risk
factors are essential as well as:
a) …………………………………………………………………………
…………………..
b) …………………………………………………………………………
…………………..
c) …………………………………………………………………………
…………………..
6. Physiotherapy prescribed weight bearing exercise, resistance exercise, aerobic

exercise, and other management techniques for osteoporosis can improve or
affect
1) Muscle strength
2) Posture
3) ………………………………………….
4) ………………………………………….
5) ………………………………………….
6) ………………………………………….
7) ………………………………………….
7. Case History
q Ms EM, 36 year old G5P2 – ages 13 and 1 year
q PMx asthma – on 40mg Prednisone daily
q IDDM – unstable
q Obese – 114kg, 156cm
q Proven stress # - 3 in Thoracic spine, 1 in lumbar
q Presents with back pain, lower limb swelling, inability to lift younger
child.

q What would you treat and how?
q What predisposing factors must be considered?
q What tests would be useful in assisting your treatment?
q With follow up, what needs of the patient should be taken into
consideration?
Discussion
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………

!.9 Part 11 Osteoporosis- Answers
Q1. a) T
b) F
c) T
d) F
e) T
f) T
Q2. All are risk factors for osteoporosis
Q3. 1 in 2 women and 1 in 3 men

50%
Women 1000mg Men 800mg
Q4. No
Dual Energy Xray Absorptiometry (DEXA)
Q5. a) Hormone replacement therapy and other medication

b) Appropriate exercise
c) An adequate intake of calcium and vitamins
Q6. Joint stability, balance, co-ordination, quality of sleep, flexibility, bone

density, pain, risk of falls
Q7. These points should be considered in your answer to the Case history.
• Treatment of pain and swelling

• Education re: posture, lifting techniques
• Previous bone density scan results
• Xrays, medication
• Planning of exercise programme for follow up considering :-
Previous fractures,
Asthma,
Diabetes (pain – decrease exercise: need for more insulin)
Obesity ( exercise, referral to dietician)
? still breast feeding (calcium, hormones)
• Family needs – may need external support for low back because
has 1 year old, ergonomic evaluation of high chair, bath, planning
rest with legs elevated in day, hydrotherapy.
• ? other problems - ? incontinence due to cough (asthma), muscle
weakness. (pain, post natal)

1.10 ACKNOWLEDGMENTS
This Independent Learning Package has been developed by a group of experienced

clinical physiotherapists working in the area of Continence and Women’s Health in
South-East Queensland. This group includes Linda Hickey (Mater Mothers Hospital),
Sheridan Guyatt (Gold Coast Hospital), Alyssa Tait (Logan Hospital) and Robyn
Sharpe, Tracey Curtis, Karen Dowling, Lorrelle Hawes (Royal Women’s Hospital),
Tanya Francis , Allison Franks(QEII Hospital) and Prue Ryan (Redlands Hospital).
The University or Queensland Department of Physiotherapy has continued to support
the deve lopment of this package throughout the process.


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WOMEN’S HEALTH

Independent Learning Package

University of Queensland, Division of Physiotherapy 1

1.1 Welcome to the Clinical Unit 4

1.2. Expectations Upon Commencing this Unit 5

1.3 List of Resources 6

1.5 Glossary of Obstetric terminology 12

1.6 Chart entry example 15

1.7 Aims & Objectives 19

1.8 Start up Test 21

1.9 Part 1 Pelvic Floor Dysfunction

University of Queensland, Division of Physiotherapy 3

University of Queensland, Division of Physiotherapy 4

University of Queensland, Division of Physiotherapy 5

• R. Sapsford, J. Bullock Saxton and S. Markwell (1998) “Women’s Health – A

• Collins, M (Ed) (1987) “Women’s Health through Lifestages” – The

• Polden M and Mantle J (1990) “Physiotherapy in Obstetrics and Gynaecology”

• Chiarelli Pauline (1992) “Women’s Waterworks- Curing Incontinence” Health

University of Queensland, Division of Physiotherapy 6

• Childbirth Graphics / Birth Atlas

• “Breast Screening Qld” Workbook - Contact Women’s Cancer Screening

• Julie A Hides PhD MphtySt Bphty

• Alastair H. MacLennan, Anne W. Taylor, David H. Wilson, Don Wilson

• Katrina Horsley, B. Phty, MBA

University of Queensland, Division of Physiotherapy 7

• Royal Australian College of Obstetricians and Gynaecologists -

• The Pregnancy Centre - www.thepregnacycentre.com

• “Labour and Delivery”

University of Queensland, Division of Physiotherapy 8

G) Resource package in Clinical facilities- A resource package has been compiled

University of Queensland, Division of Physiotherapy 9

ACH After – Coming Head

APH Ante-Partum Haemorrhage

ARM Artificial Rupture of Membranes

ATSP Asked to see patient

BBA Born Before Arrival (at Hospital)

CPD Cephalo Pelvic Disproportion

CTSP Called to See Patient

DCGD Diet-controlled gestational diabetes

EBL Estimated blood Loss

EDC Expected/Estimated Date of Confinement

EDD Expected/Estimated Date of Delivery

FTP Failure To Progress

G,P,M,T Gravida, Parity, Miscarriage, Termination

GTT Glucose Tolerance Test

IDGD Insulin dependent gestational diabetes

IHD Ischaemic Heart Disease

INT Intact Perineum

INUFD Intra Uterine Foetal Death

IUGR Intrauterine growth retardation

University of Queensland, Division of Physiotherapy 10

LNMP Last Normal Menstrual Period

LSCS Lower Segment Caesarean Section

MR Manual Removal (of Placenta)

PET Pre-Eclamptic Toxaemia

PID Pelvic Inflammatory Disease

POP Persistent Occipito Posterior

PPH Post-Partum Haemorrhage