Women's Health and Fertility PDF

Women’s health and fertility Polgári Timea Physiotherapist MSc – Manual therapist 1 Fertility High body weight can affect female fertility Obesity has become an increasingly serious problem in the world in recent decades. In Hungary, unfortunately, 30% of the population is considered obese and 30% overweight. According to a 2015 report, 37% of women of reproductive age can be considered overweight and 39% obese. This number is extremely high. In addition, 62% of the Hungarian population rarely or never does physical activity. Unfortunately, the level of inactivity increases with age 2025. 01. 09. 2 Prevention This situation can cause many health problems and can negatively affect our ability to conceive The fat tissue of our body not only serves as an energy store, but also functions as an endocrine organ Women with a high BMI have a higher level of the hormone estrogen in their bodies, which is also produced by adipose tissue. Of course, estrogen is one of the most important female sex hormones, but the existence of a progesterone-estrogen balance is the most important 2025. 01. 09. 3 Prevention If the balance is disturbed and the so-called estrogen dominance develops, then the chance of pregnancy decreases Progesterone plays a very important role at the beginning of the pregnancy If the progesterone level is low, unforunatelly it can lead to misscarriage The imbalance of the hormonal levels (estrogen higher), can trigger low libido, endometriosis, PCOS, cycle problems and infertility 2025. 01. 09. 4 Prevention However, we must not forget that a too low BMI also has a similarly bad effect on the sensitive hormonal balance 2025. 01. 09. 5 Prevention A healthy fat percentage is one of the pillars of normal female hormonal functioning A normal BMI should be between 18.5 and 24.9 (In practice, this means that the energy we take in with food and drinks and the energy we burn with our basic metabolism and our everyday activities, including sports, are in perfect balance.) If this does not happen, it is much more difficult to restore normal body weight later than to maintain it 2025. 01. 09. 6 Prevention Women with a high BMI often have higher circulating insulin levels. Which, by disturbing the hormonal system, can lead to menstrual disorders and also ovulation dysfunctions High insulin levels, like hyperinsulinaemia, play a major role in the development of polycystic ovary syndrome (PCOS). Several studies have shown that ladies with a higher BMI are expected to take longer to conceive than normal-weight women. 2025. 01. 09. 7 Prevention In a Dutch research, the data of more than 3,000 women with normal cycles were presented Essentially, they found that the likelyhood of spontaneous conception decreased with each BMI point above 29 kg/m2. (Van der Steeg, 2008) Also, obesity seems to influence the results of assisted reproductive interventions 2025. 01. 09. 8 Prevention This also proved that higher body weight does not only play a role in the development of ovulatory dysfunctions Women with a high BMI undergoing in vitro fertilization (IVF) may have smaller oocytes, making the procedure less likely to be successful (Mutsaerts et al, 2016) 2025. 01. 09. 9 Prevention Regular physical activity is one of the cornerstones of achieving an ideal body weight In addition, the anti-inflammatory effect of the hormones produced by the muscles during work helps the normal functioning of our body. It can help protect us against many diseases and help preserve our fertility 2025. 01. 09. 10 Prevention After reviewing several studies in 2020, Harrison et al. described that intense physical activity definitely plays a role in preserving fertility. The researches they used, were prepared with the participation of 26,955 women. It has been shown that every hour/week of intense exercise can reduce the risk of infertility by 7%. Unfortunately, no research has been done on moderate physical activity, but it is assumed that it can also have a positive effect. 2025. 01. 09. 11 Current guideline (ages 5 – 17 - WHO) 60 minutes of moderate to intense physical activity each day is recommended Supplemented with strengthening focused on different muscle groups 3 times a week It is recommended to reduce the time spent sitting, Especially the interval that young people spend in front of a screen 2025. 01. 09. 12 Current guideline (ages 18 – 64 - WHO) For adults, 150 minutes/week of moderate-intensity physical activity Or 75 minutes/week of high-intensity physical activity is recommended Let's start with what we like/enjoy doing 2025. 01. 09. 13 In practice What does „moderate intensity” mean? How would you explain it for a patient? 2025. 01. 09. 14 In practice It can be simply explained as a movement during which we can still talk, but not sing :) E.g.: fast walking, cycling on a flat road or on a gentle incline, dancing, water aerobics, tennis 2025. 01. 09. 15 In practice What do we mean by "high intensity" or intense exercise? 2025. 01. 09. 16 In practice When our breathing and heartbeat quicken. We can still communicate with a few words, but we can't talk anymore. E.g.: Running, cycling fast or on a steeper incline, swimming, squash... 2025. 01. 09. 17 In practice It is important to be patient to ourselves. If until now we have been inactive, then let's not start immediately with high-intensity forms of exercise. This is important to tell this, because many people tend to skip the medium intensity right away. After all, half the time, with the same effects. 2025. 01. 09. 18 Current gideline Muscle strengthening 2 times a week is recommended Let's focus on the large muscle groups → legs, muscles around the hips, abdomen, back, shoulder muscles, arms, neck muscles A series should consist of - as many repetitions as - it is tiring to do. This series is repeated at first 1 time, later 2-3 times. Later, both of these numbers can be increased 2025. 01. 09. 19 Infertility 2025. 01. 09. 20 Causes Ovulatory dysfunction (21%) Fallopian tube damage and blockage (endometriosis, infection, previous ectopic pregnancy, adhesions after pelvic or abdominal tumors) (14%) Endometriosis (6%) Sexual problems (6%) Cervical factor (3%) Problems with the partner (hypogonadism, post-testicular defects, seminiferous tubule dysfunction) (26%) Unexplainable (28%) 2025. 01. 09. 21 What can we do? We can influence some of the ovulatory dysfunctions by restoring and maintaining a healthy body weight. We talked a lot about this 2025. 01. 09. 22 Endometriosis In the case of endometriosis, endometrium parts can be found outside of the uterus, most often embedded in the ovaries, peritoneum or uterine wall They are called implants 2025. 01. 09. 23 Endometriosis Their appearance has already been described in quite extreme places, including in joints and muscles. Involvement in the muscles around the spine and in the hip flexor (M. iliopsoas) muscles has already been described As we know, these hormone-sensitive endometrial parts also thicken monthly 2025. 01. 09. 24 Endometriosis And also bleed monthly, this blood can not leave the body and will form chocolate cysts. They irritate the surrounding tissues They can cause inflammation around them, and lead to adhesions 2025. 01. 09. 25 2025. 01. 09. 26 2025. 01. 09. 27 Endometriosis These adhesions can be one of the root cause of the patient's complaints This also plays role in fertility problems Endo can not be seen and it is very hard to be dignosed. 2025. 01. 09. 28 Endometriosis Triggers can be: The most common theory is that menstrual blood containing endometrial cells flows back through the fallopian tube into the pelvic cavity. Or the bloodstream carries endometrial cells to other parts of the body Genetical factors also plays a role in its development Also, insufficient functioning of the immune system 2025. 01. 09. 29 Endometriosis Also connected to its development: Abdominal trauma Chronic stress Irregular and bad eating habits Lots of sitting 2025. 01. 09. 30 Endometriosis Symptoms Painful menstruation – extreme pain Pain at other times (defecation, urination, ovulation) An increased amount of menstrual bleeding may occur Infertility We need to pay attention: Pain during bowel movements Diarrhea-constipation Bloody stools and urine 2025. 01. 09. 31 Endometriosis So as you can see the symptomes are not too specific. That is why it is so hard to get to the diagnosis And we don’t really hear about this sickness Despite the fact that every 10th person has diabetes and every 10th woman of reproductive age has endometriosis What do you think? 2025. 01. 09. 32 Video 2025. 01. 09. 33 Endometriosis Sedentary lifestyle can also play a role in development of endometriosis Regulary exercising can play a major role in its prevention On the other hand, it seems that, with the actual disease, regular exercise can help against inflammatory processes, as it increases the systemic level of cytokines with anti-inflammatory properties. 2025. 01. 09. 34 Endometriosis In a review, after studying 935 scientific articles in 2014, they found: The first study on exercise and endometriosis was published in 1986. In which 286 women took part, it was shown that women who exercised regularly before starting the study had a significantly lower risk of endometriosis compared to those who did not exercise. Based on this, exercise had a protective effect only on those women who started exercising before the age of 26, at least two hours a week. (Bonocher et al.) 2025. 01. 09. 35 Endometriosis In a later case-control study in 1997, scientists studied the issue in a more nuanced way. Their research concluded that women who exercised 4 hours or more per week had a 65% lower risk of endometriosis compared to women who exercised less than 4 hours per week. (Signorello et al) In 2010, others also showed the preventive role of intensive exercise in the development of endometriosis. They also pointed out that the protective effect of low-intensity physical activity is smaller than that of high-intensity. (Vitonis et al) 2025. 01. 09. 36 Endometriosis In this research, however, no evidence was found that exercise or any physical therapy could help in the treatment of already developed endometriosis. International clinical guidelines recommend that exercise should play a role in the therapeutic approach of women with endometriosis-related symptoms 2025. 01. 09. 37 Endometriosis Secondary Musculoskeletal Problems Caused by Endometriosis Lumbar, sacroiliacal, and pelvic floor pain Muscle shortening Trigger points (common in the pelvic floor and lumbar spine) Connective tissue dysfunction Urinary urgency Scar tissue adhesion 2025. 01. 09. 38 For example: Quadratus Lumborum 2025. 01. 09. 39 Enometriosis Physiotherapy Leser Therapy Electrotherapy Magnetotherapy 2025. 01. 09. 40 Endometriosis Low-Level Leser Therapy (LLLT): Endometriosis treatments with laser therapy have a profound effect on tissue regeneration and restoration. 2025. 01. 09. 41 Endometriosis At the tissue level, there is: An increase in blood and lymph circulation A decrease in intra-capillary pressure An increase in nerve ending excitability Stimulation of the immune system 2025. 01. 09. 42 (Read at home of you are really interested) At the cellular level, laser irradiation causes: Increased adenosine triphosphate (ATP) production Increased activity of membrane enzymes Increased synthesis of deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) Accelerated electrolyte exchange between the cell and its environment. 2025. 01. 09. 43 Endometriosis Magnetotherapy The application of an electromagnetic field causes internal tissue heating. The treatment is used on the lower abdomen. The treatment method, duration, and number of treatments in a series are all individually tailored to the patient's condition and severity of symptoms. It is used to treat chronic conditions in which deep overheating and hyperaemia are indicated, and these should not be used in women who can be pregnant. It is preferable to use a pulse wave in this group of patients because a similar effect, and with almost complete elimination of the heat factor. 2025. 01. 09. 44 Endometriosis Electrotherapy Electrotherapy, which has an analgesic and hyperemic effect, is used in the physiotherapeutic management of endometriosis patients. Currents of medium and low frequency are used. Interference currents and Transcutaneous Electrical Nerve Stimulation (TENS) both can be used to relieve pain in the pelvic area. 2025. 01. 09. 45 Endometriosis Other parts of the therapy Pelvic floor strengthening Trigger point management Manual therapy Stretching and flexibility exercises Spinal mobilizations Nerve glides Relaxation exercises 2025. 01. 09. 46 Endometriosis Physiotherapy is an important part of the treatment for endometriotic patients, and it involves selecting an exercise programme which is individually planed. Excersicing is also essencial for patients after sergeries. 2025. 01. 09. 47 PolyCystic Ovary Syndrome The prevalence of PCOS is 8-13% of women of reproductive age but this varies (up to 20%) depending on the diagnostic criteria used. It is currently recognized as the leading cause of anovulatory infertility and the most prevalent endocrine disorder amongst women of reproductive age. This is the most common hormonal change in this period of life, which can also lead to infertility 2025. 01. 09. 48 PCOS There are more types of PCOS One, when the eleveted inzulin level dominates the sickness. These ladies are more likely to be overweighted and obese The other when the higher testosterone level dominates These ladies are more musculine But these two hormonal circles are connected to each other, and the most problemeatic needs to be treated first. And an endless combination is possible too (Its not exacly our field, the physiotheapy is more or less the same) 2025. 01. 09. 49 PCOS It is characterized by two or more of the following: Irregular menstrual periods Hyperandrogenism(!) Polycystic ovaries 2025. 01. 09. 50 PCOS Multiple illneses are associated with PCOS, including infertility, metabolic syndrome, obesity, insulin resistance, type 2 diabetes mellitus, cardiovascular risk, depression, obstructive sleep apnea, endometrial cancer, and nonalcoholic fatty liver disease 2025. 01. 09. 51 PCOS 50% of these women have amenorrhea 30% of these women have abnormal menstrual bleeding 60% of these women are obese 40% of women with PCOS have insulin resistance and type 2 diabetes mellitus 2025. 01. 09. 52 PCOS Signs and Symptoms Enlarged polycystic ovaries Obesity Male pattern of hair growth primarily on the face, back, chest, lower abdomen, and inner thighs (!) Development of male features including balding of the frontal portion of the scalp, voice deepening, atrophy of breast tissue, increased muscle mass(!) 2025. 01. 09. 53 Video 2025. 01. 09. 54 PCOS Anovulation - failure of the ovaries to release an oocyte Amenorrhea - the absence of a menstrual period in women of childbearing age Oligomenorrhea - the presence of menstrual cycles greater than 35 days apart Dysfunctional uterine bleeding Acnes 2025. 01. 09. 55 PCOS Infertility; first trimester miscarriages PCOS can make it harder to get pregnant and increase the risk for pregnancy complications and miscarriage. Weight loss and other treatments can improve the chances of having a healthy pregnancy. 2025. 01. 09. 56 PCOS A physiotherapist and diet changes are highly recommended as first-line treatments. Exercise training has shown great improvement in 50% of the women diagnosed with PCOS, by targeting menstrual irregularities and promoting ovulation. Weight reduction is an important component of the physical therapy program since weight reduction improves glucose intolerance which in turn could resolve the reproductive and metabolic problems often associated with PCOS. 2025. 01. 09. 57 PCOS Physical therapy interventions seek to decrease the main symptoms of polycystic ovarian syndrome (PCOS) by addressing hormonal imbalances, obesity, and seeking to improve the quality of life for these women. High Intensity Interval Training, Cardiovascular training, and Resistance Training help increase heart rate, which have a positive impact on overall physiological effects on cardiovascular health and hormone regulation, including insulin sensitivity. Physiotheapy can also help in the reduction of experienced symptoms in PCOS. 2025. 01. 09. 58 PCOS High Intensity Interval Training (HIIT) Anaerobic HIIT is a highly desirable workout because it engages all muscle fibers, the fast and the slow ones as well. The benefits of H.I.I.T for PCOS include improvements of in aerobic capacity, insulin sensitivity, menstrual regulation and hormonal profiles. HIIT has also been shown to decrease stress, anxiety, and depression level. 2025. 01. 09. 59 PCOS A H.I.I.T workout for PCOS would include: Warm Up such as walking, jogging, biking to a 50-65% of heart rate’s max. 2 to 3 rounds of 2 minutes of exercises performed at a high speed with low to moderate weight varying in difficulty, with 75%-90% of heart rate max 2025. 01. 09. 60 PCOS Example: Round 1: Squats and shoulder presses (with or without waight) for 10 seconds - 2 minutes Round 2: High knees and/or Mountain climbers for 10 s - 2 minutes Round 3: Side lunges and triceps dips for 10 s - 2 minutes Cool down such as walking and active stretching to lower heart rate 2025. 01. 09. 61 PCOS The kind of exercises can vary depending on the individual's abilities and accessibility to equipment, but the method is consistent. And you must first calculate heart rate max prior to training (220- participants age) and multiplying that value by the percentage you aim to target. 2025. 01. 09. 62 PCOS During training the participant can use a watch that monitors their heart rate to make sure they are meeting the target heart rate, or they may count their pulse for a minute immediately after exercise And then you can modify if needed 2025. 01. 09. 63 PCOS Aerobic training Aerobic training can include running, walking, and bike riding. There is no specific method that is superior to the other, each type of aerobic training can help to decrease the severity of PCOS symptoms. Performing an aerobic activity that will increase their heart rate to 60-70% can show improvements in anti - inflammatory functions. 2025. 01. 09. 64 PCOS The intensity of aerobic training will depend on personal max heart rate. The monitoring methods mentioned earlier are also work here perfectly. 2025. 01. 09. 65 PCOS Resistance Training Resistance training (RT) is another effective way to help improve and decrease PCOS symptoms. RT has been shown to reduce testosterone levels and waist circumference. It has been found that RT can also help improve the hormonal levels are part of the pathophysiology of PCOS. 2025. 01. 09. 66 PCOS By improving the hormonal level, Resistens Training is helping to address some of the hormonal imbalance caused by PCOS and can improve symptoms and overall health. A general recommendation for resistance training for women with PCOS includes training 2-3 days per week for 30-60 minutes per session. “Loading for strength training should be between 8 and 15 repetitions with a 1RM percentage between 60% and 85%.” Shrestha et al., n.d. Exercises can include weights, thera-bands, weighted pulley machines and body weight. 2025. 01. 09. 67 PCOS 1 RM (repetition maximum) is defined as the maximal weight an individual can lift for only one repetition with correct technique. How can we test it safty While 1RM is a very useful tool, it does have limitations. Measuring your 1RM is not simply a matter of grabbing the biggest weight and getting a person to perform a rep. By definition, you will be stressing this muscle to its maximum and placing person at risk of an injury if you don't do it correctly. You need to prepare to do it properly. 2025. 01. 09. 68 PCOS Choose which move you are going to test (squat, bench press, etc.). Patient warms up with light cardio activity and dynamic stretching for at least 15 to 30 minutes. Patient performs 6 to 10 reps of chosen move using a weight that's about half of what you think their max will be. Then allow a rest for at least one to two minutes. Increase the weight up to 80% of what you think max might be. The patient performs three reps, then rests for at least one minute. 2025. 01. 09. 69 PCOS Increase the weight with 10% at the time, and after 1 rep, let the patient reast for 1-2 minutes. The maximum weight successfully lifted, with good form and technique, is 1RM. 2025. 01. 09. 70 PCOS Full-body exercises can be squats, pushups, and burpees, while isolated body parts exercises include biceps, triceps, or hamstring curls and single leg raises. Depending on the resources available, a variety of RT exercises can be done. Please pay attention to the patient. Maybe if she is very masculine already it is better to focus less on the upper body muscles. 2025. 01. 09. 71 PCOS Muscolosceletal pain connected to PCOS can be: Sacral pain Low back pain Pelvic floor pain (Abdominal pain) 2025. 01. 09. 72 PCOS TENS With TENS, electrical pulses can reduce pain and provide short-term pain relief. TENS is essential for PCOS because it decreases chronic pain associated with the pelvic floor muscles. If the patient experiences severe pain during menstruation, the treatment should last 20-30 minutes. 2025. 01. 09. 73 PCOS Hot pack/Heat Therapy In areas where women experience PCOS-related discomfort, hot packs, and heat treatments can relax tense muscles, increase blood flow, and decrease pain. Heat exposure reduces inflammation. Most Heat Therapy participants had improved menstrual function and lower serum testosterone levels. The stress of repeated heat exposure is a potent stimulant that affects both metabolic and ovarian function. 2025. 01. 09. 74 Summary Physical activity as a prevention option is very important for both diseases On one hand, due to its anti-inflammatory effect, and on the other hand, in order to maintain a normal body weight Physiotherapy can be also useful to decrease the patients’ complaints and as mentioned, manage the inflammations and hormonal inbalaces We can help to improve the quality of life 2025. 01. 09. 75 Other specific Physiotherapy methods 2025. 01. 09. 76 Aviva - method Aviva method is one of the best-known treatments, which we usually hear, when we speak about gynecological problems. Pelvic tilts and pelvic floor exercises are used to increase blood circulation in the lower abdomen. Unfortunately, I can neither deny nor confirm the effectiveness of the method, as I have not found any research on the subject And since I am not an Aviva mehod tutor, I would like to show you a video about it. 2025. 01. 09. 77 Video 2025. 01. 09. 78 Pelvic Floor Training Pelvic floor exercises sometimes are also recommended as an infertility treatment option And yes, it also plays a role in increasing blood circulation in the pelvis However, its official indications are: Treatment of urinary and fecal incontinence (also during pregnancy or after childbirth) Treatment of sexual dysfunctions Pelvic pain reduction 2025. 01. 09. 79 Pelvic Floor Training Muscle conditioning to help with childbirth Reduction and prevention of pelvic organ prolapse Treatment and prevention of hemmorids 2025. 01. 09. 80 Manual therapy A manual examination method in which we are able to find reversible dysfunctions of the joints and surrounding soft tissues (ligaments, capsule, muscles...) and restore them with specific techniques. We can help with the above-mentioned symptoms by manually stretching and relaxing the shortened muscles (e.g. abdominal muscles can shorten due to a lot of bloating and pain) 2025. 01. 09. 81 Manual Therapy There are also muscles in the human body that can not be actively stretched or it is very difficult (for example: the small muscles of the pelvic floor). Also, the joint movement restrictions, that have developed as a result of muscles shortening, can also be solved with these techniques (in pelvis and spine joints) If we use manual therapy in combination with the others mentioned above, we can decrease patients' complaints more quickly 2025. 01. 09. 82 Visceral Therapy With this therapeutic method, possible adhesions of internal organs and surrounding tissues can be felt through the abdominal wall The organs with limitation in their free movements can also have functional problems Certain adhesions can be resolved by using fine manipulation techniques This method is widely recommended for dissolving adhesions in the pelvic cavity, as an additional treatment option for patients with painful menstruation and endometriosis 2025. 01. 09. 83 Visceral Thearapy It can also be used as a possible treatment method for certain forms of infertility A study entitled Treating Fallopian Tube Occlusion with a Manual Pelvic Physical Therapy was performed in 2008 by Wurn, BF. et al. This study described the efficiancy of a non-invasive soft tissue physical therapy treatment in opening bilateral occluded fallopian tubes in infertile women with a history of abdominal-pelvic adhesions. In this study it was discovered that non-invasive therapy such as manual techniques may be useful as an additional therapy in treating tubal occlusion caused by adhesions 2025. 01. 09. 84 STRESS? 2025. 01. 09. 85 STRESS The effect of stress on fertility is still a question in Hungary. There is a lot of evidence that exercise helps reduce stress and improve mental health Even if we cannot offer a sertain cure, it is still worth our attention. If we manage to reduce the stress the patinets experience, through exercises and relaxation techniques, we have already done something for the health and better quality of life of our patients. 2025. 01. 09. 86 Thank you. 2025. 01. 09. 87 Warburton D.E.R., Bredin S.S.D. (2017) Health benefits of physical activity: a systematic review of current systematic reviews, Pubmed, DOI: 10.1097/HCO.0000000000000437 Harrison C.L., Brown W.J., Hayman M., Moran L.J., Redman L.M. (2016) The Role of Physical Activity in Preconception, Pregnancy and Postpartum Health, Pubmed, doi: 10.1055/s-0036-1583530 Mutsaerts M.A.Q.,van Oers A.M., Groen H.,Burggraaff J.M., Kuchenbecker W.K.H.,Perquin D.A.M., Koks C.A.M., van Golde R., Kaaijk E.M.,Schierbeek J.M.,Oosterhuis G.J.E.,Broekmans F.J., Ph.D., et al. (2016) Randomized Trial of a Lifestyle Program in Obese Infertile Women, The New Englang Journal of Medicine, DOI: 10.1056/NEJMoa1505297 World Health Organisation, 2022.október. 05. https://www.who.int/news-room/fact-sheets/detail/physical-activity (last download: 2023. 03. 11) 2025. 01. 09. 88 Bonocher C.M., Montenegro M.L., Rosa e Silva J.C., Ferriani R.A. & Meola J. (2014) Endometriosis and physical exercises: a systematic review, Reproductive Biology and Endocrinology,DOI:https://doi.org/10.1186/1477-7827-12-4 Tennfjord M.K., Gabrielsen R. & Tellum T. (2021) Effect of physical activity and exercise on endometriosis-associated symptoms: a systematic review, BMC Women's Health, DOI: https://doi.org/10.1186/s12905-021-01500-4 Physiopedia, Category:Womens Health, https://www.physio- pedia.com/Category:Womens_Health (last download: 2023.03.11.) 2025. 01. 09. 89 Delivery and postpartum Polgári Timea Physiotherapist MSc - Manualtherapist 2024.11.06. 1 Cesarean section 2024.11.06. 2 Cesarean section A cesarean section can be defined as the procedure in which the delivery of a baby happens through an incision in the abdominal wall and uterus, rather than through the pelvis and vagina. Generally, spinal or epidural anesthesia is used. The incision used during a cesarean section can be vertical (up- and-down) or transverse (side-to-side). However, the condition of the mother and the fetus decides which type of incision will be used 2024.11.06. 3 Cesarean section Births by caesarean section are rising, worldwide. The latest datas (2016) show that 25% of births in Western Europe happened by caesarean delivery; in North America it was 32%, and in South America 41% Caesarean sections can be lifesaving for both mother and baby Studies have found that babies born by planned caesarean have an increased risk of breathing problems after birth, and an increased risk of childhood obesity, asthma and diabetes 2024.11.06. 4 Cesarean section Mothers requiring a caesarean for medical reasons shouldn’t worry as these are performed to protect their health, and the health of their child. It’s also important to remember that many factors affect development – including nutrition, childhood experiences and genetics – which are all key in helping babies keep up with others in their age 2024.11.06. 5 Cesarean section Some women request C-sections with their first babies — to avoid labor or the possible complications of vaginal birth or to take advantages from the planned delivery. However, this is discouraged if patient plans on having several children. Women who have multiple C-sections are at increased risk of placental problems as well as heavy bleeding, which might require surgical removal of the uterus (hysterectomy) 2024.11.06. 6 Cesarean section There are two types of incisions that can be used for a caesarean section 1 Lower segment incision – will be used when possible. This is a horizontal cut through the abdomen and a horizontal cut through the lower part of the uterus, sometimes known as a ‘bikini line’ incision. These cuts heal better, are less visible and are less likely to cause problems in future pregnancies 2024.11.06. 7 Cesarean section 2 Classical incision – refers to a vertical cut on the uterus. The cut on the abdomen may be horizontal or vertical. This type of incision is usually only used for extreme emergencies or in specific situations, such as if the placenta is lying very low, if the baby is lying sideways or if the baby is very small. It can increase the chance of having problems in later pregnancies and births 2024.11.06. 8 2024.11.06. 9 Cesarean section To achieve a cesarean delivery, the surgeon must traverse all the layers that separate him/her from the fetus First, the skin is incised, followed by the subcutaneous tissues. The next layer is the fascia overlying the rectus abdominis muscles After separating the rectus muscles the surgeon enters the abdominal cavity through the peritoneum 2024.11.06. 10 Cesarean section The uterus is next incised. It consists of the serosal outer layer (perimetrium), the muscle layer (myometrium), and the inside mucosal layer (endometrium). All three of these layers are incised to make the uterine incision. Depending on the status of the patient’s amniotic membranes (if her “water is broken” or intact), the surgeon could meet the amniotic sac upon incision of the uterus. 2024.11.06. 11 Cesarean section The amniotic sac, if present, would be the last layer between the surgeon and the fetus At this point the fetus is delivered, achieving the primary goal of the cesarean section 2024.11.06. 12 Reasons Some cesarean deliveries are planned and scheduled, while others are performed as a result of complication that occurs during labour. There are several conditions in which cesarean delivery is more likely to occur: Fetal distress, indicated by abnormal fetal heart rate Abnormal position of the fetus (breech or transverse positioning) 2024.11.06. 13 Positions 2024.11.06. 14 Positions 2024.11.06. 15 Other reasons Labour that fails to progress Size of a baby is too large to be delivered vaginally Placental complications like placenta previa Maternal medical conditions such as diabetes, high blood pressure, HIV infection 2024.11.06. 16 Reasons Active herpes infection in the mother’s vagina or cervix Carrying twins Previous history of cesarean delivery (?) At the begining, clinicians were sure about the scar from the previous birth will rupture However, growing evidence is supporting safe vaginal birth after caesarean (VBAC). 2024.11.06. 17 Risks Baby Breathing problems. Babies born by scheduled C-section are more likely to develop transient tachypnea (abnormally fast breathing during the first few days after birth). Surgical injury (rare) 2024.11.06. 18 Risks Mother Infection: an infection of the lining of the uterus (endometritis) A C-section might cause heavy bleeding during and after delivery Adverse reactions to any type of anesthesia are possible A C-section might increase the risk of developing a deep vein thrombosis Wound infection 2024.11.06. 19 Risks Surgical injury: Although rare, surgical injuries to the bladder or bowel can occur during a C-section Increased risks during future pregnancies: The more C-sections a person has, the higher the risks of placenta previa and other problems with the placenta 2024.11.06. 20 Physiotherapy Physical therapy can significantly improve a mothers ability to return to functional activities postpartum Caring for a newborn typically requires static postures, lifting, carrying, and bending that require a significant amount of strength and stability in the pelvis, back, abdomen, neck, and shoulders 2024.11.06. 21 Educate the patient Getting into and out of bed: When turning over in bed, bend one knee at a time and support the belly with a hand or a small pillow, if necessary, while turning shoulders, hips, and knees all at the same time to avoid excessive twisting. When getting into bed, keep shoulders, hips and knees facing the same direction while lowering body down onto the side and bringing both feet up onto the bed together before rolling onto your back. Reverse this sequence when getting out of bed by rolling onto your side, lowering both legs off the side of the bed, and pushing up to a seated position with your arm 2024.11.06. 22 Educate the patient Sitting and feeding: When breastfeeding or bottle feeding, make sure that the mother has adequate support for low back and uses a pillow to bring the baby close to avoid the bed positions. Remember the mother can also lie on side for feeding. Coughing and sneezing: It is important to keep your chest clear. You can do this by taking a deep breath 2-3 times per hour. Your tummy may be sore but try not to hold back a cough or sneeze. To make these more comfortable, you can lean forward, resting your hands on your legs or bring your knees to your chest if you are lying in bed. Support your belly with your hands or a small pillow 2024.11.06. 23 Educate the patient Posture: Try to stand tall and avoid leaning forward. When changing diapers, place your baby on a changing table that is high enough to avoid bending 2024.11.06. 24 Exercises After surgery, give breathing and circulation support exercises Exercises with the upper limbs and walking Walking with a good posture is very important to prevent adhesions The total duration should be around 30 minutes per day 2024.11.06. 25 Exercises Performing gentle pelvic floor muscle contractions as soon as possible. Regular use of these muscles helps improve normal bowel and bladder control, improve and prevent prolapse, and restore sexual function They can be strated on the first postop day Do not lift anything heavier than the baby for the first few weeks 2024.11.06. 26 Scar management Once the scar has healed completely, it can be beneficial to start doing some work to stretch the scar and make it less sensitive 2024.11.06. 27 Advices Women should eat a healthy, high-fibre and high – protine diet and drink plenty of water. Every day to avoid constipation. They can use warmth on their wound. Warmth can have a soothing effect. Try a heat bag or hot water bottle. In accordance with the midwife’s or the doctor’s instructions, they can take pain-relieving medication regularly to prevent pain. If they are breastfeeding, any medication they are using must be safe for the baby too. 2024.11.06. 28 Advices Keep the wound clean and dry. They should look for signs of infection (such as redness, pain, swelling of the wound or bad- smell). These must be reposted to the doctor 2024.11.06. 29 Episiotomy 2024.11.06. 30 Episiotomy An episiotomy is the most common obstetric surgical procedure performed in the second stage of labour. It is done to reduce the incidence of serious perineal tears during labor. A controlled incision is made in the perineum to enlarge the vaginal opening, making a difficult delivery resulting an easily repairable incision compared to an uncontrolled vaginal trauma 2024.11.06. 31 Episiotomy Episiotomy had become one of the most commonly performed surgical procedures Episiotomy is associated with lesser posterior perineal trauma, lesser need for suturing, and fewer complications related to healing The World Health Organization (WHO) and other professional societies recommend restrictive over routine episiotomy since the 1990s. The prevalence of episiotomy varies worldwide, with rates declining in developed countries but higher in less developing countries 2024.11.06. 32 Indications Episiotomy is suggested to be used during difficult vaginal deliveries to control and avoid potential injuries at the time of delivery: Complicated vaginal deliveries Incision-related scars in the genital area When there is poor tissue elasticity, that tear seems to be unavoidable 2024.11.06. 33 Benefits for the mother Reduction in the likelyhood of perineal tears The preservation of the muscle relaxation of the pelvic floor and perineum, leading to improved sexual function Reduced risk of fecal and urinary incontinence Ease of repair and better healing than in tearing because it is a straight and clean incision 2024.11.06. 34 Benefits for the baby It is also suggested that episiotomy increases the APGAR score of the baby, reduces the prolonged second stage of labour, and may also reduce the possibility of fetal shoulder dystocia. In some cases, rigid perineum could lead to fetal complications. (Fetal dystocia: the baby not exiting the pelvis because it is physically blocked during childbirth although the uterus contracts normally) 2024.11.06. 35 Fetal dystocia 2024.11.06. 36 Types The two main types of episiotomy are the median and mediolateral, although seven different incisions have been described in the literature. Mediolateral episiotomy was preferred in Britain and most European countries, midline episiotomy was done most frequently in North America. 2024.11.06. 37 Types 2024.11.06. 38 Types Research states mediolateral episiotomy lowers the risk of tear. Midline compared to mediolateral episiotomy resulted in more deep perineal tears The procedure is done during the last part of the second stage of labour to enlarge the vaginal opening and is repaired by suturing 2024.11.06. 39 Complications bleeding infection prolonged wound healing, dyspareunia, pelvic floor dysfunction urinary fistulas, and inappropriate wound scarring 2024.11.06. 40 Management The patient should be monitored for pain and urinary incontinence in the post-delivery phase. The sutures used to close an episiotomy will reabsorb in the tissues within 6 to 8 weeks. There is no specific treatment and personal hygiene is a key to healing A paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause pain relief 2024.11.06. 41 Management In the first 48 hours, the patient should be placed in positions that will avoid strain on the episiotomy site and help reduce perineal oedema. Lie on a flatbed and on to their side when breastfeeding, and avoid overuse of seated positions. The patient should also be informed to avoid activities that may increase intra-abdominal pressure for the first six to 12 months after delivery. To ensure that wound should be washed and patted dry after toileting. The patient should inspect the wound daily using a hand mirror for any signs of wound breakdown. 2024.11.06. 42 Physiotherapy Sits baths help in relaxing the pelvic floor and reliefing pain. Ice packs help in reducing swelling and can cause analgesia 20 minutes of cryotherapy (bag of crushed ice on the perineal region) effectively provided perineal pain relief in women in the immediate postpartum period after vaginal birth with episiotomy TENS is effective in pain relief 2024.11.06. 43 Physiotherapy Pelvic floor exercises are must be explaned to the patient to train the pelvic floor muscles They can start it on the first few postop day, but very gently 2024.11.06. 44 Breastfeeding The mother can be sitting or lying down, or standing, if she wishes. However, she needs to be relaxed and comfortable, when she is on her back. If she is sitting, her back needs to be supported, and she should be able to hold the baby at her breast without leaning forward. Considering that WHO recommendations state that exclusive breastfeeding should be done for 6 months and breastfeeding should continue to 2 years, and that breast feeding should be done frequently for at least 15-20 minutes each time, improper positioning can cause musculoskeletal disorders for mothers, mostly affecting the neck, upper back and lower back 2024.11.06. 45 Physiotherapy Prenatal classes can be used to help inform women about the health advantages of breastfeeding, both for babies and mothers, and we can explain to women the process and techniques they can use to breastfeed. Proper attachment and positioning can be taught prenatally and postnatally to the mothers and their family. Improper positioning of the mother can cause neck, upper back and lower back pain. 2024.11.06. 46 Physiotherapy Postural advice to ensure ergonomic efficiency is recommended; the proper positioning of the mother during a feed, with the back and forearm supported with no forward leaning is advised. The heaviness of the breast during postnatal period can also strain upper back; it is advisable for mothers to wear a suitably supportive bra. Simple exercises with neck, shoulder and scapular muscle stretching exercises, and scapular retractor strengthening exercises during the postnatal period are advisable. 2024.11.06. 47 Diastasis Recti Abdominis 2024.11.06. 48 Diastasis Recti Abdominis Diastasis recti (rectus diastasis) is a stretching of the linea alba with abnormal widening of the gap between the two medial sides of the rectus abdominis muscle (increased inter-recti distance) The degree of widening needed for the diagnosis is controversial However, more then 15-25 mm is usually considered abnormal depending on time since birth. Additionally, the normal width varies depending on the level at which the linea alba is measured (narrower at the prosessus xiphoideus and widest at the level of the umbilicus) 2024.11.06. 49 Diastasis Recti Abdominis Excessive inner-abdominal pressure causes diastasis recti. During pregnancy, the abdominal muscles and connective tissues are stretched out from the expanding uterus. They’re helped along by the pregnancy hormones relaxin and estrogen. Pushing during delivery can also lead to diastasis recti. Experiencing some abdominal separation during and following pregnancy is expected In the past, body mass index (BMI), weight gain during pregnancy, weight of the baby, and maternal age were considered risk factors. But a 2015 study found no connection between these factors and pregnant women being more or less likely to experience the condition 2024.11.06. 50 Diastasis Recti Abdominis Cosmetic appearance can be affected by rectus diastasis due to extension and loss of tension of the linea alba causing a bulging of the abdominal wall. This bulging, is commonly referred to as “mummy tummy” and can be seen when women are going from lying down to sitting, when exercising, or even at rest. It is associated with worse body image in women with rectus diastasis, and it may be indicated to include body image and body satisfaction outcome measures and management when treating pregnant and postpartum women with this condition. 2024.11.06. 51 VIDEO 2024.11.06. 52 Diastasis Recti Abdominis in newborns Newborn babies are sometimes born with diastasis recti, especially if they’re premature. That’s because their abdominal muscles aren’t fully developed and connected. The condition usually corrects itself with time 2024.11.06. 53 Pathology Pregnant or postpartum women Growing uterus stretches the rectus abdominis Diastasis is more common in multiparous women due to repeated stretching Newborns Rectus abdominis is not fully developed and may not be sealed together at midline More common in premature and black newborns 2024.11.06. 54 During pregnancy The linea alba softens due to hormones and the mechanical stretch resulting from the growing fetus Because of this, there will be a progressive increase in the width of the linea alba through the trimesters, with the highest incidence occurring in the third trimester 2024.11.06. 55 Diagnosis An adult is considered to have rectus diastasis when they present with an increased inter-recti distance (IRD), characterized by an observable and palpable separation between the two bellies of the rectus abdominis muscle Here is no agreement as to the size of inter-recti distance considered to be pathological. The following parameters are given: 10 mm above the umbilicus, 27 mm at the umbilical ring and 9 mm below the umbilicus (below 45 years of age) and 15 mm, 27 mm and 14 mm (above 45 years of age), above 2 cm, and in some older studies a less precise parameter - above the 2 - finger width when measured in a crook lying position 2024.11.06. 56 Diagnosis Another study shows a criteria to diagnosis diastasis recti, an inter-recti distance of >2 mm at 3 cm below the umbilicus, >20 mm at the umbilicus, and >14 mm at 3 cm above the umbilicus is considered as diastasis (it is an ultrasonographic diagnostic criteria). In the clinical practice, different measurement methods are applied 2024.11.06. 57 Physiotherapy Our abdominal muscles play an important role in postural control, trunk and pelvic stability, trunk movement and respiration Some studies have found weak abdominal muscles in causing abdominal and lumbo-pelvic pain and dysfunction during pregnancy It has also been hypothesized that weak abdominal muscles can result in ineffective pelvic floor muscle (PFM) contraction 2024.11.06. 58 Physiotherapy Beginning exercises prenatally may help to maintain the tone and control over abdominal muscules to decrease some stress of the linea alba A study (2005) found that the occurrence and size of diastasis recti is greater in pregnant women who do not exercise Chiarello CM, Falzone LA, McCaslin KE, Patel MN, Ulery KR. The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy. 2005 Apr 1;29(1):11-6. 2024.11.06. 59 Education It is important to educate our patients on diastasis recti abdominis during and after pregnancy in order to manage patient expectations, limit fear and anxiety, and best prepare our patients for the pregnancy and birth-related changes their bodies will experience 2024.11.06. 60 Education Mota and colleagues (2015) have suggested that 100% of women will exhibit an increased inter-recti distance in the third trimester. This statistic, as well as the used language such as “gap” and “separation”, can be extremely fear-inducing and has the potential of increasing stress and anxiety in our patients, which can have negative physiological and psychological effects on both mom and baby 2024.11.06. 61 Education It is important to remind patients that are trying to get pregnant, and those who already are, that women’s bodies have been designed to grow and expand in order to accommodate a growing fetus Hormonal changes in pregnancy result in increased laxity and softening of connective tissues, resulting in the widening of the linea alba to create space for the baby 2024.11.06. 62 Education Not only is this process a natural part of pregnancy, it is also necessary in order for the baby to have adequate room to grow Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy. 2015 Feb 1;20(1):200-5. 2024.11.06. 63 Therapy In the postpartum phase, patients and physio will often direct focus to the management of rectus diastasis in order to optimize function Decreasing the inter-recti distance is the most common management strategy Restoring the alignment of the rectus abdominis muscles, by decreasing the „gap”, will also restore the function of these muscles 2024.11.06. 64 Other opinion Linea alba tension, as opposed to a decrease in inter-recti distance, may be more important to support abdominal contents and to effectively transfer force between opposing abdominal muscles In patients with diastasis recti, the linea albas tension is reduced , when the inter-recti distance is decreased 2024.11.06. 65 Other opinion Increasing linea alba tension could be a more effective management and rehabilitation plan than closing the “gap” and decreasing the inter-recti distance as it “is unlikely to optimally support the abdominal contents (potentially producing less desirable cosmetic appearance), and could induce less effective mechanical function” Lee D, Hodges PW. Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. journal of orthopaedic & sports physical therapy. 2016 Jul;46(7):580-9. 2024.11.06. 66 Other opinion There is a growing consensus suggesting that DRA is not necessarily a condition physiotherapists and patients need to prevent and treat, but in fact a very normal part of pregnancy that women’s bodies are naturally designed to do to create space for the growing baby However, there are multiple techniques physiotherapists can prescribe to their pregnant and postpartum patients to help maintain and optimize strength and function 2024.11.06. 67 Treatment In pregnancy Usually it doesn’t cause any complaints, then I do not treat it. But it can cause mostly unstability feeling in the trunk or pain (but that is very rare) During pregnancy I treat it with kinesiotaping 2024.11.06. 68 Tape 2024.11.06. 69 Treatment – in postpartum We should avoid the activation of the rectus abdominis We have to work with transversus abdominis, multifidus, diaphragm and pelvic floor muscles First we need to focus on the controlled isolation of each muscle, then the co-activation of them Once isolation of the inner muscles is achieved, exercises should be progressed to include the outer muscles, as well as, exercises that are more functionally based 2024.11.06. 70 Treatment Patient is in supine crook-lying positon Once in the proper position, instruct the patient to palpate their TA muscle using their index and middle fingers just 2 fingers medial to their front pelvic bones Following this, the patient will try to draw in the abdomen and contract the TA muscle while preforming relaxed breathing We can help, with saying: „imagine you are pulling your pelvic bones together in a straight line” or “bring your belly button towards your spine” 2024.11.06. 71 Treatment The patient should hold the contraction for 3-5 seconds while exhale and relax the TA muscule during inhalation She can perform 3 sets of 10 repetitions, 3-4 times per week Ensure there is no compensatory strategies such as posterior tilting of the pelvis, depression of the ribcage, breath-holding or bulging of the abdomen VIDEO 2024.11.06. 72 Treatment Multifidus activation can be done on prone position Have the patient imagine a line that connects their left and right sides of the posterior pelvis Next tell the patient to contract the multifidus to try draw together their left and right halves along this line The individual should practice relaxed breathing, ensuring to contract their multifidus during exhalation The contraction should be held for 3-5 seconds, 3 sets of 10, 3-4 times per week 2024.11.06. 73 Treatment No anterior tilting of the pelvis, flexion of the hips VIDEO 2024.11.06. 74 Treatment Diaphragmatic breathing is the next technique we learn Diaphragm is displaced upwards approx. 4 cm to accommodate for the increasing size of the uterus As a result, the work placed on the diaphragm increases and compensatory solutions such as increased accessory muscle activations occur In the postpartum periods, a tension-free diaphragmatic breathing pattern should be adopted This means that during inhalation, the diaphragm should descend downward and the lateral costal rib cage should expand outward 2024.11.06. 75 Treatment To facilitate diaphragmatic breathing pattern, the following breathing exercises can be practiced Supine position with their knees bent. Try to relax Have the patient place one hand on their chest and one hand over the highest point of the abdomen Instruct the patient to breathe into their hand with short, shallow breaths The individual should only feel their hand rise at their abdomen and not at their chest 2024.11.06. 76 Treatment Encourage inhalation through the nose and exhalation through the mouth The patient can practice this technique 5-10 minutes at a time, 1- 4 times per day, gradually building up their tolerance Later deepen the breathing VIDEO 2024.11.06. 77 Treatment Then we teach to the patient to contract multifidi, TA and pelvic floor togther and combine it with breating. Like contract the PF, TA and the multifidi at the same time while exhale and then relax Then try to hold it and just breath normally to the belly They can practice it 3-4 times a week with holding for 5-10 seconds as a start VIDEO 2024.11.06. 78 Pubic Symphysis Dysfunction 2024.11.06. 79 Pubic symphisis Dysfunction Pubic Symphysis Dysfunction has been described as a collection of signs and symptoms of discomfort and pain in the pelvic area, including pelvic pain radiating to the upper thighs and pelvic floor These occur due to the pelvic ligament relaxation and increased joint mobility seen in pregnancy. The severity of symptoms varies from mild discomfort to serious pain 2024.11.06. 80 Pubic symphisis Dysfunction It has also been discussed using other terms in the literature including pubo-sacroiliac arthropathy, pelvic insufficiency, symphysis pain syndrome, pelvic joint syndrome, pelvic girdle pain, pelvic relaxation syndrome and most of all symphysis pubis dysfunction 2024.11.06. 81 Pubic symphisis Dysfunction In Hungary you will see as symphysiolysis or symphyseolysis Symphysis pubis dysfunction occurs where the joint becomes sufficiently relaxed to allow unstability in the pelvis. In serious cases of pubic symphisis dysfunction the symphysis pubis may partially or completely ruptured. Where the gap increases to more than 10 mm this is known as diastasis of the symphysis pubis 2024.11.06. 82 Pubic symphisis Dysfunction The exact cause of this condition is unknown, but there are some theories Pregnancy leads to a bigger pelvic load, lax ligaments and weaker muscules. This leads to pelvical unstability, which manifests itself as symphysis pubic dysfunction. In the early stages of the pregnancy the corpus luteum secretes a lot of relaxin and progesterone. From the 12th week of the pregnancy, this function is continued by the placenta. Relaxin breaks down collagen in the pelvic joint and causes laxity and softening. Progesterone has a similar effect. 2024.11.06. 83 Pubic symphisis Dysfunction Other factors of pubic symphisis dysfunction include physically hard work during pregnancy and fatigue with poor posture and lack of exercise. Weight gain, multiparity, increased maternal age and a history of difficult deliveries, may also play a role. 2024.11.06. 84 Pubic symphisis Dysfunction In short, the causes for this unstability include hormonal (relaxin and progesterone), biomechanical (load of pregnancy or physical exercise), weak muscules, body weight, anatomical and genetic variations 2024.11.06. 85 Prevalence First trimester of pregnancy for 9% of women Second trimester of pregnancy for 44% of women Third trimester for 15% of women Postnatal 2% of women Occasionally may occur in labour or six weeks postpartum 2024.11.06. 86 Clinical Presentation Symphysis pubic dysfunction is a condition that causes excessive movement of the pubic symphysis in the anterior or lateral direction and causes pain 2024.11.06. 87 Symptoms Pain Burning, shooting or stabbing Mild or prolonged Usually relieved by rest Radiating to the back, abdomen, pelvic floor and legs Disappears commonly after giving birth (not in every case) 2024.11.06. 88 Symptoms Discomfort sense in the front of the joint Clicking of the lower back, hip joints and sacroiliac joints when changing position Difficulty in movements like abduction and adduction Depression, possibly due to the discomfort and pain 2024.11.06. 89 Symptoms Locomotor difficulty Walking Ascending or descending stairs Rising from a chair Weight-bearing activities Standing on one leg Turning in bed 2024.11.06. 90 Diagnosis As in all dysfunctions, an early diagnosis is important to minimize the possibility of a long term problem. However, not all healthcare practitioners recognise this condition Leadbetter and colleagues described, according to their findings, a scoring system to diagnose symphysis pubic dysfunction based on pain during four activities and previous injury Leadbetter, R. E., D. Mawer, and S. W. Lindow. "Symphysis pubis dysfunction: a review of the literature." The Journal of Maternal- Fetal & Neonatal Medicine 16.6 (2004): 349-354 2024.11.06. 91 Can be helpfull Pubic bone pain 1. Standing on one leg 2. Climbing stairs 3. Turning over in bed 4. Previous damage to lumbosacral spine or pelvis When you let the patient stand on one leg, they are unable to maintain their pelvis in the horizontal line cause the opposite side drops 2024.11.06. 92 Diagnosis A diagnosis is often made symptomatically after pregnancy Radiography, like an MRI, x-ray, CT or ultrasound, has been used to confirm the separation of the symphysis pubis In pregnancy MRI or ultrasound can be used 2024.11.06. 93 Palpation Palpation with the patient in supine of the entire anterior surface of the symphysis pubis provokes pain that stays for more than 5 seconds after the removal of the examiner’s hand Pain can occur in other regions: 1 Tenderness of the sacroiliac joint 2 Tenderness of the symphysis pubis 3 The sacrotuberous ligament 4 The tenderness of muscles including gluteal muscles, M. iliopsoas or M. piriformis 2024.11.06. 94 Range of Motion Range can be limited by pain, during rotation and during abduction. 2024.11.06. 95 Physiotherapy Aids to assist load-bearing Elbow crutches Pelvic support devices Lumbopelvic belt The belt must be positioned just cranial to the greater trochanters Sometimes even walking frame 2024.11.06. 96 Therapy Wheelchair in very severe cases Pain killers 2024.11.06. 97 Belt 2024.11.06. 98 Position during birth Women with this contidion should give birth in an upright position, with knees slightly open During labour and delivery leg abduction (=separation) should be kept to a minimum 2024.11.06. 99 Education Avoid activities that put strain on the pelvis (squatting, hard exercises, prolonged standing, lifting and carrying, stepping over things, twisting movements of the body, vacuum cleaning and stretching exercises) The lumbopelvic belt combined with information is superior to exercise. The women are allowed to remove the belt only during sleeping. 2024.11.06. 100 Exercises Aerobic exercises Walking with a medium intensity Defined as 60 to 75% of maximum heart rate For 25 minutes per day and 3 days per week 2024.11.06. 101 Exercises Stabilisation/core stability exercises: Aimed at improving motor control and stability through improving force closure of the pelvis At the begining: contraction of the transverse abdominis muscle Specific training of the deep local muscles like the transversus abdominis muscle with co-activation of the lumbar multifidus Also give excersises for the hip muscles and the palvic floor muscles 2024.11.06. 102 Thank you! 2024.11.06. 103 Manopause, Incontinence and Neonatal care Polgári Timea Physiotherpist MSc - Manualtherapist 2024.11.06. 1 Menopause 2024.11.06. 2 Menopause Natural menopause occurs when there is a complete, or near- complete loss of ovarian follicular activity, resulting the end of the menstrual cycle. It occurs at a median age of 51.4 years and the months and years leading up to this, are called peri-menopause Menopause before the age of 40 is considered abnormal 2024.11.06. 3 Types of Menopause Physiological Menopause: Also known as a spontaneous progressive decline of the menstrual cycle due to the decline of ovarian function, the average age is between 40-51 years of age Pathological Menopause: Has three types 2024.11.06. 4 Types of pathological manopause Premature menopause: cessation of ovarian function before the age of 40. Females who experience premature menopause have a greater chance of developing early mortality and morbidity rates Artificial or surgical menopause: permanent cessation of ovarian function due to surgical intervention, or medical treatment like chemotherapy or pelvic radiation therapy Delayed menopause: cessation of ovarian function after the age of 51 2024.11.06. 5 Symptoms Hot flashes A hot flash typically begins with a sudden sensation of heat in the upper chest, face, and back, often associated with sweating Occurs in up to 85% of women Hot flashes can begin in the late reproductive years and symptoms become more common during the early menopause, late menopause, and the early post menopause period 2024.11.06. 6 Symptoms Vaginal dryness and/or Sexual dysfunction Genitourinary syndrome of menopause (GSM) refers to atrophic symptoms that women may have in the vulvovaginal and bladder- urethral areas from the loss of estrogen that occurs with menopause Epithelial lining of the vagina and urethra are estrogen-dependent tissues, therefore, estrogen deficiency leads to thinning of the vaginal epithelium, resulting in vaginal atrophy, which leads to dryness, itching, and often dyspareunia 2024.11.06. 7 Symptoms Estrogen deficiency leads to a decrease in blood flow to the vagina and vulva, which causes sexual dysfunction One of the earliest signs of estrogen insufficiency is noticed when there is a decrease in vaginal lubrication upon sexual intercourse Vaginal dryness affects up to 85% of women over 40 years of age, with an additional 29-59% reporting dyspareunia and another 26-77% reporting vaginal itching and irritation Women may also experience heavy and unexpected bleeding 2024.11.06. 8 Symptoms Depression Here is a significant risk of depression during menopause when compared to pre-menopausal women. There are many hypotheses as to why the rate of depression increases in menopausal women. For example, middle-aged women tend to be faced with many other challenges through the transition into menopause, such as grown children leaving home, physical disease, and the death of relatives, which can all impact one's ability to cope. 2024.11.06. 9 Symptoms Changes in body shape, weight, and size, as well as sleep problems and changes in skin, hair, and sexual function can all contribute to depression in the menopausal years 2024.11.06. 10 Symptoms Sleep Women with menopause report an increase in sleep difficulties more than women in perimenopause such as, difficulty falling asleep and nighttime awakening. This may also be secondary to hot flashes and mood changes. Anxiety and depression may have a negative effect on sleep during this time. Treatment of sleep difficulties depend on clinical presentation 2024.11.06. 11 Symptoms Joint pain/ Musculoskeletal pain Joint pain appears to increase during menopause, which may be due to estrogen deficiency. Painkillers such as oral NSAIDs or intra-articular injections can be used as treatments Although still under review, HRT (hormonal replacement therapy) has not been shown to decrease joint pain 2024.11.06. 12 Symptoms Musculoskeletal pain increases in both pre and post menopause, however, the mechanism in which estrogen causes musculoskeletal pain is still not clear. Weight control and regular exercise are recommended as the best treatments for musculoskeletal pain during menopause 2024.11.06. 13 Symptoms Cognitive changes Estrogen plays a role in cognitive function therefore, with estrogen deficiency women may experience memory loss and difficulty concentrating 2024.11.06. 14 Long term Effects of Menopause Bone loss The loss of cortical bone affected by estrogen deficiency and age related trabecular bone loss Cardiovascular disease The American College of Cardiology/American Heart Association Guidelines recognize the postmenopausal state as a risk factor for cardiovasular disease The increased risk may be due to a change in the lipid profile - an increase in low density lipids (LDLs) in women going through menopause 2024.11.06. 15 Long term Effects of Menopause Body changes During the postmenopausal period women often gain fat mass, mostly central abdominal fat Due to spontaneous decrease of activity, decrease in energy levels, and decreased metabolic rate 2024.11.06. 16 Long term Effects of Menopause Balance Estrogen deficiency has been linked with decreased balance in postmenopausal women 2024.11.06. 17 Management As part of the healthcare team, physiotherapists should be aware of the menopausal process and the symptoms that can come along with this transition. Many of the symptoms and health concerns described above can have a negative impact on women's health and overall quality of life. It is crucial to be able to identify symptoms in menopausal women through assessments and provide appropriate management options, such as exercise and pain management, or sugestions to other healthcare professionals when needed 2024.11.06. 18 Physiotherapy Weight-bearing exercise: Low impact weight-bearing activity such as walking, Tai Chi, and yoga. High impact weight-bearing activity such as jogging Resistance and Strength Training Exercise: Examples include weight lifting, swimming, cycling Physical activity and exercise have been shown to have reduce the risk of osteoporosis, cardiovascular disease, depression and obesity 2024.11.06. 19 Osteoporosis and Bone Density Studies show that physiotherapists are able to treat people at risk of osteoporosis and reduced bone density. However, not all exercises have the same osteogenic effects on bone mineral density (BMD). Resistance exercise has a stronger osteogenic effect, and for exercise to be effective its mechanical load should exceed that of activities of daily life. 2024.11.06. 20 Osteoporosis and Bone Density To obtain the best results, a combination of exercises that include both resistance and weight-bearing exercises is the best choice to optimize strength and function. Resistance exercise affects muscular loading and weight-bearing exercises have a mechanical loading effect on bone The mechanisms in which exercise impacts bone density is still not clear but research suggests that exercise increases the activity of osteoblasts and inhibits osteoclast activity. Bone strength increases the cross-sectional area due to mechanical loading, which in turn increases bone resistance 2024.11.06. 21 Osteoporosis and Bone Density A systematic review by Howe and collages (2011), examined the effectiveness of exercise interventions in preventing bone loss and fractures in postmenopausal women, and they found that exercise was a safe and effective way to prevent bone loss in this population Additionally, higher levels of participation in physical activity were independently associated with lower weight and risk of weight gain Howe TE, Shea B, Dawson LJ, Downie F, Murray A, Ross C, Harbour RT, Caldwell LM, Creed G. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane database of systematic reviews. 2011 2024.11.06. 22 Cardiovascular Disease Regular aerobic exercise programs can improve cardiorespiratory endurance and decrease the risk of Cardiovascular Disease (CVD). Some research suggests that exercise increases levels of high-density lipoproteins (HDL), decreases low-density lipoproteins (LDL), and controls hypertension, which in turn improves cardiovascular health 2024.11.06. 23 Depression Exercise therapy has the ability to relieve some symptoms in people with depression when compared to participants without clinical depressive symptoms. The mechanisms in which exercise impacts depression is not clear 2024.11.06. 24 Obesity Regular exercise programs show to increase metabolic rate and energy expenditure, promoting the loss of abdominal fats and helping with obesity 2024.11.06. 25 Urinary Incontinence 2024.11.06. 26 Clinically Relevant Anatomy of the Pelvic Floor The pelvic floor is made up of muscles, ligaments, and fascial structures that act together to support the pelvic organs and to provide compressive forces to the urethra during increased intra- abdominal pressure. The pelvic floor muscles refer to the muscular layer of the pelvic floor. It includes the levator ani, urogenital sphincter, external anal sphincter, ischiocavernosus, and bulbospongiosus 2024.11.06. 27 Clinically Relevant Anatomy The urethra, vagina, and rectum pass through the pelvic floor and are surrounded by the pelvic floor muscles. During increased intra-abdominal pressure, the pelvic floor muscles must contract to provide support. When the pelvic floor muscles contract the urethra, anus, and vagina close. The contraction is important in preventing the involuntary loss of urine or rectal contents. The pelvic floor muscles must also relax in order to void 2024.11.06. 28 Urinary Incontinence Urinary Incontinence is a common condition that often goes untreated It is estimated to affect about 50% of adult women and 3% to 11% of adult men; however, only 25% to 61% of those women seek care 2024.11.06. 29 Definition Urinary incontinence defined by International Continence Society as an involuntary urinary leakage. There are different types of urinary incontinence and identifying the classification of urinary incontinence can help to guide treatment, however, an individual could exhibit symptoms from more than one of the classifications 2024.11.06. 30 Types Stress urinary incontinence is the most common type, affecting an estimated 50% of all incontinent women. It is defined as a complaint of involuntary loss of urine on effort or physical exertion (like sporting activities), or on sneezing or coughing. Urgency (sometime urge) urinary incontinence is more prevalent in older women and accounts for a small group of women with urinary incontinence. It is a complaint of involuntary loss of urine associated with urgency. A compelling desire to pass urine which is difficult to resist. 2024.11.06. 31 Types Mixed urinary incontinence is a complaint of involuntary loss of urine associated with urgency and also effort or physical trigger or on sneezing or coughing. Overactive bladder (OAB, urgency) syndrome is a urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology 2024.11.06. 32 Types Nocturnal enuresis is an involuntary loss of urine occur during sleep. Other types of urinary incontinence may define as urinary leakage during the sexual intercourse or giggle incontinence 2024.11.06. 33 Pathophysiology Urinary incontinence is more frequent in women than men because of the differences in the anatomy of the pelvic floor muscles, the ligament structures and the effect of childbirth and maternal injury Although female urinary incontinence pathophysiology is not yet clear, some possible mechanisms of incontinence can be found in the literature. First, a deficient urethral closure mechanism result in weak pelvic floor muscles and urethral hypermobility following childbirth can cause urirany incontinence 2024.11.06. 34 Pathophysiology Additionally, the baby's head distends and stretches the PFM and worsens the normal function of connective tissues and nerves during the vaginal delivery. Another possible mechanism is the change of the hormone levels such as progesterone and relaxin during pregnancy, breastfeeding and postpartum 2024.11.06. 35 Stress urinary incontinence etiology Urethral hypermobility: Increases in intra-abdominal pressure (from coughing or sneezing) with insufficient support of the pelvic floor muscules and vaginal connective tissue to the urethra and bladder neck can lead to incontinence. Pregnancy and vaginal birth, post-partum, obesity, chronic cough, chronic heavy lifting, and constipation: If there is an increase in abdominal pressure that is greater than the opposing force of the pelvic floor muscles, it can result in stress incontinence 2024.11.06. 36 Etiology A systematic review identifying the pregnancy and obstetric- related risk factors that predict pelvic floor disorders for women later in life suggests that: urinary incontinence during pregnancy, an instrumental vaginal delivery, an episiotomy, tears, and constipation are the noticeable risk factors leading to urinary incontinence postpartum. Lim YN, Dwyer PL. Effectiveness of midurethral slings in intrinsic sphincteric-related stress urinary incontinence. Current Opinion in Obstetrics and Gynecology. 2009 Oct 1;21(5):428-33. 2024.11.06. 37 Etiology Urgency urinary incontinence: This may be secondary to neurologic disorders (spinal cord injury), bladder abnormalities, increased or altered bladder microbiome, or may be idiopathic Overactive bladder: This could be due to neuropathy, an infection (urinary tract infection), weak pelvic floor muscles, diet, medications, excess weight 2024.11.06. 38 Etiology Mixed Incontinence: Individuals can present with more than one type of incontinence For example, stress incontinence and/or urge incontinence might be "masked" by an overactive bladder (frequently using the bathroom to avoid leakage) 2024.11.06. 39 Before physiotherapist examination I tell the patient, before meeting her, to try to do a pelvic floor contraction at home If she does not know how, or she is unable to, then I tell her to try to stop herself passing urine for a second or two when using the toilet But it is not an excersise what is suggested to do frequently Can be done only 1-2 times just to feel how to do a contraction 2024.11.06. 40 Modified Oxford grading system – we use 0 - no contraction 1 - flicker 2 - weak squeeze, no lift 3 - fair squeeze, minimal lift 4 - good squeeze with lift 5 - strong squeeze with a lift 2024.11.06. 41 Plapation Palpation of the pelvic floor muscles per the vagina in females must be PERFECT P - power, may use the Modified Oxford grading scale E - endurance, the time (in seconds) that a maximum contraction can be sustained R - repetition, the number of repetitions of a maximum contraction 2024.11.06. 42 Palpation F - fast contractions, the number of fast (one second) maximum contractions ECT - every contraction timed, reminds the therapist to continually overload the muscle activity for strengthening 2024.11.06. 43 Examination My examination happens in a gynecological examination chair I put one of my finger into the vagina and I ask for a pelvic floor muscle contraction It is very important to not to skip this examination Cause if the strength is 0, then I have to send her to the Urology There a long-term electrical stimulation therapy can be prescribed To

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