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Textbook of

Physiotherapy for Obstetric and Gynecological Conditions

Textbook of

Physiotherapy for Obstetric and Gynecological Conditions

GB Madhuri

MPT(Orthopedics) PGDPC DYT

Lecturer in Physiotherapy DCMS College of Physiotherapy Owaisi Hospital and Research Center Hyderabad, Andhra Pradesh India

Owaisi Hospital and Research Center Hyderabad, Andhra Pradesh India JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New

JAYPEE BROTHERS

MEDICAL PUBLISHERS (P) LTD New Delhi

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Textbook of Physiotherapy for Obstetric and Gynecological Conditions

© 2007, GB Madhuri

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.

This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2007

ISBN 81-8061-813-7

Typeset at JPBMP typesetting unit

Printed at Ajanta Press

To My Father and Beloved Husband Ramesh

Preface

The book titled Textbook of Physiotherapy for Obstetric and Gynecological Conditions has been designed to cater the needs of the students of the Bachelor of Physiotherapy degree especially in their second year, third year and final year. This book is also useful for professionals of physiotherapy, obstetricians, gynecologists, rehabilitation professionals, other paramedics and every woman in her childbearing year. This book has been prepared as per the curriculum of obstetric and gynecology for Bachelor of Physiotherapy degree course devised as per MCI regulations and universities syllabus. Not many books on physiotherapy for obstetrics and gynecology are available in India. Especially the book is written for the students of physiotherapy in India. This subject is essential and is a basic subject of physiotherapy for the undergraduate and as well as for the postgraduate courses. None of the books by the Indian authors are available. Very few textbooks by foreign authors are available in the market. To avoid confusion in understanding each topic of the entire subject and students referring many books for topics in the syllabus, this Textbook of Physiotherapy for Obstetric and Gynecological Conditions has been written in a systemic manner in a very simple approach for the students, professionals of physiotherapy, teachers, doctors, rehabilitation professionals, obstetricians, gynecologists, other paramedics and to every woman who is in childbearing year. Recently, lots of advances have taken place in the field of obstetrics and gynecology. Utmost efforts have been made to cover all the necessary aspects of electrotherapy. All the chapters have been written in a very simple manner and clearly expressed. In ancient times, woman who is pregnant was asked to be under regular medical supervision and medication. In recent times every woman is preferring to exercise for the health benefits. This is taught by the physiotherapist by a specially designed exercise regime during pregnancy. Physiotherapy is an ever- advancing field. Recent advances have made physiotherapy very interesting and playing an important role in working women with regard to ergonomics at work place to prevent further complications like low backache, etc. for fitness throughout pregnancy, regaining shape back to normal, woman will be learning stress-free techniques like relaxation and breathing techniques which are useful during normal labor and every woman prefers today because of minimal complications and to get back shape easily. All these techniques are found to be

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effective by every woman nowadays. Utmost efforts have been made to update this textbook starting from the introduction of physiotherapy for obstetric and gynecological conditions to the recent advances; all the aspects have been covered with details. I have tried to give a fairly complete coverage of the subject describing the most common method known to the women employed by physiotherapist at appropriate time. The intention is to explain how the method works and their effect upon the woman and fetus. In the initial chapter, I have tried to lay the foundation of the principles of physiotherapy for obstetric and gynecological conditions because a thorough understanding of these principles will ultimately lead to safer and more effective pregnancy, labor and postpartum period. Introduction covers about physiotherapy in obstetrics and gynecology starting from the definition of physiotherapy, need of physiotherapy during pregnancy, fitness during pregnancy, exercise regime during antenatal period, perinatal period, puerperium, postnatal period, after six months period, regain shape back and electrotherapy treatment have also been added. Chapter one covers about anatomy of bones and joints of pelvis, abdominal and pelvic floor, female reproductive system, ovaries, fallopian tubes, vulva and perineum. Chapter two has been explained in detail about female reproductive system, hormonal regulation, menstrual cycle, ovulatory phase and postovulatory phase. Chapter three is about National Women’s Health Policy, fitness in childbearing year and role of physiotherapy during pregnancy. Chapter four has tests done for the confirmation of the pregnancy and the tests that are harmful for the fetus also explained in this chapter. Chapter five covers introduction to biomechanics, sacral region, its movements and functions, posture in detail. Chapter six consist of definition of kinesiology, types of muscle tissue, aims of kinesiology, care during pregnancy, lower body exercises, upper body exercises, abdominal and pelvic floor exercises and muscles contraction and action done. Chapter seven covers definition of ergonomics, aims of ergonomics, risk assessment, risk factors, high risk areas and tasks, risks association with lifting, low back pain, workplace ergonomics. Risk control, task rationalization and implementation. Consideration of movements, planning lifting activities. Chapter eight is about pregnancy weight gain, pelvic viscera, fascia, ligaments, urinary system, pulmonary system, cardiovascular system, musculoskeletal system, thermoregulatory system, posture and balance changes. Chapter nine explains about physiotherapy assessment include general assessment, pelvic floor assessment and also diastasis recti assessment.

Preface

ix

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

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Textbook of Physiotherapy for Obstetric & Gynecological Conditions

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

GB Madhuri

Acknowledgements

Textbook of Physiotherapy for Obstetric and Gynecological Conditions is a book that provides basic knowledge and methodology. Exercise regimes along with updated knowledge of the important aspects of physiotherapy in obstetrics and gynecology.

I am indebted to G Anandarao, my father for inspiring me and encouraging me at every step of my life.

I am thankful to my husband, Mr. Ramesh for always supporting me and

motivating for writing this book and endured two years of emotional stress while I was deeply engrossed in preparing this book. This book is a complete, authoritative, latest and easily readable book. This book has been designed to effectively meet the needs and requirement of the undergraduate students. The book focuses on the basic principles and their application during pregnancy. In preparing this book, I have consulted and utilized the knowledge of

many authors and books. I wish to express my appreciation and gratitude to all of them who helped me with their valuable suggestions in this venture.

I have made every effort to keep the book comprehensive without eliminating

basic information. The emphasis has been laid entirely on accuracy, authenticity, simplicity and reproducibility by the student. How far I have succeeded in my efforts is for students and teachers to judge. I shall welcome their suggestions and comments. I especially thank Dr Aditya Sir and Dr Mohankrishna Sir who have encouraged me a lot for bringing this book out. My special thanks to Mr Md Fakruddin (Graphics and Design—mdfakruddin007@yahoo.com) and Mr Md Zubair Mohiuddin Farooqui who helped me a lot in setting up the material.

I owe my special thanks to Shri JP Vij, Chairman and Managing Director,

M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi and his whole team for publishing this book in such a nice manner.

Contents

1.

Anatomy

1

2.

Physiology

7

3.

Women’s Health and Role of Physiotherapy

11

4.

Pregnancy Tests and Investigations

14

5.

Biomechanics

17

6.

Kinesiology

21

7.

Ergonomics

31

8.

Physiological Skeletal Changes during Pregnancy

36

9.

Physiotherapy Assessement Chart

39

10.

Relaxation

45

11.

Breathing Techniques

49

12.

Massage

54

13.

Embryonic and Fetal Development

58

14.

Relieving Pregnancy Discomfort

75

15.

Identification of High Risk Woman

82

16.

Labor and Delivery

86

17.

Breastfeeding

100

18.

Assessment and Handling of Newborn

105

19.

Exercise Therapy Regime

110

20.

Electrotherapy

150

21.

Complications of Pregnancy

1 71

22.

The Methods of Infection Control for Physiotherapist

Working with Women’s Health

1 82

Glossary

184

Bibliography

189

Index

190

Introduction

Pregnancy is the time of great change and growth, for someone it is an exciting, challenging state, for others it is the time of stress, emotional change and lifestyle reassessment.The physiotherapy plays an vital role and physiotherapist must consider all the factors when designing the exercise throughout the pregnancy and postpartum period. So the concept of fitness in pregnancy must encompass emotional and psychological aspects in addition to physical fitness. The physiotherapist needs to be aware of normal pregnancy weight gains and should refer the women to a dietician if indicated. The physiotherapist need to recognize the different needs of the woman who wishes to continue to exercise safely during pregnancy to cope with the physical demands of pregnancy and labor. So assessment must be done which includes physical aspects, history and psychological influences.

In the promotion of healthy lifestyle in the childbearing years, physiotherapist

must reinforce the value of exercise and back care as a part of multidisciplinary

team involved in the antenatal care. Physiotherapist must have the expert and skill to provide the pregnant woman, who wishes to exercise safely during her pregnancy and the physiotherapist should have the ability to understand the

biomechanical and physiological changes during pregnancy and their influence on exercise, must be able to assess muscle strength, muscle length and posture, analyze movement, design appropriate exercise regime, must be able to reinforce the principles such as relaxation, breathing techniques, back care, lifting and bending technique, etc. and manage the musculoskeletal problems associated with the childbearing Pregnancy is the time of great change and growth. A physiotherapist offer a best service by promoting its benefits to the well-being of the pregnant and postpartum woman by arranging the exercise classes and demonstrating the exercises which are specially designed to meet the needs of the woman in the childbearing year. Thus, fitness is very important.

A Physiotherapist will give an accurate idea of physiological changes of

pregnancy and puerperium, postpartum period, preventive practices, ergonomics, safe exercise guidelines, specific exercises for strengthening and stability, physical management of pregnancy and discomfort, musculoskeletal problems and its management, relaxation techniques, breathing techniques, positioning throughout pregnancy, labor and postpartum period, coping skills for labor, massage, fitness program, baby handling, baby massage, specific

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treatment modalities in the form of electrotherapy for complications after delivery for pain relief, muscle stimulation, strengthening, promotion of healing of acute and chronic tissue problems, breast engorgement, mastitis and blocked ducts, etc.

Exercise regime is the ideal gentle and effective exercise system during pregnancy for woman’s health at all stages of the pregnancy, helps to cope up with labor, childbirth, care of newborn, breastfeeding, handling of newborn, identifying for the early pediatric problems and regaining her shape back by specific exercises designed. Thus, physiotherapy is useful in the months leading up to baby’s birth and in the weeks following to get woman’s body back in shape and achieve the longer, leaner and stronger.

CHAPTER 1
CHAPTER
1

Anatomy

BONES AND JOINTS

The bones of the pelvis comprising hips, sacrum and coccyx form a cavity through which the fetus passes during labor. The two large hip bones meet together in the midline, anteriorly forming the symphysis pubis and the sacrum, posteriorly form two sacroiliac joints. These joints allow a small amount of movement during birth-giving the fetus an easier fit. The hormone relaxin increases ligament laxity. The pelvis brim divides into the false pelvis above and true pelvis below. The brim is known as the pelvis inlet and in the female it is wider and deeper than in the male. It is apple-shaped. The pelvic outlet at the base of the true pelvis comprises of tip of the coccyx, posteriorly ischial spines, laterally tuberosities, and anteriorly pubic arch. It is a diamond-shaped. At midcavity the true pelvis assumes circular shape. It is the shape of the bony pelvis that allows the fetus accommodation during the process of birth (Fig. 1.1).

MUSCLES

The abdominal and pelvic floor muscles are very important during pregnancy and labor.

Abdominal Muscles

It forms a four way stretch elastic support for the abdominal contents. They are:

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Textbook of Physiotherapy for Obstetric & Gynecological Conditions

Physiotherapy for Obstetric & Gynecological Conditions Fig. 1.1: Bones and joints of the pelvis Rectus Abdominis

Fig. 1.1: Bones and joints of the pelvis

Rectus Abdominis

Origin: Pubic creast and pubic symphysis.

Insertion: Cartilage of fifth to seventh ribs and xiphoid process.

Nerve supply: Branches of thoracic nerves T7-T12.

Action: Compresses abdomen to aid in defecation, urination, forced expiration and childbirth, a flexes vertebral column. It stretches on either side of the linea alba ligament attaching to its midline running from the pubic arch below the ribs and xiphoid process and helps in flexion of the spine and gives support the growing pregnant uterus not only stretches the abdominal muscles but due to the laxity of linea alba caused by relaxin, the recti separates, leaving a gap of some 1 to 3 cm between the two muscles by the end of the pregnancy.

Transverse Abdominis

Origin: Iliac crest, inguinal ligament, lumbar fascia and cartilages of last six ribs.

Insertion: Xiphoid process, linea alba and pubis.

Nerve supply: Branches of thoracic nerves T8-T12, iliohypogastric and ilioinguinal nerves consist of horizontal fibers.

Anatomy

3

Action: Compresses abdomen.

Oblique Muscle

Internal oblique:

Origin: Iliac crest, inguinal ligament and thoracolumbar fascia.

Insertion: Cartilage of last three or four ribs and linea alba.

Nerve supply: Branches of T8-T12, iliohypogastric and ilioinguinal nerves.

Action: Contraction of both compresses abdomen, contraction of one side alone bends vertebral column laterally, laterally rotates vertebral column.

External oblique:

Origin: Lower eight ribs.

Insertion: Iliac crest, linea alba.

Nerve supply: Branches of T7-T12 and iliohypogastric nerve.

Action: Contraction of both compresses abdomen, contraction of one side alone bends vertebral column laterally, laterally rotates vertebral column. Two pairs of oblique muscles interlaced diagonally deep to the recti, take part in trunk rotation, side flexion, along with pelvic floor helps to maintain intra-abdominal pressure. The deepest of the groups is the transverse abdominis muscle. The internal and external oblique muscles cover it. From each side these three muscles insert into a broad aponeurosis that connects the linea alba, this tendinous raphe, which is wider above the umbilicus than below, is formed by decussating aponeurotic fibers. The two recti abdominis muscle which runs in sheaths reinforces the aponeurosis formed in the aponeurosis on either side of the linea alba. The each rectus abdominis muscle has three transverse fibers insertions that are firmly attached to the anterior wall of the enclosing sheaths. The lower intersection is above the level of the umbilicus and sheaths are deficient posterior in the lowest portion.

Muscles of Pelvic Floor

Structure

Levator ani and coccygeus muscles. Levator ani muscles comprise two parts ilio coccygeus and pubococcygeus, which helps to form the floor of the pelvis and separate the pelvic cavity from the perineum. This forms a major portion of the floor of the pelvis. Medial borders of the right and left muscles are separated by the visceral outlet through which pass the urethra, vagina and anorectum.

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Textbook of Physiotherapy for Obstetric & Gynecological Conditions

Pubococcygeus

Origin: Posterior aspect of the pubis.

Insertion: Sphincter, urethra, wall of vagina, pineal body and rectum.

Nerve supply: S3-S4 and perineal branch of pudendal nerve.

Action: Supports and slightly raises pelvic floor, resists increased intra-abdominal pressure, draws anus toward pubis and constricts.

Iliococcygeus

Origin: Ischial spine, obturator fascia.

Insertion: Last two coccygeus segments.

Nerve supply: S3-S4 and perineal branch of pudendal nerve.

Action: Supports and slightly raises pelvic floor, resists increased intra- abdominal pressure draws anus toward pubis and constricts.

Coccygeus

Origin: Spine of the ischium.

Insertion: Lower sacrum and upper coccyx.

Nerve supply: Sacral nerve S3 or S4.

Action: Supports and slightly raises pelvic floor resists intra-abdominal pressure and pulls coccyx forward following defecation or parturition (childbirth). Voluntary contraction of the levator ani muscle help to constrict the opening in the pelvic floor (urethra and anus) and prevented unwanted micturition and defecation (stress incontinence). Involuntary contraction of these muscles occur during coughing or holding ones breath when the intra-abdominal pressure is raised. In women these muscles surround the vagina and help her to support the uterus. During pregnancy the muscles can be stretched or traumatized and result in stress incontinence. When ever intra-abdominal pressure is raised. The coccygeal muscle assist the levator ani in supporting pelvic viscera and maintaining intra-abdominal pressure.

FEMALE REPRODUCTIVE SYSTEM

The female organs of reproduction include the ovaries, which produce secondary oocytes (cells that develop into mature ova only after fertilization) progesterone and estrogen (female sex hormones) inhibin and relaxin, the uterine (fallopian

Anatomy

5

tubes) which transport ova to the uterus, the uterus in which embryonic and fetal development occurs, the vagina and the external organs that constitute the vulva or pudendum. The mammary glands are also considered as part of the female reproductive system. The specialized branch of medicine that deals with the diagnosis and treatment of the disease of the female reproductive system is called gynecology.

Ovaries

The ovaries and female gonads are paired glands. These are in almond size and shape. Ovaries descend to the brim of the pelvis during the third month of the development. They lie in the upper pelvic cavity one on each side of the uterus. Three ligaments hold the ovaries in position, broad ligament of the uterus attaches to the ovaries by a double-layered fold of peritoneum called the mesovarium. The ovarian ligaments anchors the ovaries to the uterus and suspensory ligaments attaches them to the pelvic wall. Each ovary contains a hilus, the point of entrance for blood vessels and nerves and along which the mesovarium is attached. Each ovary consists of the following parts—ovarian follicles, graafian follicles, and corpus luteum.

Uterine Tube (Fallopian Tube)

Females have fallopian tubes also called oviducts that extend laterally from the uterus and transport the ova from the ovaries to the uterus. It is 10 cm long, tubes lie between folds of the broad ligament of uterus. The funnel-shaped distal end is called infundibulum. It ends in finger-like projections called fimbriae.

Uterus

The uterus or womb forms a pathway for sperm to reach the uterine tubes. It is site of menstruation, implantation of a fertilized ovum, development of fetus during pregnancy and labor and it is situated near urinary bladder and rectum. The shape of uterus is inverted pear. Uterus has dome-shaped portion called the fundus, central portion called body and inferior narrow opening into vagina called cervix.

Vagina

It is tubular fibromuscular organ lined with mucous membrane and measures about 10 cm in length. It serves as a passage way for menstrual flow and childbirth. It also receives semen from the penis during sexual intercourse.

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Textbook of Physiotherapy for Obstetric & Gynecological Conditions

Vulva

It is called external genitalia of the female. It has mons pubis, labia majora, labia minora, clitoris, and vestibule.

Perineum

It is a diamond-shaped area between the thighs and buttocks of both males and females that contain external genitalia and anus.

Mammary Glands

The mammary glands are modified sudoferous (sweat) glands, which produce milk. They lie over muscles like pectoralis major and serratus anterior and attaché by layer of connective tissue.

Internal Structure

Each mammary gland consists of 15 to 20 lobes separated by adipose tissue. In each lobe are several smaller compartments called lobules, composed of connective tissue in which clusters of milk-secreting glands called alveoli. Alveoli convey milk to secondary tubules to mammary ducts, then to the lactiferous sinus where milk is stored, lactiferous ducts end in nipple. The pigmented area of skin around nipple is called areola. It has modified sebaceous glands, Cooper’s ligament support the breast. The structure of the glandular elements of the mammary glands varies considerably at different periods of life as follows:

A. Before the onset of puberty the glandular tissue consists of ducts, connective tissue and fat.

B. During pregnancy ducts undergo proliferation and branching their terminal parts develop into alveoli, each lobe is called tubuloalveolar glands, at the end of the pregnancy alveoli starts secreting milk and alveoli becomes distended. The development of the breast tissue during pregnancy takes place under the influence of hormones produced by cerebri.

Physiology

7

CHAPTER 2
CHAPTER
2

Physiology

FEMALE REPRODUCTIVE SYSTEM

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

Female Reproductive Cycle

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

HORMONAL REGULATION

The uterine cycle and ovarian cycle are controlled by gonadotropin-releasing hormone (GnRH) from the hypothalamus. GnRH stimulates the release of the

8

Textbook of Physiotherapy for Obstetric & Gynecological Conditions

follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary gland. FSH stimulates the initial development of the ovarian follicles and secretion of estrogen by the follicles. LH stimulates the further development of ovarian follicles, brings ovulation and stimulates the production of estrogen, progesterone, inhibin and relaxin by the corpus luteum.

Estrogen

It promotes development and maintenance of female reproductive structures; secondary sex characteristics and fat distribution to the breasts, abdomen, mons pubis, hips, voice pitch, broad pelvis and hair pattern. They help to control the fluid and electrolyte balance, they increase protein anabolism. Estrogen inhibition causes inhibition of GnRH, LH, FSH use for contraceptive.

Progesterone

It works with estrogen to prepare the endometrium or implantation of a fertilized ovum and mammary glands for milk secretion.

Inhibin

It is secreted by the corpus luteum of the ovary. It inhibits the secretion of FSH,GnRH, LH. It helps in decreasing secretion of FSH and LH towards the end of the uterine cycle.

Relaxin

It is produced in its highest concentration by the corpus luteum and placenta during the last trimester of pregnancy. It relaxes the pubic symphysis and helps to dilate the uterine cervix to ease delivery.

PHASES OF FEMALE REPRODUCTIVE SYSTEM

The female reproductive cycle normally ranges from 24 to 35 days, events occur during the cycle are divided into three phases.

1. Menstrual phase.

2. Preovulatory.

3. Postovulatory.

Menstrual Phase (Menstruation)

The menstrual phase lasts for 5 days. It has 50 to 150 ml of blood, tissue fluid, mucus, epithelial cells derived from the endometrium. This discharge occurs because the declining level of estrogens and progesterone causes the uterine

Physiology

9

spiral arteries to constrict. As a result the cells they supply become ischemic and start to die. Entire stratum functionalis tears off. At this time the endometrium is very thin because only the stratum basalis remains. The menstrual flow passes from the uterine cavity to the cervix and through the vagina to the exterior. During this stage FSH begins to increase by 25th day of the previous cycle, primordial follicles begins to develop into primary follicles. Towards 4 to 5 day of menstrual cycle, primary becomes secondary (growing) follicle. It has secondary oocytes.

Preovulatory Phase

It is the second phase of the female reproductive system. It is the time between menstruation and ovulation. It lasts from 6 to 13 days in 28 days cycle. Out of 20 follicles, one gets mature into vesicular ovarian (graafian) follicle or mature follicle, a follicle ready for ovulation. This follicle is visible as a blister-like bulge on the surface of the ovary. Fraternal or nonidentical twins may results if two vesicular ovarian follicle forms. All hormonal production increases like estrogen, FSH, GnRH, progesterone. Estrogen is liberated into the blood by ovarian follicle stimulate the repair of the endometrium. Cells of the stratum basalis undergoes mitosis and produce stratum functionalis. As endometrium thickens becomes 4 to 6 m. Preovulatory phase is also called proliferative phase because endometrium is proliferating. The menstrual phase and preovulatory phase together called follicular phase because ovarian follicle are growing and developing.

Ovulation

It is the rupture of the vesicular ovarian (graafian follicles) with release of secondary oocytes into the pelvic cavity usually occurs on the 14 day in a 28 days cycle. During ovulation, the secondary oocytes remains surrounded by cells called corona radiata. It generally takes 20 days for a primordial follicle to develop into mature vesicular ovarian. During this time the developing ovum completes reduction division (meiosis I) and reaches metaphase of equatorial division (meiosis II). At the time of ovulation the secondary oocytes are in metaphase of equatorial division. The fimbriae of the uterine tubes drape over the ovaries and become active near the time of ovulation. Movements of the fimbriae and uterine tube mucosa and ciliary’s action creates currents in the peritoneal serous fluid that carry the secondary oocytes into the uterine tube. All the hormonal levels increase. This sudden surge of LH triggers ovulation.The sign of ovulation is an increase in basal temperature (body

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temperature at rest). It is 0.4 to 0.6 degree Fahrenheit. Ovulation occurs about 14 days after the start of the last menstrual cycle and due to increasing levels of progesterone. The 24 hours following this rise in temperature is the period immediately after ovulation and is the best time to become pregnant. Another sign of ovulation is the amount and consistency of cervical mucus. Its secretion is regulated by estrogen and progesterone. At midcycle increasing levels of estrogen causes secretory cells of the cervix to produce large amounts of cervical mucus. As ovulation approaches, the mucus becomes clear and very stretching, if grasped with forceps; the mucus may stretch as far as 12 to 15 cm. This type of mucus indicates the time of greatest fertility. The cervix also exhibits signs of ovulation. The external os opens, the cervix rises and becomes softer. Some women also experiences a pain in the area of one or both ovaries around the time of ovulation. Such pain is called mittelschmerz meaning pain in the middle and may last from several hours to

a day or two.

Postovulatory Phase

It is the most constant in duration and last for 14 days from 15 to 28 in a 28 day

cycle. It represents the time between ovulation and onset of next menses. After the ovulation LH secretion stimulates remains of vesicular ovarian follicle to develop into corpus luteum. Corpus leuteum secrets more quantity of estrogen and progesterone. This phase called luteal phase. Progesterone is responsible for preparing the endometrium to receive a fertilized ovum. Preparatory activities include growth and coiling of endometrium glands, which begin to secrete glycogen, vascularization of the superficial endometrium, thickening of the endometrium and increase in the amount of the tissue fluid. These changes are maximum about one week after ovulation. This phase is also called secretory phase because secretory activity of the endometrial glands. If fertilization and implantation do not occur the rising levels of both

progesterone and estrogen secreted by the corpus luteum inhibit GnRH and LH secretion. As LH decreases, the corpus luteum degenerates and become corpus albicans or white body. This decreased secretion initiates another menstrual phase. Once fertilization and implantation occur hormonal regulation maintained by placenta. Corpus luteum maintained by human chorionic gonodotropin (hCG) a hormone produced by the chorion, which develops into the placenta. Corpus luteum secrets estrogen and progesterone. The presence of hCG is an indication of pregnancy. The placenta secretes estrogen to support pregnancy and progesterone to support pregnancy and breast development, corpus luteum becomes minor.

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CHAPTER 4
CHAPTER
4

Pregnancy Tests and Investigations

Pregnancy tests and investigations are useful for diagnosing whether a woman is pregnant or not and if pregnancy helps to rule out the further problem. It is confirmed by the following tests:

URINE TEST

This test is performed after six weeks from the last menstrual period to sixteen weeks. It is a diagnostic test that depends on the presence of human chorionic gonodotropin (hCG) in the urine. hCG is found in the concentrated form in the first urine passed in the early morning. The test is highly-reliable. If performed before six weeks or later sixteen weeks will get a negative result.

ROUTINE TEST

In each antenatal visit the midstream urine is examined for the presence of sugar, protein, ketones which cause potential problems, and presence of bacteria in the early pregnancy where antibiotic treatment is given to prevent further problems.

ROUTINE BLOOD TEST

This test is done for hemoglobin estimation, detecting anemic, blood group, rhesus factor to find out cross-matched blood in the event of hemorrhage during pregnancy, labor or puerperium, rhesus incompatibility between mother and infant blood types, serological tests for syphilis or other venereal infection

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15

(VDRL), rubella antibodies are tested to know if the woman is immune, if so, it results in fetal abnormalities like deafness, cataract, heart defects or if woman is susceptible, vaccination is usually offered after the birth of the baby.

SPECIFIC BLOOD TESTS

Hemoglobin electrophoresis to detect conditions such as sickle cell anemia and thalassemia, serum alpha-fetoprotein is to detect open neural tube defects such as spinal bifid or anencephaly. Hepatitis (A, B, C) screening to detect the presence of hepatitis and avoid infection of health care workers during blood taking or delivery. Glucose tolerance test to measure the woman’s ability to stabilize blood sugar levels after the ingestion of glucose, a random finding of glucose in the urine is common in pregnancy, to exclude diabetes mellitus in pregnancy when there is family history of diabetes, marked obesity, history of previous baby weighing over 4.5 kg or unexplained stillbirth. The test is done with fasting blood sugar or urine specimen, the woman takes glucose by mouth, the blood and urine samples are collected at half-hourly intervals for two hours.

ULTRASOUND

Diagnostic ultrasound is commonly used in obstetrics for the identification of early pregnancy, accurate pregnancy dating, assessment fetal growth, early diagnosis of multiple pregnancy, estimation of fetal health, diagnosis of certain abnormalities, localization of placental site and amniocentesis.

AMNIOCENTESIS

Amniotic fluid is taken from the uterus for analysis of detection of fetal abnormalities such as Down’s syndrome, open neural tube defects, identification of sex in sex-linked disorders such as hemophilia and Duchenne muscular dystrophy and identification of biochemical disorders must be performed by 16 to 18 weeks, complications include abortion, preterm labor and limb deformities.

CHORIONIC VILLUS SAMPLING

It is used for fetal abnormality between nine and twelve weeks of pregnancy, guided by ultrasound a small tissue sample is taken from the edge of the placental (the chorion) and tested to exclude abnormalities such as Down’s syndrome, spinal bifida, sex-linked disease or chromosomal abnormalities, risk of complications such a miscarriage. Test is conducted earlier in the pregnancy results in three days.

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ESTRIOL TESTS

Assessment of the amounts of estriol or human placental lactogen (hPL) gives an indication of the functioning of the placenta. The estriol tests and blood tests are conducted three times over five days to determine if the estriol level is stable or failing. It is rarely used.

FETAL MOVEMENTS RECORDING KICK CHART

One sign of healthy baby is vigorous movement, the pregnant woman may be asked to record the time it takes for the fetus to more 10 minutes (any time from a few minutes to twelve hours) low movements counts indicate a need for closer fetal monitoring.

ANTENATAL CARDIOTOCOGRAPHY

Fetal heart rate traces can be recorded. A normal trace shows a fetal heart rate between 100 and 160 beats per minute and abnormalities may give warning to deliver fetus and indications are low movement count, evidence of placental insufficiency, antenatal bleeding following amniocentesis, multiple pregnancy.

CHAPTER 5
CHAPTER
5

Biomechanics

Pregnancy results in an alteration of every organ system with in the woman’s body. The effects of pregnancy on the biomechanics of the chest wall are apparent during the second half of the pregnancy especially during the last trimester. Progressive uterine distension repositions the diaphragm cephalad with a resultant increased chest circumference (Fig. 5.1).

cephalad with a resultant increased chest circumference (Fig. 5.1). Fig. 5.1: Biomechanical changes during pregnancy

Fig. 5.1: Biomechanical changes during pregnancy

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SACRAL REGION

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

significantly from birth through adulthood (Fig. 5.2). Fig. 5.2: The sacroiliac joints MOTIONS AT SACROILIAC JOINTS

Fig. 5.2: The sacroiliac joints

MOTIONS AT SACROILIAC JOINTS

The movements at sacroiliac joints are nutation and counternutation.

Nutation

It is commonly used term to refer to movement of the sacral promontory of the sacrum anteriorly and inferiorly while the coccyx moves posteriorly in relation to the ilium (Fig. 5.3).

anteriorly and inferiorly while the coccyx moves posteriorly in relation to the ilium (Fig. 5.3). Fig.
anteriorly and inferiorly while the coccyx moves posteriorly in relation to the ilium (Fig. 5.3). Fig.

Fig. 5.3: Nutation

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COUNTERNUTATION

It refers to the opposite movement in which the anterior tip of the sacral promontory moves posteriorly and superiorly while the coccyx moves anteriorly in relation to the ilium (Fig. 5.4).

coccyx moves anteriorly in relation to the ilium (Fig. 5.4). Fig. 5.4: Counternutation The change in

Fig. 5.4: Counternutation

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

FUNCTIONS OF SACRAL REGION: STABILITY AND MOBILITY

During pregnancy, relaxin a polypeptide hormone is produced by the corpus luteum and deciduas. This activates the collagenolytic system that regulates new collagen formation and alters the ground substance by decreasing the viscosity and increasing the water content. The action of relaxin is to decrease the intrinsic strengthen and rigidity of the collagen, softening of the ligaments supporting the sacroiliac joints and symphysis pubis. So, joints become more mobile and less-stable and the likelihood of injury to these joints is increased. The combination of loosened posterior ligaments and anterior weight shift caused by a heavy uterus may slow excessive movement of the ilia on the sacrum and result in stretching of the sacroiliac joint capsule.

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Posture

Normal pregnancies are accompanied by a weight gain, an increased in weight distribution in the breast and abdomen and softening of the ligamentous and connective tissue. The location of the woman’s center of gravity changes because of the increase in weight and its distribution anteriorly. Postural changes in pregnancy include an increase in the lordotic curves in the cervical and lumbar areas of the vertebral column, protraction of the shoulder girdle and hyperextension of the knees, head position, anterior pelvic tilt. The lumbar angle increased by an average of 5 to 9 degrees, the anterior pelvic tilt increased by average of 4 degree, head become more posterior as pregnancy progressed from first through third semester. These changes in posture represent adaptations that help to maintain the center of gravity centered over the base of support. Softening of ligamentous and connective tissues especially in the pelvis, sacroiliac joints, pubic symphysis and abdomen changes the support and protections offered by these structures and predisposes pregnant women to strains in supporting structures. So, many women experience backache during pregnancy.

Kinesiology

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CHAPTER 6
CHAPTER
6

Kinesiology

DEFINITION

Kinesiology is the study of how muscles work and contract muscle tissues.

AIMS OF KINESIOLOGY

1. To maintain, develop, strengthen or endurance in major muscle groups

2. To promote good posture

3. To develop body awareness and control

4. To maintain and develop muscle tone, improving body image.

Exercises are categorized into:

1. Lower body exercises: Quadriceps, straight leg extension, hamstring curls, toe

pull ups or foot lifts, side-leg lifts, lying on side, heel raises.

2. Upper body exercises: Press-ups, triceps extension, lateral pulls, trapezius squeezes.

3. The abdominal muscles: Rectus abdominis, internal oblique, external oblique muscles, abdominal curls, static abdominal contraction.

4. The pelvic floor: Levator ani and coccygeus.

Lower Body Exercises

Quadriceps

Four muscles make quadriceps muscle group. They are rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius. These are located in the

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anterior surface of the thigh and these muscles extend the leg by straightening the knee when running and walking. The quadriceps contraction helps slow down and stabilizes the body when coming to land after jumping. And also keep the knees straight when standing; the rectus femoris also flexes the hip.

Advantages

1. Strengthening of quadriceps aids in ability to bend and lift effectively and correctly.

2. Strong quadriceps allows performing effectively so walking is an excellent way of working aerobically while pregnant, thereby, minimizing on relaxin affected joints.

3. Quadriceps helps in taking the increasing pressure of extra-weight and potentially-increased instability caused by relaxin hormone and stability of the knee joint is maintained by vastus medialis.

4. Leg exercises that contract the quadriceps muscle group include: half squats, straight leg extensions.

Half Squats

Position of patient: Standing with or without support, feet should be hip distance apart.

Technique: Bend the knees into half squat position, do not take knee joint beyond the range of foot, and try to keep in line, come back to the normal position. Work for 8 to 10 repetitions, this can be worked as aerobic work, pool environment, dryland.

Uses: Warmup muscle tissue, mobilizing hip joint.

Straight Leg Extension

Position of patient: Seated on a chair, feet should touch floor and or stability; hold the sides of chair under the seat.

Technique: Lift one foot from the floor and straighten leg out in front until the knee is fully-extended. Return the foot to floor. Movement should be smooth and controlled, not jerky. Try 8 to 10 repetitions, then do the same with the other leg, then alternate legs, totally perform 2 or 3 sets.

Hamstring

These are the group of muscles situated at back of upper thigh. They are semimembranosus, semitendinosus and biceps femoris. The function of these muscles is to flex or bend the knee and to extend the hip when the knee is flexed, rotation of the knee can occur.

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Position of patient: Standing with support of a chair, wall, and exercise barre in pool holding the scum rail.

Technique: Both the legs on ground until toes touching ground. Bend the knee of one leg and touch the buttock with heel. This action is by hamstrings. Return the foot to the ground by extending and straightening knee.

Advantages: Improving the strength of the hamstrings helps the pregnant woman’s ability to bend and lift with good technique, reducing stress on the vertebral column as pregnancy advances, maintain correct pelvic tilt, maintains correct alignment between pelvic tilt and spinal column thus, helping good posture and alleviate backache. Repetitions should be decreased in the third trimester as increasing body weight makes more difficult to maintain correct body posture while exercising.

Toe Pull-ups or Foot Lifts

Tibialis anterior works for this. Origin: Upper two-thirds of the tibia.

Insertion: Inner surface of foot, first metatarsal

Nerve supply: Deep tibial nerve.

Action: Inversion and plantar flexion of the foot.

Position of patient: Seated on a chair, on the floor or standing in a pool. If using a chair ensure that both feet touch the floor, if not use lumbar support (towel or sweat shirt) to move the buttock forward a little. If seated on the floor place both hands behind and to the side as necessary to give support while working. Upright seating position in last trimester of pregnancy is tiring for the back muscle so frequent rest periods by leaning back on the hands between sets of repetitions.

Technique: Seated on chair, pull the upper part of the foot up towards the lower leg dorsiflexing the ankle and return the foot to the floor. This exercise can be performed with the both feet together or alternate feet seated on floor sit with legs straight out in front, hip distance apart. Pull the upper part of the foot up towards the tibia of the lower leg, dorsiflexing the ankle as this is performed. Return the foot to the starting position. Repeat 8 to 10 times, rest, and rotate to different muscle groups, return and repeat.

Advantages: It gives support to the long arch of the foot when the soles of the foot are turned inwards (inversion) and helps counteract flat feet. The added weight of pregnancy and extra stress imposed on the ankles and foot can be considered by exercising the tibialis anterior muscle.

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Side-leg Lifts

Muscles are tensor fascia lata, gluteus medius, gluteus minimus.

Tensor fascialata:

• Origin: Anterior superior iliac spine.

• Insertion: Inferior tibial tract.

• Nerve supply: Obturator nerve.

• Action: Bends and abducts hip and straighten the knee joint.

Gluteus medius:

• Origin: Outer surface of ilium.

• Insertion: Greater trochanter.

• Nerve supply: Obturator nerve.

• Action: Abuction and medial rotation of hip.

Gluteus minimus:

• Origin: Outer surface of ilium.

• Insertion: Greater trochanter.

• Nerve supply: Obturator nerve.

• Action: Abduction and medial rotation of hip.

Position of patient: Standing with support, e.g. chair, wall, and lying on floor on side.

Technique: In standing she has to take weight on supporting leg and lift opposite leg out to the side and return to starting position, small lift will be sufficient as the high leg lift will create stress on the pubic symphysis joint at the front of the pelvis as the inside leg muscles are attached to this joint. Great care must be taken as relaxin hormone has affected of the pelvic girdle an increasing weight of the uterus and its contents. Perform eight repetitions before changing side, avoid tiredness especially last trimester (6-9) months of pregnancy. Pregnant women tire easily so ensure that support is available. Free-standing should be avoided.

Lying on Side

Ensure clean, warm and safe floor surface. Teach and observe the correct technique for pregnant women to get down safely on the floor or exercise mat.

Position of patient: Adapt the position on the floor, bottom leg should slightly bent with knee in front of body line. Top leg should be straight. Support head on hand with bent arm position, upper arm and hand can be used to support by placing hand on the floor in front of chest.

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Technique: Lift straight leg up, and then lower back down to starting position. Do not lift the leg too high as this caused stress on the pubic symphysis joint. Rests when you need to do approximately eight repetitions, if felt tired do less.

Advantages:

1. This helps to strengthen leg and gluteal muscles to aid women correct bending

and lifting technique.

2. Helps to maintain pelvic stability.

Heel-Raises

The gastronemius and soleus muscles are used during this movement called calf musculature, situated in the lower legs.

Gastrocnemius:

• Origin: Lower end of femur.

• Insertion: Achilles tendon at the back of the heel.

• Nerve supply: Posterior tibia nerve.

• Action: It helps in propelling the body forwards and upwards when running, jumping, hopping and skipping. Heel-raises exercises with the knees fully locked out.

Soleus:

• Origin: Upper two-thirds of tibia and fibula.

• Insertion: Achilles tendon.

• Nerve supply: Posterior tibial nerve.

• Action: Soleus is one of the most important plantar flexors of the ankle. It is effective when the knees are slightly bend. Any movement with body weight on the foot with the knees flexed or extended produces contraction of the soleus muscle. Running, jumping, hopping, skipping and dancing activates the soleus.

Position of patient: Stand with support, e.g. using chair, wall.

Technique: Stand with feet hip distance apart, toes pointing forward, feet flat on floor. If using a chair as a support ensure that the back rail is the correct height for the participant. Raise heel together from the floor, lower and return to starting position. Use of double heel rises if working on land. It increases stability.

Advantages:

1. Mobility of the ankle joints helps maintain general mobility of walking or performing exercises routine using the legs in antenatal and postnatal exercise class.

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3. The natural pump effect of these muscles when contracting can aid in maintaining venous return from the calf back to the heart, thus minimizing the risk of varicose veins and improving blood flow.

Upper Body Exercises

These exercises include:

1. Press-ups

2. Triceps extension

3. Lateral pulls

4. Trapezius squeeze.

Press-ups

The pectoralis major muscle that is used during this exercise is situated on the anterior surface of the chest wall, either side of the sternum, filling these space of the chest region between the shoulder girdle and the sixth rib.

Pectoralis major

Origin:

A. Upper fibers: From clavicle.

B. Lower fibers: From the first six ribs.

Insertion: In bicipital groove on humerus bone in the upper arm.

Nerve supply: Nerve to pectoralis major.

Action: (1) When arm is held in the horizontal position, this muscle draws the arms across towards the chest midline, (2) When the arm is away from the body (abducted), and pectoralis major moves the arm down towards the body, (3) It is also responsible for internally rotating the humerus bone in the upper arm intowards the body.

Position of patient: Seated on a chair or on the floor, standing either on land. In box position, on your hands and knees on the floor called quadripued position.

Technique:

Seating or standing: Both the arms with elbows bent, hands uppermost draw both arms inwards towards midline to meet and return back to normal position.

Advantages:

A. Improve the ability to lift a carry both antenatally and postnatally.

B. Muscle tone is improved by giving extra-support to the breast tissue.

C. Helps in improving the shape of the breast.

D. Blood supply to the breast area is increased; lactation is improved as prolactin levels are elevated for those who are regular exerciser.

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Triceps

Triceps brachii muscle is situated on the back of the upper arm and is responsible for extending or straightening the elbow.

Origin: Scapula bone.

Insertion: On ulna.

Nerve supply: Radial nerve.

Action: Pushing movements and hand balancing, extension of shoulder joint.

Position of patient: Standing or seating.

Technique: Keep the shoulders relax, do not tense up slightly bent the arms and a loose fist, place the upper arms into close contact with the body and slide the elbows back until they are behind the body and return to the starting position by flexing at the elbow joint. And other way is working by clasping both the hands above the head with bent elbows, and straightening the arms in this position will also contract triceps brachii muscle. Minimize the repetitions in this position due to potential rise in blood pressure.

Pushing activities such as prams and pushchairs and carrying

Advantages:

and balancing activities such as travelling with baby and toddler, i.e. carrying

changing bags, shopping with. Baby is better coped with and performed with greater care if the triceps brachii is well-toned or exercised.

Lateral Pulls

The latissimus dorsi muscle is situated either side of the spinal column, on the back, lower six thoracic vertebrae (T6 to T12), lowest three ribs, lumbar region of the spine and the sacrum.

Origin: Iliac creast, back of sacrum, thoracic, lumbar vertebrae, lowest three ribs.

Insertion: Intertubercular groove of humerus bone.

Nerve supply: Long thoracic nerve.

Action: To pull the abduction arm down to the side and towards the midline of the body, e.g. rope climbing, dips on parallel bars, rowing and pulling a bar on weights down towards the shoulder will contract the muscle.

Position of patient: Free-standing or side-standing with support or sitting on a chair or in hest deep water in swimming pool.

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Technique: Standing with both the hands above the head, grasp an imaginary rail down behind the head towards the shoulders. Return both arms to starting position. Maintain the anterior pelvic tilt, try to reduce lumbar lordosis if standing, keep the movement smooth, relax before performing next repetition, minimize repetitions to 8 to 10 as prolonged arm raising can effect the blood pressure, if seated on a chair, make sure that there are no chair arms, as they inhibit performance of the exercise and bruise the elbows.

Trapezius

The trapezius is situated on either side of the spinal; column in the cervical and thoracic areas on the back extending up into the base of the skull and out to the sides of clavicle an scapula.

Origin: Muscle fibers originate on the base of the skull, cervical and thoracic vertebrae.

Insertion: In clavicle and scapula.

Nerve supply: Thoracic nerves.

Action: It is responsible for pulling upwards and raising arms above the head. When arm are held out at the side of the body, the head. When arms are held out at the side of the body, the trapezius fixed the scapula in place and allows this to happen. When lifting the hands, e.g. heavy bags, the trapezius contracts and also carrying baby or heavy objects on the edge of the shoulder contracts the trapezius muscle.

Position of patient: Standing on floor or in water, sitting on a chair or on the floor

Technique:

Standing: Raise arms with bent elbows, push the shoulder backwards, drawing shoulder blades closer together on the upperback, while pulling the elbows towards the back of the body, return to the starting position. Other is taking both arms above the head. Imagine you are grasping a rail above your head. The action of taking the arms above your head and pulling down the imaginary rail behind your head towards your shoulder contacts the trapezius and will activate latissimus dorsi muscle. In standing when performing either exercise think about maintaining correct posture throughout, feet hip distance apart, do not lock knee joints, avoid excessive lumbar lordosis by tucking bottom in and trying to maintain a pelvic tilt that does not stress the lumbar region of the spine.

Sitting: If seated ensure that feet touch the floor. If they do not tuck a rolled up towel or sweatshirt behind too to bring your bottom further forward on the chair.

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Advantages: Well tones trapezius muscles will help to ease the stress of lifting and carrying. Helps in lifting and carrying tasks involving equipment, e.g. prams, push chairs, changing bags, all the paraphernalia that goes with having a baby and toddlers. Lifting and carrying children and push chairs of the car, up and down escalators can be exhausting, coping more efficiently by regularly exercising the trapezius muscle.

The Abdominal Muscles

The area of the body that usually concerns most women before, during and definitely after pregnancy is the abdominal corset or stomach area. The abdominal muscles fill the gap between the ribs and pelvis and form a natural elastic corset. The muscles are rectus abdominis, internal obliques, external obliques, transverse abdominis and quadratus lumborum.

Function

A. They act as a protective splint for the spine.

B. They help to maintain the correct pelvic tilt and realign the pelvis with the spine.

C. They support and protect the abdominal contents.

D. They allow and produce controlled movements.

E. They provide support for the pregnant uterus.

F. They aid expulsive movements such as coughing, vomiting, defecation and pushing during the process of childbirth during the second stage of labor when the transverse abdominals act as secondary powers to help the contracting uterus push out and expel the baby along the birth canal, all utilize the contraction of abdominal corset muscles.

Static Abdominal Contraction—Pelvic Tilt: On Bed

Position of the patient:

Standing or sitting position lie on firm surface on bed or floor with the knees bent, feet hip distance apart, hands placed either side on abdomen.

Technique: Breathe in as she exhales push the back down towards the floor or bed, tighten the abdominal muscles pulling them in. Hold this tightening for a few seconds and as she releases breathe out, ready to repeat again. Remember to breathe out on the exertion phase of the exercise i.e as she tighten and pull in the abdomen. Remember three Ts, i.e. tuck, tilt, and tighten. Perform 6 to 8 repetitions, repeat 3 or 4 times.

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Pelvic Floor

A

sling of muscle attached to the pelvic bone at the front, passing in two halves

to

the sacrum and coccyx at the back of the pelvis. The two halves to the sacrum

and coccyx at the back of the pelvis. The two halves fan out to form the floor of

the pelvis. Three opening pass through this urethra, vagina and rectum.

Role of Pelvic Floor

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

Pelvic Floor Muscles

It is made up of two layers—a deep layer of muscle and a superficial layer of

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

Superficial Muscle Layer

It forms transverse perineum as bulbocavernous and ischiocavernous.

Exercising the Pelvic Floor

Position of patient: Standing, sitting with knees apart, lying with both knees bent or sitting in a chair.

Technique: Tighten the muscles of vagina and pull up inside, hold for 4 to 6 seconds then release.

1. Hold your breath. Once you have tightened your pelvic floor take a slow deep breath in and breath out then release the pelvic floor muscle.

2. If holding for much longer time 6 seconds or more will make it stronger or faster because made up of fast twitch fibers.

3. Tailor sitting, sitting with the soles of feet together, squatting or sitting with knees pulled up and apart. Stretch inner thigh muscles and increased flexibility in this area may make the second stage of labor position more comfortable for women.

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CHAPTER 7
CHAPTER
7

Ergonomics

DEFINITION

It is scientific study of the relationship between people and their working environment. Term environment means environment, with tools, materials and their methods of work and the organization of their work, either as individual or working group. Today’s women often carry responsibilities involving one hour of duty. Women employed in industry or with major home care responsibilities can be involved in variety of tasks requiring strong mental, physical, emotional and social abilities. The careers of woman with a family is all faced with the challenges of coin with prolonged demands on both their energy and time. Some traditional female jobs in the work force are also susceptible to special stresses, these include nursing, computer operation, repetitive work on an assembly line. There are many tasks performed by women in which the sitting or standing position is maintained for long periods, if correct height relationships are not assumed their posture is inadequate and static work by specific muscle groups must be sustained for prolonged periods. Household and industrial tasks require that the head, trunk or arms be held in antigravity positions or strain and aching of the muscles of the shoulder girdle, neck and upper back may soon result. Many industrial task require repetitive small movements involving the elbows, forearms, wrist and finger, if there is insufficient time for relaxation, muscles are liable to fatique, soft tissue injuries. Shoulder susceptible to sub- deltoid bursitis followed by repetitive shoulder motion, elbow to contusions and bursitis due to rapid, repetitive forearm rotation and the wrist tendinitis from repetitive movements of hand. Prolonged standing with poor posture can

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also lead to the development or aggravation of leg pain, foot pain, arthritis and varicose veins. Low back pain in women is also common. Women are not as strong physically as men they cannot lift the same weight, stretch or reach as far, nor they stand as straight, but work under same conditions as men. So, they are prone for repetitive task and at greater risk of musculoskeletal injury because of overuse of muscles involved, muscles strains associated with the sustained posture to a large extent are the reasons for the occurrence of injuries or the development of specific symptoms such as fatigue or pain can be found in the neglect of personal requirements in design of the machine, workplace or last. It is, therefore, important to examine the risk to which women are exposed to consider the areas presenting those risks, and to apply principles which would ensure resolution of potential problem to health and welfare such an approach is embodied in the practice of ergonomics. Ergonomics is concerned with ensuring that the workplace is designed that work-induced injuries, diseases or discomfort are prevented and safety is ensured and that efficiency and productivity are maintained or increased.

AIMS OF ERGONOMICS

1. Reduce health and safety risks.

2. Ensure appropriate workloads both physical and mental.

3. Develop usable system and products

4. Achieve a good quality of working life and job satisfaction.

5. Increasing a good quality of working life and job satisfaction. Increase productivity, e.g. by increasing output rate, decrease absenteeism, turn over and improving quality.

Factors Causing Risk

For risk control and protection of the woman against musculoskeletal and posture load, it is important to evaluate the risk in the workplace. Analysis of workplace characteristics and identification of risk factors involve considerations of the many factors, which could influence workload. These could include:

1. The general layout

2. The design of implements

3. The task itself

4. The persons working technique

5. The general organization.

Ergonomics

33

Risky Areas

It is important to identify high-risk areas. Depending on the woman’s circumstances in the home, these could be the kitchens, the bathroom, laundry and the bedroom. High risk women involve lifting, e.g. a heavy household implement, loads of washing or a small child, reaching a high-storage levels, stooping to do gardening, to reach low storage or low electrical outlet or to manipulate household objects, placing an infant into a car seat, bending over a bath or cot, standing at the kitchen sink or at the ironing board. All the above precipitating events of female back injury include working in confined spaces such as toilet or bathroom, moving heavy objects with insufficient assistance, carrying out tasks which are beyond the woman’s capacity, acting hastily without consideration of safety measures and transferring young or disabled children or elderly parents from one position or level to another.

Lifting and Its Risk

The high incidence of low backache in women emphasizes the need to consider closely the particular risks associated with lifting. The factors that influence the load on the spine. These include:

1. The weight of the object to be lifted.

2. The horizontal distance from the body from which or to which it is lifted.

3. The body posture of the worker.

4. The duration of period of lifting.

5. The frequency of lifting.

6. The size and bulk of the object lifting.

7. The height or vertical distance of the lift.

8. The speed of the lift.

9. The stability and steadiness of the load.

Causes of Injury

Fatigue is commonly associated with pregnancy, especially in the first trimester and at term, e.g. carrying loads and walking up slope are example of activities which cause the fatigue. Fatigue can also affect posture, influence stability of the spine. Variety of approaches such as relaxation program, which include breathing exercises, awareness of specific muscle activation for the maintenance of stability may help a woman to cope with demands more effectively. Physiological changes in pregnant woman’s weight gain and increase in abdominal depth which can impose increased demands for postural alignment and can limit performance and endurance of everyday activities and tasks.

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ERGONOMICS APPLICATION

Once a risk has been identified, it is important to decide whether it can be eliminated or minimized. It is better to eliminate the risk and this could be achieved by changing the work process to remove the need for the activity creating the hazard. This often requires considerable adaptations, since most people develop patterns of behavior and work, which can be difficult to change. It is the role of the physiotherapist in controlling the risk and prevention strategies should initially focus upon where woman herself will learn to identify and control risk factors in her own work situation. If stress is high long-term planning can often minimize the problem. At office stress could be alleviated during periods of peak demand by directing telephone calls to an answering service at times. At home too the severe stress can be relieved by careful planning of priority tasks.

ERGONOMIC SOLUTION

Solution to control the risk for injury in women at home or workplace by taking into consideration of space requirement, dynamic and static posture, the physical work load, the work environment and organization factors pertaining to efficiency and stress reduction. The important aspect of the ergonomic approach is the concern for careful specifications of the work—task relationship within the design process so that the load on the locomotor system is reduced. It is important to design the process to avoid peak strains and static loads.

SAFETY MEASURES

The physiotherapist must take care of woman involving in lifting children or weight has persistent demands placed on her spine and need to show an appropriate a safe method of handling which will ensure maintenance of balance, postural control and avoidance of stress on the spine. The physiotherapist advising on correct lifting procedures should recommend the following practice:

1. Plan ahead.

2. Avoid lifting heavy objects alone, seek assistance.

3. Ensure adequate space is available.

4. Use a wide base of support.

5. Keep the weight close to the body.

6. Bend the knees and hips comfortably and maintain normal spinal curvatures where possible.

7. Avoid lifting combined with rotation.

8. Minimize the distance over which the load is carried.

Physiotherapist should teach about alternative equipment and procedures are available to substitute for manual lifting. These include walking belts, gait

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35

belts, use of slings for hand-gripping, mechanical hoists, e.g. hoyer, trans-aid, ambu lift, power–driven overhead lift system. Out of these ambu lift is the most effective. If women working at hospital situation include bath shower grab rails, sliding boards, overhead trapezes, hand blocks and drag sheets. Alternative to lifting and pulling methods designed following a biomechanical evaluation. One and two person pulling methods of transferring patients are significantly less stressful. Women need to receive advice an education on ergonomic principle which they can apply to their own work situation using appropriate self-assessment guides.

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CHAPTER 8
CHAPTER
8

Physiological Skeletal Changes during Pregnancy

PREGNANCY WEIGHT GAIN

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

kg and the total weight put around is 9.70 to 14.55 kg (Fig. 8.1). Fig. 8.1:

Fig. 8.1: Distribution of weight gain during pregnancy

Physiological Skeletal Changes during Pregnancy

37

PELVIC VISCERA, FASCIAE AND LIGAMENTS

The uterus increases from a prepregnant size of 5 by 10 cm to 25 by 36 cm. It increases 5 to 6 times in size, 3,000 to 4,000 times in capacity and 20 times in weight by the end of pregnancy. By the end of pregnancy each muscle cell in the uterus has increased approximately 10 times its length prior to pregnancy. Once the uterus expands it becomes abdominal organ. Uterosacral ligament provide suspensory support for the uterus.

URINARY SYSTEM

Kidneys increase in length by 1 cm. The ureter enter the bladder at a perpendicular angle because of uterine enlargement. This causes urine to flow in a back into the ureter so chance of developing urinary tract infection because of urinary stasis.

PULMONARY SYSTEM

Edema and tissue congestion of the upper respiratory tract occurs in early pregnancy. Changes in rib position increases subcostal angle anteroposterior and transverse chest diameter each increases by 2 m. Total chest circumference increases by 5 to 7 m. The diaphragm is elevated by 4 cm. There is increase in oxygen consumption to meet the increased oxygen demands of pregnancy. Dyspnea is common with mild exercise by 20 weeks of pregnancy.

CARDIOVASCULAR SYSTEM

Blood volume increases by 2 liters during pregnancy and will come back to normal by 6 to 8 weeks after delivery. Plasma volume increases than RBC so it leads to physiological anemia, this to because of hormonal stimulation to meet oxygen demands. Venous pressure in the lower extremity increases when standing as a result of increased uterine size. Pressure in the inferior vena cava rises in last trimester in supine position because of compression of uterus. Aorta is compressed in supine position. Heart size increases and heart is elevated because of movement of diaphragm. Heart rate increases 10 to 20 beats per minute by 9 months and return to normal by 6 weeks after delivery. Cardiac output increases in left side lying position, uterus has least pressure on aorta. Blood pressure decreases in the first 3 months, still decreases by 5 months then rises and becomes normal by 6 weeks after delivery.

MUSCULOSKELETAL SYSTEM

Abdominal muscles are stretched, muscle contraction is decreased, and shift of center of gravity is decreased. Ligament strength is decreased because of change

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in relaxin and progesterone level. Joint becomes hypermobile which leads to joint and ligament injury, e.g. back, pelvis, lower limb. The pelvic floor muscles must take weight of the uterus and pelvic floor drops by 1 inch, may be stretched, torn during birth process. The degrees of incision in the perineal body is called episiotomy. First degree is only skin, second degree includes underlying muscle, third degree extends to anal sphincter, fourth degree tears into the rectum. Pudendal nerve gets stretched when baby’s head comes out of birth canal during second stage of labor so affects both muscles and nerves of the pelvic floor.

THERMOREGULATORY SYSTEM

Basal metabolic rate and heat production increases to 300 kilocalories per day to meet metabolic needs of pregnancy. The fasting blood glucose levels will be less.

POSTURE AND BALANCE CHANGES

Center of Gravity

The center of gravity shifts upward and forward because of the enlargement of the uterus and breasts. Shoulder girdle gets protracted, upper extremity, internal rotation because of breast enlargement, pectoralis muscles get tightened and scapular muscles get weakened. Cervical lordosis increases in the upper cervical spine a forward head posture develops. Lumbar lordosis increases for shift of center of gravity, knees hyperextended for change in line of gravity. Weight shifts towards the heels and bring center of gravity posteriorly. Child care also causes faulty posture. So, correction must be emphasized at the earliest.

Balance

Woman walks with wider base of support, increased external rotation at the hips, activities like walking, stooping, stair climbing, lifting and reaching will become difficult.

Physiotherapy Assessment Chart

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CHAPTER 9
CHAPTER
9

Physiotherapy Assessment Chart

The patient should be positioned facing away from the door and should carry out the physiotherapy assessment in the private room where questioning cannot be overheard and where there is no fear of intrusion for the other staff members. The physiotherapy assessment should include:

1. Name

2. Age

3. Weight of woman

4. Occupation

5. Residential address

6. Doctor under consultation

7. Chief complaints if any, list the problems in order of importance as perceived by the patient.

HISTORY

Medical History

Hypertension, cardiac disease, respiratory conditions, diabetes, hypothyroidism, irritable bowel syndrome, back pain and cystitis.

Obstetric History

Long, active second stage, forceps, large babies, precipitate delivery, cesarean section, prolonged epidural, episiotomies, tear –2nd, 3rd, 4th degree, close

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pregnancies. Previous complications as premature labor, miscarriage, type of delivery [vaginal, cesarean, assisted (forceps or vacuum extraction)].

INVESTIGATIONS

A. Urinary: Microurine, urine culture, cystoscopy, IVP, urodynamics.

B. Gynecological: Papanicolaou smear.

C. Anorectal: Barium enema, sigmoidoscopy, colonoiscopy, and anorectal physiology, studies: EMG study, colon transit study, videoprocography.

PREVIOUS MANAGEMENT AND EFFECTS

a. Medical—drugs

b. Surgery—effect

c. Physiotherapy—define modalities

d. Other—diet, acupuncture, herbal remedies.

SUBJECTIVE ASSESSMENT

a. Fitness/obesity activities

b. Hormonal status and influence—Effect of menstrual cycle, lactation

c. Pain

d. Current medications—effects

e. Genuine stress incontinence

I. Urine loss on sneeze, cough, laugh, and lift, run, rising from a chair, sexual

activity.

II. Amount of loss—spot, wet pants, wet-clothing. If more than small amount with each event the cause may be detrusor instability triggered by increase in intra-abdominal pressure.

III. Midstream flows stop—note effect of attempted stop.

IV. Urethral hypofunction—intensive loss, greater loss with movement.

V. Aggravated by alpha-adrenergic blockers.

f. Urgency and urge incontinence

1. Sensory urgency: mucosal hypersensitivity, infection, and inflammation

2. Motor urgency: detrusor overactivity, instability.

I. Loss—large volume, frequency

II. Triggers—sexual activity, moving and bending

III. Ability to defer—less than 2 minutes, 2 to 5 minutes, less than 10 minutes

IV. Would you be wet if you did not go to the toilet immediately

V. Do you get wet as you try to undress

VI. Aggravated by caffeine, alcohol, and diuretics.

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41

g. Overflow incontinence i. Decreased detrusor contractility—hesitancy, slow to start, poor stream, strain to void prolonged time to void incomplete emptying, frequent and small voids

ii. Frequent urinary tract infections

iii. Retention/overflow—detrusor contractility, urethral obstruction distended palpable bladder, pain, continual dribble loss day and night, infection iv. Self-catheterization

h. Reflex incontinence

i. Nocturnal enuresis

j. Fluid intake—amount of fluids and type small amount less than 600 ml and large amount more than 3 liters intake

k. Frequency/volume chart—3 days recommended output greater than fluid intak except in hot weather. Note minimum average and maximum volumes, occasions of loss day/night ratio regular output less than 6 to 700 ml indicates decrease bladder sensitivity and overstretch.

l. Anorectal function—frequency, awareness, urgency, puts off urge, strain to empty completeness of emptying content consistency, pain where and when, bleeding.

m. Diet—details of daily food and fiber intake like cereal, bread, fruit, and vegetables, bulking agents, laxatives.

OBJECTIVE ASSESSMENT

a. Defecation: Position, stimulated pattern, waist, lower abdomen, lumbar spine

b. Muscle assessment:

Pelvic Floor Muscles

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

Pelvic Floor Assessment

This physiotherapy assessment is done to all aspects of the pelvic floor

dysfunction.

Digital Assessment

A waterproof underpad, covering sheet, vinyl or latex gloves, a bin is required. The patient is positioned in crook-lying with a neutral lumbar spine, hips abducted and feet apart. Through hand-washing must be done and open wounds should be covered.

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1. The perineum, noting scars and skin condition, excoriated skin indicates sustained wetness or soiling

2. Ask the patient to tighten her muscles and draw in and around the introitus. There should be closing of the opening and a lift towards the head.

3. Ask the patient to cough and observe any descent, bulging or urine loss

4. Gently stretch anal area, note skin tags and hemorrhoids. Observe skin puckering and any perineal lift.

5. Separate the labia gently, slide the palmar surface of the fingers along the posterior vaginal wall to full finger length check whether there is rectocele. Watch patient’s face for signs of discomfort while doing this.

6. While pressing posteriorly, ask the patient to draw in strongly around the vaginal opening and lift up towards your head. Feel the anterior shift. This is the puborectalis

7. Palpate laterally to one side feel the medial shift and elevation. This is pubococcygeus.

8. Check the superficial perineal muscle at the introitus. It is easier to detect their contractions using fingers so feeling a compression effect. The strength of the pelvic floor muscles can be taken as follow. Grade-0—No movement palpable Grade-1—Minimal or very small muscle bulging on palpation Grade-2—Small range of movement, weak with brief hold Grade-3—Definite muscle movements, up to half range Grade-4—Firm muscle movement closing around finger, half to three quarter

range Grade-5—Very firm muscles pull which compresses finger, full range and strong hold. Testing in standing and lying is also done.

Perineometers: Air-filled pressure probes is used to register vaginal pressure as an indication of pelvic floor strength.

Perineal palpation: A hand held against the perineum can detect quite small degrees of perineal lifts. This is useful way for girls and others to detect the correct muscle action for them.

Stop test: The patient is asked to stop or slow the flow of urine in midstream. This action probably reflects the strength of the periurethral and pelvic floor muscles, intensity of the detrusor muscle activity.

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43

Vaginal weights: Weights such as femina cones of increasing mass are developed as a method of providing BFB and resistance for pelvic floor musculature.

Electromyography: This is the most effective method of objectively recording the muscle activity and the data is collected by a fine wire or needle electrodes. External electrodes are placed on the perineum records superficial muscle activity. Surface electrodes are used intravaginally or intraanally in some rehabilitation used as biofeedback mechanism.

Diastasis assessment: This is the separation of the rectus abdominis muscle in the mid-line at the linea alba, the cause is unknown, but the continuity of the abdominal wall disrupted.

Diastasis Recti Test

Position of the patient: Woman in crook-lying. Ask the woman to raise slowly her head and shoulders off the floor, reaching her hands towards the knees, until the spine of the scapula leaves the floor. The therapist places the finger of one hand horizontally across the midline of the abdomen at the umbilicus. If a separation exists, the finger will sink into the gap. The diastasis is measured by the number of fingers that can be placed between the rectus muscle. Diastasis can also present as a longitudinal bulge along the linea alba. Since a diastasis recti can occur above or below or at the level of the umbilicus. This should be tested at all three areas.

PHYSIOTHERAPY MANAGEMENT DURING

Antenatal Period

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

Perinatal Period

It is the period just before and after birth; it is from 20 to 29 weeks to 1 to 4 weeks after birth.

Puerperium

It is the final phase in the child-bearing continuum and is for the period of 6 to 8 weeks following delivery in which women’s genital tract returns to a non- pregnant stage.

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Postnatal Period

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

• Physiotherapy treatment plan

• Aims of physiotherapy

• Plans of physiotherapy

• Home program

• Next appointment.

CHAPTER 10
CHAPTER
10

Relaxation

DEFINITION

The ability to relax is called relaxation. Relaxation is spending quiet times, spent listening to music or reading a book, allow mother to tune into baby and be away from the other distraction of her life. Relaxing women’s body and mind during pregnancy create a sense of well- being. It allows physical recovery and helps to prevent the tension that can lead to high blood pressure. It also helps the parts of women’s body that may ache, e.g. back, legs, abdomen, and rest from the extra weight and effort of holding her body upright because it sharpens women’s mental faculties and releases natural painkillers. It can be particularly helpful in managing her in labor. A relaxed body is closely linked to a related mind. Stress and worry can manifest as headache or backache while physical pain or exhaustion increase worry and stress. Throughout pregnancy a woman should try to find a little time everyday to devote to herself. By doing this, she will feel more energetic towards her work. Try to get plenty of sleep. If women’s work situation is so stressful that she is finding it hard to cope, should take to the employer about starting the maternity leave early or working part-time for a while.

PRACTICING RELAXATION

Relaxation is very simple. The art of relaxation lies in taking time for practicing. Relaxation can be practiced for a period of 15 to 20 minutes in the morning, or after return from work or, after bath, or before going to the bed. Relaxation time

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is never go waste because it helps woman to take up the responsibility of mother, handling of newborn with free of stress and to cope in all areas of daily living.

RELAXATION TECHNIQUES

These are some of the ways, which can be practiced any where any time in sitting, lying positions. They are:

1. Raise your shoulders up towards your ears count five and go back to initial position.

2. Bring shoulders to front and then back to normal and take them each five times.

3. Try to bring both the eyebrows near to each other as you are frowning, press your lips and tighten your eyes, hold them and count five and release them.

4. Relax all the features of face one by one.

WHOLE BODY RELAXATION (FIG. 10.1)

Breathing techniques and general relaxation are very much useful for a woman during her pregnancy, breathing techniques can be used as an instant-free of stress followed by general relaxation. Take time in a day and try to spend minimum of 10 minutes or more on focused relaxation. Find a quiet spot and lie comfortably with a small pillow under head lie down in a calm area, lose your idea and try to imagine each part of your body and relax them part by part.

imagine each part of your body and relax them part by part. Fig. 10.1: Whole body

Fig. 10.1: Whole body relaxation

Procedure

Woman in supine-lying or half-lying, the mind is concentrated on normal breathing. All the major and minor parts are mentally viewed, their shapes are recalled and visualized, and let loose one after another continuously in the following sequence.

Relaxation

47

Upper Limb

Thumb—forefinger—middle finger—ring finger—little finger—back of the palm—the palm—wrist forearm—upper arm—shoulder (both sides).

Lower Limb

Big toe—second toe—third toe—fourth toe—little toe—the upper part of the foot—sole—heel—ankle—calf—knee—thigh—thigh joint (both sides).

Back

From the bottom of the backbone to the neck—the right side of the back—the back of the right shoulder—the left side of the back—the back of the left shoulder—the back of the neck.

Abdomen Chest and Throat

Navel—the left side of the navel (including urinary organs)—the right side of the navel—the upper side of the navel—the central part of the chest—right breast—left breast—the pit below in the throat—throat.

Head

Chin—lower lip—tongue—right nostril—right cheek—right ear—right eye— left eye—left ear—left cheek—left nostril—tip of the nose—the center of the eyebrows—forehead—right side of the head—back of the head—left side of the head—top of the head. Each part should be concentrated for 10 to 20 seconds. The shape should be visualized by the mind with closed eyes. While looking so, the concentration spot should be freely let loose. The entire process may be completed by 15 to 30 minutes. This is called one round.

ADVANTAGES

1. It helps in relieving stress and tension.

2. It helps in getting peaceful sound sleep.

3. Mind and body gets complete rest. They are totally relaxed.

4. Quality of sleep improves, sleep duration is reduced, time is saved.

5. Tiredness of the body is relieved.

6. All the part of the body are relaxed to their maximum and they are re- charged with energy.

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Textbook of Physiotherapy for Obstetric & Gynecological Conditions

8. The woman feels physically stable and mentally peaceful.

9. Memory, will power, inner energies and knowledge are developed.

10. Regular practices play a big role in the higher practices of concentration, meditation and self-realization. In the later stages of pregnancy the women can be comfortable in side-lying. Always end your relaxation session slowly, gently, yawning, stretching, and shaking your limb and woman can adapt this everyday irrespective of place whenever she feels tensed, so first concentrate on breathing slowly and rhythmically, breath in through nose and breath out through mouth, relax the shoulders by raising up, down front, backwards positions, tighten your fingers and loosen them, speak softly if she has to so. This quick relaxation technique is

very helpful during labor and birth and in the early weeks of motherhood when the baby is crying or mother having sleepless nights with baby. This helps in relieving the tension situation and helps the mother to tackle the situation of her baby well.

TRAINING FOR LABOR

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

CHAPTER 11
CHAPTER
11

Breathing Techniques

DEFINITION

Taking air in through nose and leaving out through nose is called breathing.

IMPORTANCE OF BREATHING TECHNIQUES

Breathing techniques are most important during pregnancy and labor. In a non-pregnant woman the air consist of oxygen which passes through the walls of the lungs enters the blood stream and circulates through out the whole body giving nourishment to the internal organs there by purifies the blood in and also takes the metabolic waste products in the form of carbon oxide which is breathe out through nose. In a pregnant woman the oxygen also passes through the walls of the womb into the placenta where it supplies oxygen to the growing baby and the metabolic waste products of the baby are carried in the form of carbon dioxide to the lungs of mother. During this procedure the diaphragm moves up and down. Thereby giving massing effect to the internal organs and muscles. Irregular breathing leads to irregular movement of the diaphragm and overall performance and function reduces. Taking breaths to fast causes residual air will be left over in the body, which impedes the flow of oxygen, the rest of the body and to the baby.

TECHNIQUE-1

Breath in through the nose and breath out through the mouth and during the muscle contraction never hold the breath as this can impede the blood flow and

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Textbook of Physiotherapy for Obstetric & Gynecological Conditions

cause dizziness which is very dangerous especially when women is pregnant. So breathe moderately deep and regular. When relaxing, concentrate on breathing and this comes through the practice of meditation, first stage called breath awareness. It is the step of concentrating the mind through breath awareness. Preparing to feel the touch of breath: the back of one palm is placed very ear to nose, with out touching, breath in normally and breath out forcefully, the touch is felt on the skin of palm. this is done for 2 to 3 minutes.

TECHNIQUE-2

Each of the following steps should be practiced for 2 to 5 minutes.

1. Either sitting comfortably or lying, the breath is inhaled and exhaled in

natural way. The touch of breath should be felt on the skin inside the nostrils while inhaling and exhaling. This should be felt continuously for few minutes.

2. The coolness should be felt in the nostrils while inhaling and the warmth while exhaling. The cool and warmth feeling should be continuously felt inside the nostrils for sometime.

3. While breathing in, it should be felt that the body is being energized by the oxygen that is inhaled and while breathing out, it should be felt that the impurities of the body and mind are sent out in the form of carbon dioxide. The woman should feel that his body is energized, the mind and body are purified with every breath continuously for sometime.

4. The divine bliss should be felt entering inside while inhaling the breath and while exhaling it should be felt that, the pains, sorrow, diseases, agony and tension are being eliminated with every breath continuously for sometime.

5. While breathing in it should be felt that the noble qualities such as love, affection, friendship, kindness, sympathy, etc. are being further developed and while breathing out the negative tendencies such as anger, lust, passion, hatred, jealousy, ego, etc. are being eliminated from the mind. Thus, every breathe one feels that she is becoming better person.

6. While inhaling, the mind should follow the breath, through the nose, throat, windpipe and deep into the lungs. Similarly, while exhaling, the mind should start from the lungs, pass through the windpipe, throat and nose and go out of the body. The mind should follow the breath, continuously for sometime. Practicing the above six processes, it should be tried gradually to acquire

efficiency in them in few days. It may take generally three to four days. Each process is to be practiced two-to-five times at the beginning.

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51

Advantages

The main purpose of the above activities is to make the practitioner in

1. using his time in a better way for a good cause.

2. developing concentration

3. making the meditation techniques easy

4. giving up the ill thoughts.

5. reducing the depression and anxiety in the mind.

6. strengthening the welfare and good thoughts etc.

Second Method

Breathing techniques can also be practiced this way (Figs 11.1Ato C):

Level-1: Sit in a relaxed position. Hold a feather about 15 cm (6 inches) away, slowly breathe out so that the feather should flutter slightly but remain upright.

Level-2: The feather should move more rapidly and should bend slightly but perceived away from the practitioner.

Level-3: The feather should clearly bend away from the practitioner.

: The feather should clearly bend away from the practitioner. A B C Figs 11.1A to
: The feather should clearly bend away from the practitioner. A B C Figs 11.1A to

A

B
B

C

Figs 11.1A to C: Breathing technique—second method

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Textbook of Physiotherapy for Obstetric & Gynecological Conditions

TECHNIQUE-3

Level-1: Sit in a relaxed position so that your partner can place the palms of his hands against your back just below the waist he can either sit in front or back. Woman can lie on her side with him sitting or lying next to her. He should feel the slight movement under his hands when she is doing level-I breathing correctly. Ask him to move his hands up, so that they are in the middle of her back behind her ribs.

Level-2: Breathing should cause movement under his hands here.

Level-3: Breathing her partners hands should be below her nape where he should feel very slight movement (Figs 11.2A to C).

below her nape where he should feel very slight movement (Figs 11.2A to C). A B

A

B

below her nape where he should feel very slight movement (Figs 11.2A to C). A B

C

Figs 11.2A to C: Breathing technique-3

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53

Breathing during Labor

Controlled breathing is taught as a technique for managing the pain of contraction in labor. Breathing regularly helps her to avoid the tendency to tense up with fear and discomfort, which then increases pain. To prepare for childbirth, different ways of breathing are there when labor begins, these techniques will offer a way to work with her body and adapt as the demands upon it changes.

Level-1: Relax and start breathing in and when she breaths out make a little more effort than she would normally do. All the air in her lungs are being emptied out. Breathe in and breathe out again in the same way, keeping the slow, regular, gentle rhythm. Breathe this way between contractions.

Level-2: Use this as she feels a contraction coming. Breathe a little more quickly and do not empty your lungs as you exhale. Continue breathing quickly without emptying your lungs completely through the peak of the pain. As she feels the contraction ending revert to slower breathing so that when the contraction is over, she will be at level-1. Signal the end of contraction with a long breath out.

Level-3: During transition or towards the end of the first stage of labor, her contraction may be intense requiring all her strength and concentration. Quick, shallow breathing will help. Breathe in quickly and blow out then breathe in quickly again. Some women will find it help to vocalize on the breathe out, say hoo hoo as she does so, to maintain rhythm and concentration.

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CHAPTER 12
CHAPTER
12

Massage

DEFINITION

Massage is the systemic and scientific manipulation of the soft tissues of the body It is rubbing and kneading of the body to reduce pain and stiffness and gives relaxation. Massage is a soft tissue technique. Massage has mechanical, chemical, physiological and psychological effects. Which has effect on muscles, ligaments, tendons, fascia and skin. Massage stimulates, refreshes, relaxes and gives comfort. It is pleasurable. Massage has therapeutic benefits. It improves circulation, alleviates digestive and excretory problems and helps with minor aches and stiffness and encourages sleep. Massaging a partner is a wonderfully intimate thing to do. Using a light lotion or vegetable oil including a few drops of essential oil which makes massage more pleasant and relaxing can do this. But during pregnancy weaker solution of essential oil should be used to allow for increased skin sensitivity and to prevent damage to fetus. So, make the skin smooth and soft use essential oil with carried oil and also add vegetable oils.

CLASSIFICATION

Massage is broadly divided into four categories. They are:

1. Stroking: Includes stroking and effleurage

2. Friction: Includes circular, transverse

3. Pétrissage: Includes kneading, picking up, wringing, rolling, shaking and pounding

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4. Percussion or tapotement: Includes clapping, hacking, vibrations, beating and tapping

INDICATIONS

Lower limb edema, constipation, and muscle relaxation.

CONTRAINDICATIONS

Hypertension.

MASSAGE TECHNIQUES

Some of the techniques are:

Stroking

This is performed with the whole hand or fingers. It comprises of the moving of the relaxed hand or fingers over the patients skin with a rhythm and pressure.

Effects

Relaxing and sedative effect.

Effleurage

In this technique, the hands pass over the skin with pressure and speed that is both soothing and will assist fluid to flow through tissue spaces, lymph vessels and veins. The hands move in the direction of the lymph and venous blood flow (distal to the proximal in the limbs and generally each stroke ends at the site of a group of superficial lymph glands. It can be done on both upper and lower limbs.

Effects

1. It helps in removal of edematous fluid from tissue spaces into lymph vessels.

2. Increases tissue fluid, lymph and venous flow.

Kneading

In this technique the hands are placed on the skin and allowed to mould to the part, then they move in a circular direction with pressure gradually applied over the top of the circle and released towards the bottom of the circle. The hands move the muscles and subcutaneous tissues applying alternate compression and release. To localize the effects the fingers and thumbs may be used.

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Effects

1. This helps in increase in flow of blood circulation.

2. Reduce tone of muscle, which are in state of excess tension.

3. It reduces chronic edema, when fibrin within the fluid can be stretched, so facilitate drainage of fluid into lymph vessels.

Hacking

It is the manipulation done using the ulnar border of medial three fingers.

Effects

1. This helps in stimulating muscles and organs.

2. Helps in maintaining tone of the muscle.

3. Helps in increasing blood circulation.

MASSAGE SESSION

Lie on side. Bend lower leg slightly and draw upper leg up to a 90 degree angle, bending at the knee, place a cushion under the bent knee. Place other pillows or cushions around body to aid for comfort, one under head, one under abdomen or shoulder. The massager should kneel or lie beside the woman.

1. Start with the back and use effleurage on either side of the backbone move from the waist to the shoulder and back again covering the sides of the back. Repeat the sequence.

2. Grasp and squeeze the flesh of the back all over, starting from the spine and working towards the side, first on one side then on other side.

3. Kneading manipulation with whole hand, fingers and thumbs too all over the back. The press should be quiet firm, make sure that the manipulation is not uncomfortable.

4. Repeat the same sequence of manipulations on the buttocks.

5. Now continue over the rest of the body including hands, legs and feet.

6. The abdomen can be massaged gently. Using the flat of your hand, apply light circular strokes. First works around the navel then work outward from it, concentrating on keeping the movements flowing and rhythmic.

SELF-MASSAGE

The manipulations done on her own body called self-massage. This is done to relieve tension and energize at any time required. Basically, this is stated with face and ends with legs.

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Face

The manipulations used are stroking, effleurage, finger kneading, etc. Massaging the face is the gentle way to relieve headache. Use a mild oil to avoid stretch to the skin. Place hands over the face and stroke slowly out towards the ears. With the eyes closed, move hands up the cheeks, make small circles over forehead with the tips of the fingers, and smooth the fingers up and across eyebrows.

Neck and Shoulders

The manipulations used are stroking. Relieve stiffness and aching by stroking down one side of neck, over the shoulders and down the arm to the elbow. Repeat the same on the other side.

Legs

The manipulations used are stroking, effleurage, squeezing, etc. Use smooth movements from the ankle to the thigh. Squeeze and release the flesh on the thighs and calves, and then stroking is done to relieve cramps. Effleurage is done to relieve edema where fluid is drained into the nearby lymph nodes.

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CHAPTER 13
CHAPTER
13

Embryonic and Fetal Development

The childbearing year is a term defined as, the time from conception to postpartum adjustment. Pregnancy is divided into three trimesters. Each trimester consists of three months and there are totally four trimesters, i.e. nine months of pregnancy plus the first three months after the birth of the baby.

THE FETUS

Fetus Physiology

This is the function of human body in the first 38 weeks from the embryonic period with active growth and maturation to till past birth into infant and adult. Inside the uterus the fetus is well-protected, living in a gravity-free environment, suspended in amniotic fluid. There is no light, temperature, very little touch, sensation and sound. This is separated from the extra-uterine life by the process of uterine contractions and passage down the vagina called labor.

Fetal Growth

A single-celled ovum is produced and gets fertilized by a sperm. The fetus grows completely by 38 weeks and cells multiply to 6 billion cells, and growth is very fast.

Placental Size and Function

Large placenta are associated with a large mean birth-weight. The fetal/ placental weight ratio increases from 32 weeks, the fetus growing faster than

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the placenta late in the pregnancy the fetal growth rate while that of placenta continues to grow at a slower rate.

Sex

Till last week of pregnancy in both male and female fetuses grow at same rate. After 32 weeks male grows rapidly and by 38 weeks will be 150 grams heavier.

Maternal Nutrition

Extreme malnutrition leads to diminish fetal growth.

Fetal Circulation

It starts by age of 21 days.

Renal Function

Kidneys do not have vital role during intrauterine life. After birth and removal of placenta baby will be able to excrete nitrogen waste products and controlling salt and water balance soon.

Central Nervous System

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

Peripheral Nervous System

Ganglia and nerves appear in human embryo between 28 to 35 days.

Skin Physiology

Skin is major organ of water balance in early pregnancy.

Alimentary Tract

During intrauterine life, nutrition is provided through placenta and alimentary tract has no immediate functions.

Respiratory System

Breathing movements are present in the fetus from 11th week of gestational age.

Placental Transfer

Nutrition come from the mother’s blood across the placenta, fetal katabolites are passed back into the mother’s circulation and disposed by mother’s kidney.

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Water Transfer

Transport between mother and fetus, placenta and amniotic fluid occur by perfusion exchange.

Gas Transfer

Respiratory gases (oxygen and carbon dioxide) cross the placenta by simple diffusion.

Fetal Hypoxia

Diminution of oxygen and increased carbon dioxide concentration due to impaired gas exchange.

Carbon Dioxide Transfer

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

Amino Acid Transfer

Amino acid levels in fetal blood are higher than maternal circulation.

Fat Transfer

Fats are insoluble in water and carried in blood stream as free fatty acids to albumin or lipoprotein. Placenta picks up fatty acids and phospho lipids and converted to simpler forms in the membrane.

THE FIRST TRIMESTER

The first trimester of pregnancy is first three months of pregnancy. The pregnant woman will be experiencing. During the first three months of your pregnancy you will experience:

• The excitement of learning that a new life has begun.

• Physical changes that nurture the unborn baby.

• Hormonal shifts that aid the formation of the baby’s major organs.

• Mood swings—mind and body adjust to new role.

• This is the time to choose the physiotherapist for guiding antenatal care.

THE FIRST MONTH

This is the period from first day of the last menstrual period to six weeks duration.

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Mother

The first month includes the menstrual cycle before implantation and the body will be preparing the womb for the potential pregnancy, then fertilization takes place, the blastocyte divides and travels down to the fallopian tube hormones cause the endometrium to thicken making the uterus ready for implantation, once the implantation occurs hormones suppress ovulation. The woman may not be aware that she is pregnant and will be waiting for the positive signal as the indication is going for a pregnancy test after forty-five days to three months (Fig. 13.1).

Baby

Five to seven days after the egg is fertilized, the blastocyte reaches the womb and becomes embedded in the lining of the womb called embryo. The embryo secretes its own protective substances which helps the mother’s body to accept the baby, because the immune system is getting activated, this is possible. The baby’s genetic make up comes both from the parents sharing 50 percent of genes that will produce the antibodies in the mother’s body. The outer cells of the embryo start to reach out in the following week,

attaching to the mother’s blood cells and forming the first lining with the mother system. This causes formation of chronic villi, which becomes placenta later. The human choronic gonodotrophin that circulates is produced and circulates throughout the mother’s body and appears in blood and urine too. The inner cells of the embryo starts dividing into three layers, the blastocyst increases in size from full stop to 6 mm in diameter.

5–7 Days: The blastocyst settles in the uterine wall

12–15 Days: Chronic villus, shape of umbilical cord and baby starts appearing.

21 Days: Somites or sections of tissue form that will become nerves and muscles of the embryo.

26–27 Days: The organ, limb buds, head with a mouth and eyes appears.

Total Weight Gain

Some woman start to put on weight right from the first month itself and will be nearly one kg or 21 lb or more in the hips, breast and thighs. Because mother’s baby need extra-weight to sustain during pregnancy and breastfeeding. A woman totally will put on 10 to 16 kg or 22 to 35 pounds of weight, most of this in the second trimester. In the last few weeks 250 grams or half pound will be accumulated. Pregnant woman should be strict regarding weight gain, so should have control on their weight which should be increased steadily, need a healthy diet

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Physiotherapy for Obstetric & Gynecological Conditions Fig. 13.1: The first month and a good level of

Fig. 13.1: The first month

and a good level of fitness, thereby prevents varicose veins and backache. Woman will be normal regarding body and womb in the first pregnancy and would not be obvious at the end of the first month.

THE SECOND MONTH

This is the period from 7 to 11 weeks duration.

Mother

Placenta starts functioning completely. The feeling of nausea and constipation starts because of the hormones level increases. There will be increased demand on the circulatory system, which produces 21 ml or 3 pints of blood in the course of the 40 weeks because of this woman become puffy and will regularly urinate. Sickness starts and causes loss of appetite and contribute to feeling of fatigue. Woman’s priority is to eat well and to take plenty of rest. There is every chance of miscarriage in one in six pregnancies so the good news can be told to every one only after the end of third month with confidence (Fig. 13.2).

The Placenta

Placenta is the baby’s life-supporting system, develops in the second month and will be functioning completely by 10 to 12 weeks and function of the

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Embryonic and Fetal Development 63 Fig. 13.2: The second month placenta is to collect oxygen and

Fig. 13.2: The second month

placenta is to collect oxygen and nutrients from mother’s blood stream, processing them and passing them on to the baby. Bring out baby’s waste including carbon dioxide that returns across the placenta for disposal. It also acts as a filter clearing out harmful substances before it reaches baby. But sends the immunities of mother through placenta to protect the baby a mother. The placenta develops from the chronic villi. The chorion becomes the outer surface of the sac and placenta to hold the embryo, the finger-like villi grows out of the chorion, on one side the villi burrows into the uterine wall to receive nourishment from the mother and on the other side becomes flat. It reaches to full thickness in diameter of about 2.5 cm or 1 inch by the 16 weeks and weighs about 500 grams or 1 pound and is about 20 cm or 8 inches by the time of delivery.

Baby

Between the 7th and 11th weeks of pregnancy, the embryo is recognized as human form by the 8th week, head develops and is bigger than rest of the body and bends forward to the chest, the spine is straight. The tail will become shorten and disappear. The embryonic period is complete by the 10th week after conception, after this baby enters into the fetal stage called fetus. So, formation of internal organs

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like brain, nervous system, and skeleton which is very important occurs in this month. The embryo contains three layers of cells. The baby’s nervous system starts to form when the top layer folds into tube and form as neural tube from this baby’s spinal cord and brain will develop. In the second month, the second layer of cells forms major internal organs like lungs, liver, kidneys and digestive system will get established well. The third layer the embryonic cells become the heart, fetus has its own blood vessels some blood vessel get connected to the mother’s blood system in the uterine wall and this becomes umbilical cord later which holds blood vessels and source of placenta to send and take away the required material of the baby. The umbilical cord has elongated and the fetus will be floating freely in the amniotic sac, which protects the baby throughout the pregnancy. The limb buds get extended and will be recognized as arms, legs and the depressions seen in the hands and feet show the fingers and toes. The facial features become more obvious, mouth and tongue are formed, eyes and nostril which are formed at the sides of the head are now at the front and the ears at the neck towards the head. By the eighth week the embryo becomes round shape and ultrasound scan shows heart beating. At the end of ninth week the embryo grows double the size of before and measures about 16 mm.

THE THIRD MONTH

This is the period from 12 to 15 weeks duration.

Mother

Pregnancy sickness decreases by 14th week the levels of hCG drops. Breast will become larger and more tender than before and color of the face and body changes. Uterus moves slightly up because the organs in the pelvic area are being displaced, so woman may notice a small bump in the abdominal area. Tiredness will be common in the first trimester. So, have plenty of carbohydrates to have energy and diet must be a well-balanced diet. Take frequent meals, and never skip a good breakfast. Try to eat number of small meals, nutritious snacks throughout the day if having and small appetite. Avoid tea, coffea, cola and eliminate alcohol (Fig. 13.3). Try to take rest at frequent intervals, and snap in the afternoon will make evening fresh. Be sure work is stress-free, go for a brisk walk, travel safely in bus, avoid standing and sit in a seat if possible, avoid rush places. If having sleeping problem try out relaxation, meditation and find out the cause and rule out. Share your problems with your partner and any fears regarding child birth, in the evening go for a brisk walk, listen to music, read books and watch a

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Embryonic and Fetal Development 65 Fig. 13.3: The third month favorite movie, try out for a

Fig. 13.3: The third month

favorite movie, try out for a fruit tea or warm milk, a warm water bath with a few drops of lavender essential oil added which also gives relaxing effect.

Baby

All the baby’s organ and limbs are completely formed by the end of the 12th week. Growth and maturation of the baby occurs in the preceding weeks. Function of placenta is full, hormones function well. The umbilical cord is barrier between baby and mother to carry nutrients and remove metabolic waste products. Baby has more space to move and float in the amniotic sac which is about 100 ml and also functions as supplying nutrients, maintaining sterile environment at constant environment and protecting from blows and jerks. Baby swallows little amniotic fluid and the development of sucking reflex takes place and moves lips, which is called as first stage of development. The baby also produces drops of sterile urine which is removed by placenta. The fingers get separated and hands are fully-developed with cuticles but finger nail are not yet developed. If the baby’s position allows the gender of the baby can be known with the help of ultrasound scanning because the external sex organs are now developed. Skeleton is made up of soft cartilage and complete in structure. The baby’s face has tiny nose and chin, the eyelids have developed over the eyes. The teeth are present inside the gums. Ears are developed well. At

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the end of 14th week the baby will be 3 inches long or 80 mm as size of small pear. The baby’s hands are 6 mm or ¼ inches long with full development and recognizable.

THE SECOND TRIMESTER

As the new life starts growing it becomes obvious to all, the second three months are best. During this period:

• Mother hair shines and skin glows.

• Tests conform baby’s health.

• Mother will be conscious of baby moving and growing.

THE FOURTH MONTH

This is the period from 16 to 19 weeks duration.

Mother

The discomforts of pregnancy are reduced and mother feel energized. By the end of the fourth month the uterus size increases to twenty fold in size and will rise out of pregnancy. The circulatory changes will bring puffiness in the face because of water retention; woman may feel thirsty and perspire more because blood volume increases because of increased production of body fluid and corpuscles. Size of heart increases and pumps more powerfully to move a greater volume of blood throughout the body. The skin pigmentation occurs because of the hormonal circulation in the body. Moles and freckles start appearing and become more prominent. A dark line called linea nigra appears from navel down the center of abdomen to the top of pubic bone. Nipples get darken and areola may begin to spread across the breast. The color fades after birth of baby. Facial color also changes; light patches appear on forehead, nose, and cheeks appears as mask. Stretch marks on abdomen appear which are pink or red in color (Fig. 13.4).

Baby

The baby starts moving vigorously and energetically with arms, leg, head and torso rolling and kicking. The mother may not perceive the movements of her baby because of amniotic fluid or water. This is absent in the first pregnancy and baby movements are felt in the second pregnancy because of abdominal muscles become lax. Baby’s major organs start working and heartbeating is around 120 to 160 beats per minute.

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Embryonic and Fetal Development 67 Fig. 13.4: The fourth month Eyebrows and eyelashes start to grow.

Fig. 13.4: The fourth month

Eyebrows and eyelashes start to grow. The baby’s hair begins to grow by 16 weeks. Soft inner hair called lanugo also grows all over the body and it functions as protecting the baby and also maintaining skin temperature. The baby will be 17 m or 6 and ½ inches long and weighs about 140 grams or 5 ounces. The baby will be aware of the sound and light which can be perceived in the uterus as a faint, reddish glow, heartbeat can also be heard. Pregnancy can be noticeable and abdomen become round.

THE FIFTH MONTH

It is the period between 20 and 24 weeks.

Mother

The woman looks like pregnant and will feel energetic and healthy, skin will be clear. Hair will be richer in oils, become thicker and glossier and there will be hair loss throughout the pregnancy. The mother gets the feeling of baby movements, which are fluttering initially and later becomes strong and frequent as the days and weeks goes on. This sensation is called quickening. These help in formation of healthy limbs and muscle tissue. Movements are only felt when the inner wall of the abdomen is lose to the outer wall of the uterus. Kick is felt

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when the baby is facing outwards. As pregnancy comes to end, baby cannot change the position frequently because there will be less space available for active kicking and punching. The best time to feel the movement is a couple of hours after a meal. Lie down and put either mother’s or partner’s hand on the abdomen. Count the movements 10 in 10 minutes. This is indication that fetus is in good health. When baby is sleeping she will become quiet. If mother cannot feel the movements have a glass of juice and lie on left side. If still not felt then consult obstetrician (Fig. 13.5).

If still not felt then consult obstetrician (Fig. 13.5). Fig. 13.5: The fifth month Baby Baby

Fig. 13.5: The fifth month

Baby

Baby movements will be more energetic, activated more complex. From this period onwards till the end of pregnancy the baby recycles the amniotic fluid in womb, by swallowing excreting through his or her bladder and urethra. In this way the baby exercises immature swallowing and digestive mechanisms. Around 20 weeks the baby’s skin develops, and a greasy whitish substance called vernix is present all over body till the birth. Babies born after 37 or 38 weeks it gets diminished. Premature babies will have more than normal. The function of vernix acts as waterproofing and helps to maintain the skin texture and temperature. The muscle tissue becomes stronger and skeleton becomes bonier. Babies can hear

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more clearly and baby jump in response to a loud noise. The teeth are present in the jaw and most babies are born with no teeth but occasionally with one. The baby’s hands and feet are well-developed to flex the toes and suck fingers.

THE SIXTH MONTH

This is the period from 25 to 28 weeks.

Mother

The uterus grows rapidly and weight is gained quickly. Mothers will be healthy fit and will maintain a high level of activity. Woman should be careful not to exhaust themselves because the heart and lungs will work 50 percent harder. Woman starts to produce colostrum or early milk for some little of milk leaks out from nipple. The baby’s heartbeat can be heard clearly either with the stethoscope or putting ear on the abdomen a listening to beat. The influence of estrogen and progesterone in the first five to six months of pregnancy, the milk duct system expands and more lobules are formed. As the lobules enlarge, protein starts to accumulate in the cells lining the alveoli. In the later pregnancy and after childbirth, a yellowish watery substance that contains proteins, sugar and antibodies. Milk is not produced until after the birth but the breasts are capable of producing milk after six months, so when woman give birth to premature baby milk can be fed (Fig. 13.6).

Baby

Baby will be growing continuously and has very little fat, so looks thin, but becomes bigger and stronger and if baby is born can survive at this stage but lung are not mature enough to function alone, if baby is born as early as this, neonatal intensive care is required. At 25 weeks the baby will be about 34 cm or 13 and ½ inches long and weighs about 600 grams or 21 oz. There will be creases on the soles of the baby’s feet and on the palm of his hands. A unique set of fingerprints start to appear on the fingertips. The eyes open by 25th week and baby starts responding to light. The baby’s skin is translucent because does not contain body fat.

THE THIRD TRIMESTER

• This trimester becomes increasingly excited to feel the baby moving, kicking

• For some women this trimester passes slowly

• This trimester causes discomfort and contributes to fatigue

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Physiotherapy for Obstetric & Gynecological Conditions Fig. 13.6: The sixth month • The third trimester is

Fig. 13.6: The sixth month

• The third trimester is a time of rapid growth and maturity for the baby. The baby will be strong and healthy.

• If the baby is born in the beginning of this trimester then he or she need a lot of specialist care to survive.

THE SEVENTH MONTH

This is the period from 29 to 32 weeks duration.

Mother

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

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survive, at 25 weeks 50 percent survive, 26 weeks 75 percent survive, 28 weeks 85 percent survive, 35 percent are fine (Fig. 13.7).

weeks 85 percent survive, 35 percent are fine (Fig. 13.7). Fig. 13.7: The seventh month Baby

Fig. 13.7: The seventh month

Baby

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

THE EIGHTH MONTH

This is the period from 33 to 36 weeks duration.

Mother

The uterus bulges above the ribcage and the navel may have popped out. Mother has to go regularly for the antenatal visit. The ultrasound is one to check the

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

centimeters or 17 inches and weighs 2.1 to 2.6 kilograms or 4 ½ to 5 ½

Fig. 13.8: The eighth month

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THE NINTH MONTH

This is period from 37 weeks to term duration.

Mother

By 36th or 37th week the baby’s head may start engaging into the vagina that eases pressure on the diaphragm and in subsequent pregnancy will engage. In 10 percent of pregnancy baby head would not engage till the labor starts and in some pelvis is too small for the baby’s head, so cannot engage properly and will be spotted before labor begins and cephalopelvic disproportion is diagnosed, either woman is asked to start the progress of labor for vaginal delivery or cesarean section is done (Fig. 13.9).

vaginal delivery or cesarean section is done (Fig. 13.9). Fig. 13.9: The ninth month The pressure

Fig. 13.9: The ninth month

The pressure on the ribs reduces and woman finds breathing easier but will have pressure on urinary tract so need to urinate frequently. The adoption of position in the uterus is called presentation or lie.

Right occiput position: The baby is head down with face towards the front and crown to the right.

Left occiput anterior: The baby is head down with his face towards back an crown to the left.

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Breech position: The baby is sitting in the pelvic cavity so that baby’s bottom will be first out

Footling breech: The baby is sitting in the pelvic cavity with one or both feet extending towards the cervix.

Baby

The baby’s head sinks down into the pelvis in the preparation for birthing the last few weeks the baby gains 200 grams a week and grows about 10 centimeters or 4 inches in length the baby’s eyesight develops rapidly and can differentiate between light and dark. From 36 weeks onwards the baby co-ordinate sucking and swallowing efficiently and has a powerful sucking instinct. Arm and leg movements are less and overall movements are restricted because less space. Baby’s lungs start getting matured and practices light breathing movements. Amniotic fluid passes into the airways from time to time and gets an occasional bout of hiccups which is a series of light rhythmic movements. By the time of term the average baby is 1.53 centimeters or 21 inches long and weighs 3.2 kilograms. The amount of vernix and lanugo covering the baby’s skin diminishes and will have little. Baby is born at or after the term.

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CHAPTER 14
CHAPTER
14

Relieving Pregnancy Discomfort

ANEMIA

Cause

During pregnancy, the volume of blood in the body increases. This can lead to drop in the blood hemoglobin level, that is the proportion of the blood that is the red, oxygen carrying cells. If this level is too low, the woman is said to be anemic. This is common in pregnancy. The heart has to work more to keep her baby supplied with oxygen. She will be tried easily and will less-likely to cope up with the labor.

Treatment

Woman has to take plenty of iron in diet, sources of iron are meat, liver and sea food, egg-yolk, dried fruits, wheat grams a pulses. Eat plenty of vitamin C in order to increase the absorption of iron. Iron tablets are not suggestible because they have side effect.

BLEEDING GUMS

Cause

The hormonal changes will lead to the problem of mild bleeding gums disease and the gums may be little tender and swollen.

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Treatment

Woman has to clean the teeth thoroughly and regularly. Use new toothbrush, use floss, avoid eating sugar especially snacks between meals. Woman can have fresh fruit, bread or toast whenever she feels hungry.

BREATHLESSNESS

Cause

Woman feel breathlessness as pregnancy advances even with slight exertion. This is due to pressure of the growing baby on to the lower lungs and also the movement of blood away from the lungs to the growing womb.

Treatment

Woman should take every care not to exert her in any activity or it may affect fetus.

CONSTIPATION

Cause

Woman has common complaint of constipation in her early pregnancy because of the hormonal changes. In the later pregnancy the woman faces the same problem because of ligament becomes relax and soften.

Treatment

If the woman is vegetarian, she should eat plenty of fiber in food such as brown rice, whole meal bread and pulses and more amount of liquid drink everyday.

CRAMP

Cause

Ischemia, pressure of uterus on nerves, phosphates in milk. This can occur on and of during pregnancy and usually in the lower legs and often in the night. The cause is not known but suspected because of low salt diets and also imbalance between calcium and magnesium.

Treatment

Calf stretch should be one, support stocking should be worn, take calcium source on doctor’s advice, massage, eat more yoghurt, cheese, and leafy vegetables and drink more milk. Exercise before going to bed, try out flexing and

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extension of feet, circling the ankle and pointing the toes up and down. This will stimulate circulation and the frequency can be reduced. Avoid excessive plantar flexion, when woman feels cramps in the beginning, stretch into dorsiflexion and massage.

INDIGESTION AND HEART BURN

Cause

Tea, coffee and spicy foods are common cause. In the early stage progesterone in early pregnancy causes lower emptying, causes increase in reflux, cardiac sphincter more relaxed. Heart burn is more common in later pregnancy because the baby will be growing so big, the uterus starts to press on the stomach. The muscle between the esophagus and stomach relaxes the enlarged uterus, pushes acid from the stomach upwards and causes a burning sensation in the chest.

Treatment

Take light frequent meals and take it by sitting straight, so it helps giving room for everything going inside, sleep in semirecumbent position, restrict intake prior to sleeping, take milk, avoid fatty foods, coffee and smoking which causes antacid preparation.

NAUSEA OR MORNING SICKNESS

Cause

Increase in estrogen and progesterone causes this. Nausea can be felt at any time of the day or in some from morning to evening woman feels physically sick, funny taste and a faint feeling. Foods like tea and coffee will make her feel bad. This prevents woman to eat properly despite her good intention to have an excellent diet. It disappears by 14 to 16 weeks. Nausea can also be cause of certain smells, so try to avoid them. Metabolic changes also slower emptying of stomach, cardiac sphincter relaxation.

Treatment

If she feels worst in the morning, try to eat something plane in the morning before she gets up from bed like plain biscuit, rice cake, dry toast, herbal tea which will cleanse and refresh her. Try not to skip meals at work place eat sandwich, rice cakes spread with a nut butter, a bag of dried fruit, nuts, a piece of fresh fruit. Ginger tea aid digestion and seems to cleanse the palate.

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Textbook of Physiotherapy for Obstetric & Gynecological Conditions

EDEMA

Cause

Progesterone increase and gravity causes venous engorgement. Slight swelling of the ankles, feet and fingers is common in pregnancy because of extra-fluid retained by the body.

Treatment

Try to rest and relax more. Try lying on the back with her feet resting against a wall. In later pregnancy this position will be uncomfortable, so should not be for more than five minutes. Stop immediately if she feels any discomfort, avoid prolonged standing.

PASSING WATER

Cause

Woman regularly passes urine, so woman may feel exhaust and will give up drink water.

Treatment

Women are advised to take extra-liquid so to avoid constipation and also blood volume increases. So, before going out carry a bottle of water.

PILES

Causes

Piles are caused during pregnancy by training if a motion is not free and after the baby is born the chances are there because of pushing into the second stage of labor.

Treatment

Woman is advised to maintain liquid diet to prevent constipation.

PRE-ECLAMPSIA OR TOXEMIA

Cause

This is less common condition, which occurs towards the end of the pregnancy. The cause is not known. Kidneys cannot cope with the extra-waste products from the baby. The symptoms are high blood pressure, edema and protein in the urine and kidneys could be prematurely damaged.

Relieving Pregnancy Discomfort

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Treatment

Woman is advised to take rest. So that their blood pressure and urine can be loosely monitored until the baby is born. After the delivery the signs quickly disappear.

VAGINAL DISCHARGE

Cause

Almost all the women have vaginal discharge during pregnancy. This is nothing to worry. If she complains of sore or itching it can be an infection. Discharge may also contain blood.

Treatment

Eat natural yoghurt, which helps fight the yeast responsible for the infection.

VARICOSE VEINS

Cause

This is caused when the blood flowing back from leg to heart is obstructed for a prolonged time. The blood then has to find a different route and uses the smaller veins closer to the surface of the skin. These then swell and show on the legs.

Treatment

Try to avoid standing for long period. Avoid constipation. Regular exercise can help to prevent the problem. Sit down with feet up for a short-time in a day.

VULVAL VARICOSITIES

Cause

Increase in progesterone and estrogen, increase in blood volume and pressure of uterus on pelvic veins.

Treatment

Sanitary pad for support should be used avoid prolonged standing, squatting, constipation and straining with defecation.

GESTATIONAL DIABETES

Cause

Diabetes related solely to pregnancy occurs when the body does not produce

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