Cesarean Section - PDF

Cesarean section Dr. Nancy Aboelnour Assist.Prof of physical therapy, Faculty of Physical Therapy, Aqaba University for Technology. Definition: It is a delivery of the fetus through an abdominal and uterine incision. INDICATIONS 1-EXTREME DEGREE OF CONTRACTED PELVIS 7- D...

Cesarean section Dr. Nancy Aboelnour Assist.Prof of physical therapy, Faculty of Physical Therapy, Aqaba University for Technology. Definition: It is a delivery of the fetus through an abdominal and uterine incision. INDICATIONS 1-EXTREME DEGREE OF CONTRACTED PELVIS 7- DIABETES 2-CEPHALO PELVIC DIS PROPORTION 8-CARDIAC DISEASES 3-UTERINE INERTIA 9- FETAL DISTRESS 4-MAL POSITION 10- PREVIOUS BAD OBSTETRIC HISTORY 5-MAL PRESENTATION 11- CERVICAL DYSTOCIA 6-PREECLAMPSIA 12- CERVICAL CARCINOMA 13-PLACENTA PREVIA 14- PLACENTAL ABRUPTION 15-UMBILICAL CORD PROLAPSE 16- VAGINAL SCARRING Contracted pelvis Cephalo-pelvic disproportion. -Uterine inertia. It means inefficient uterine contractions either primary or secondary to abnormal fetal position -Cervical dystocia It means failure of cervix to dilate in spite of strong uterine contractions (due to uncoordinated uterine contractions Umbilical cord prolapse Placenta previa: It means implantation of placenta in lower uterine segments Placental abruption.  Placental abruption premature separation of placenta a- Moderate abruption: separation of more than one fourth but less than two third of placenta surface. b- Severe abruption: separation of more than two thirds of placental surface  Fetal distress syndrome -If fetal heart rate is above 160 or below 140 beats/min or irregular or delayed to return to normal at end of uterine contraction, CS is indicated. - Normal FHR is between 120-140 beats/min. Vaginal scarring: Due to repair of vesico-vaginal fistula (an abnormal communication between the bladder and vagina, resulting in continuous urine leakage through the vagina), repair of uterovaginal prolapse)  Timing of C.S.  Elective C.S.: Cesarean section is done before the onset of labour (about one week before the expected date of delivery).  Selective (Emergency) C.S.: Cesarean section is done at or immediately after the onset of labour. Types of C.S. operations Types of C.S: Complications of Cesarean Section Respiratory complications ( due to inhibitory effect of pain + anesthesia + immobilization). Circulatory complications (physiological changes + immobilization = DVT ). Intestinal complications. Hemorrhage  Role of Physical Therapy in Caesarean Section I- Pre-operative : 1-Prepare the woman emotionally. - By reassurance to eliminate negative feeling about the operation. 2-Improve pulmonary function and prevent post operative pulmonary complications. - By deep breathing exercises - Teaching her right way of cough to get rid of expectoration postoperatively. - Early ambulation. 3-Improve circulation and prevent post operative circulatory complications - By circulatory exercises. - Early ambulation. 4- Prepare the woman physically for rapid mobilization. - By teaching her the right way of getting up early from the bed with minimal strain and pain. II- Post-operative physical therapy management (Elective and selective cases) Aims: Improve respiratory function & prevent respiratory complications. Improve circulation & prevent circulatory complications. Prevent pelvic floor dysfunction. Correct posture and prevent postural problems. Strengthen abdominal muscles. Improve lactation and prevent breast sagging. Decrease incisional pain. Promote wound healing. Physical therapy program Post-partum care : C.S and NL A:Circulatory exercises: -5: 10 minutes of: - active ankle and foot range of motion exercises -Active knee flexion and extension exercises via heel slides and short arc quadriceps -Quadriceps and gluteal isometrics -Every 1/2 hour are easily accomplished while in bed B: Right way of lactation & comfortable and effective breast feeding: flexion, abduction, and external rotation upper extremity.  -Postural exercises to ↓back ache by placing the back against the wall with heels, calves, buttock, thoracic, head, and arms touching the wall.  While arms and elbows are in contact with the wall, slide them up overhead and hold this position for minimum of 30 seconds  C- Post-operative pain Ice Application: Ice packs are applied to the painful area for 10- 15 minutes every 8 hours for 72 hours. TENS Application : The treatment with TENS is started immediately after recovery from anesthesia and continue until the women feel she no longer need to it. Parameters of TENS : Frequency: 120 Hz. During Pain. 2 Hz Between episodes of pain. Pulse width: 200 micro-second. Intensity: according to the woman’s tolerance. Electrode placement: Paraincisional Mechanism of action: Gate control theory. Opiate theory. Gate Mechanism According to the gate control theory of pain, three main types of nerve fibers are involved in the process of pain perception: A fibers, C fibers, and the “gate” interneurons. The diameters of these fibers vary in size. A-beta fibers have a large diameter and are myelinated, resulting in quick transmission of impulses. C fibers are smaller in diameter and are not myelinated, resulting in the slower transmission of impulses. A-delta fibers, another form of A fiber, are also small in diameter and have a function similar to that of C fibers. The gate through which the pain pathways send signals to the nervous system is located in the dorsal horns of the spinal cord. The dorsal horns are composed of several layers, called laminae. Two of these layers make up the substantia gelatinosa, the hypothesized location of the gate mechanism. Both the small-diameter A-delta and C fibers and the large-diameter A-beta fibers travel through the substantia gelatinosa. The interneurons, located in the substantia gelatinosa, are the hypothetical gating mechanisms. Activity of the large-diameter A-beta fibers produces an initial burst of activity in the spinal cord, followed by an inhibitory response. If the interneurons of the substantia gelatinosa are stimulated by activity in the large A-beta fibers, the interneurons produce an inhibitory response and do not allow pain sensations to be relayed up to the brain. Therefore, when the interneurons are stimulated by large fiber activity, the gate closes and no pain is experienced. Activity of the small-diameter A-delta and C fibers produces prolonged activity in the spinal cord. This type of activity promotes sensitivity and subsequently increases sensitivity to pain. If the interneurons are inhibited by the action of the small-diameter C fibers or A-delta fibers, or if they are not stimulated at all, the interneurons allow pain sensations to be sent up the brain. Thus, if the interneurons receive activity from small-diameter fibers, the gate remains open and results in the experience of pain. Opiate theory: Stimulation of the release of endogenous opioids (endorphin and enkephalin) resulting in prolonged activation of descending analgesic pathways Opioid receptors block neurotransmitter release (Substance P - the main neurotransmitter for C-fibres, and Glutamate - the main neurotransmitter for A-delta fibres) from the nerve fibre terminals in the dorsal horn of the spine. Inhibiting peripheral nociceptive nerve fibres, reducing nociceptive transmission from the periphery.  D- Post operative wound healing 1- Laser: A sterile tape measurement was adhered to the abdominal wall by adhesive plaster, just above incision of the operation by 2 cm Divide length of incision into equal units of 1 cm. Parameters Laser is applied for 90 second/Cm2 at a distance of 1-2 cm above the operation site. Wavelength: 904 nm First session of treatment performed after 24 h of the operation then every other day. Mechanism of action: Enhance protein synthesis through DNA & RNA synthesis. Accelerate the inflammatory phase of healing process. Improve immune function. Has bactericidal effect. 2- Ultrasonic: Parameters: intensity (1 -2 W Cm2) Duration: 10-15 minutes daily over the incisional site until complete healing. Mechanism of action: Micro-massage effect. VD so, increasing number of WBCs that invade microorganisms. 3- Ultraviolet Radiation (UV): used to promote the healing of non infected and infected wound. Mechanism of action: Destruction and removal of the slough in the infected wound. Has bactericidal effect. Enhances granulation tissue formation. E- Reduce gas pain and promote bowel movement 1-Intestinal massage should begin at the day of delivery stimulates the bowel activity. 2- Massage to the abdominal soft tissues surrounding the C section incision. *Patient position : side lying position *Therapist: A-begin small circles in a clockwise direction, starting four finger widths inferior to the right ASIS, moving superior to the ribs B- then clock wise along the transverse colon to the left lateral border of the ribs, and proceeding inferior to the inside of the left ASIS *Facilitate peristalsis and gas elimination. 3- Active anterior and posterior pelvic tilting for 5:10 minutes every hour to activate the abdominal muscles. 4-Heat over the anterolateral lumbar region help comfort. 5- TENS over the abdomen may facilitate peristalsis. 6- Static abdominal exercises. 7- Early ambulation -Protocols ranging from 30-80 kegel pelvic muscle exercises holding for 8 to 10 seconds on daily basis, followed by an equal number of quick contractions holding for 2 to 4 seconds to 300 contractions. -Bio-feedback and electrical stimulation to reinforce pelvic floor muscles. -Functional application of pelvic floor muscle contraction before sneezing, coughing and laughing are helpful in reducing episodes of UI. -If the sensation is impaired and the mother does not know how to lift up and in, the therapist should use SEMG with eternal perineal electrodes or a mirror with verbal instruction to help locate the muscle for the patient and demonstrate the correct movement. H: Promote normal voiding intervals Bladder voiding interval retraining of 3:4 hours during the day should resume as soon as possible with limited to no nighttime voiding except in breast feeding mothers, with increased fluid intake, may need to void at night. If stress or urge incontinence persists physical therapy intervention is needed. I: Minimize diastasis recti It is a gap between the recti abdominis muscles in the mid line in the linea alba ˃ 25mm or 2.5 fingers. -It may occurs during pregnancy or in expulsive stage of labor. Management: 1. Static abdominal ex. 2. Graduated dynamic abdominal ex. a) Kinesiotaping during abdominal ex. b) using a sheet or towel. 3. Electrical stimulation: (frq. 80 pulse ∕ sec, pulse duration 0.1-0.5 ms for 1 ∕2 hr daily.) 4. Therapist should teach a mild concentric shortening contraction of the transversus and rectus abdominus muscles in supine or sitting. 5. Abdominal crunches and sit ups are not recommended.