Post-Op Cesarean Section and Hysterectomy PDF

ROLE OF Ph Th IN POST OPERATIVE CASE (CESAREAN SECTION – HYSTERECTOMY) Prof.Dr. Asmaa Mahmoud Aly Prof. of P.T for Women’s Health  Cesarean section (CS) Caesarean section ro c- section is delivery of a viable foetus through incisions in anterior abdominal wall and uterine wall.  I...

ROLE OF Ph Th IN POST OPERATIVE CASE (CESAREAN SECTION – HYSTERECTOMY) Prof.Dr. Asmaa Mahmoud Aly Prof. of P.T for Women’s Health  Cesarean section (CS) Caesarean section ro c- section is delivery of a viable foetus through incisions in anterior abdominal wall and uterine wall.  Indications of cesarean section.1-Extreme degree of contracted pelvic one or more of the diameters is reduced and interferes with normal mechanism of labour. Degrees of contracted pelvis: ❖ Minor degree eurt eht : 10-9 si etagujnoccm. ❖ Modrate degree eurt eht : 9-8 si etagujnoccm. ❖ Sever degree: the true conjugate is 8-6cm. ❖ Extreme degree: the true conjugate is less than 6 cm. 2- Cephalopelvic disproportion: The head of the foetus is too large to come through the pelvis. 3- Uterine Inertia: Inefficient uterine contraction. 4- Placenta Previa: Implantation of placenta in the lower uterine segment. 5- Premature separation of placena: 6. Malposition and mal- presentation 7. Pre-eclampsia 8. Cardiac diseases. 9. Vaginal STENOSIS and scaring. 10.Carcinoma of the cervix. 11. Prolapse of the umbilical cord. 12. Diabetes ( causes over size of the foetus). 13- Cervical dystocia (failure of the cervix to dilate in spite of strong contraction of the uterus). 14- A previous vertical uterine incision. 15-Fetal distress (HR above 160 or below 100, irregular ). 16-Bad past obstetric history (baby habitually dies in the uterus. 17-Failure of labour to progress despite adequate stimulation. Contra-Indications of cesarean section Dead of foetus  Timing of C.S 1) Elective timing: (before the onset of labour by one week). 1) Selective timing: (after the onset of labour, it is preferred).  Types of cesarean section 1- The classical caesarean section : longitudinal (vertical) incision A midline longitudinal (vertical) incision which allows a larger space to deliver the baby. However, it is rarely performed today as it is more prone to complications. 2- The lower uterine segment section : It is the procedure most commonly used today; it involves a transverse cut bladder transverse cut just above the edge of the bladder and results in less blood loss blood loss and is easier to repair. Advantages of the lower segment: The wound is extra peritoneal so less risk of infection. Healing scar is better. The risk of rupture of the scar is less (0.2 %). Hemorrhage is less. Placenta is away from the incision. Disadvantages of the lower segment: The incision may extend down to the bladder. Disadvantages of classical operation: More liable to chest infection. More liable to intestinal distension. The scar is more liable to scar rupture. Indications of classical caesarean section when the lower segment is abnormally vascular. when the lower segment can not identified due to adhesion. when caesarean section is done post mortem. When the foetus lie is transverse and can not be corrected. When hysterectomy will follow caesarean section  Intermediate and Late Complications of C.S 1- Respiratory complications: due to inhibitory effects of pain, immobilization in post operative period and anesthesia. So, - encourage deep breathing exercises. - teach the patient huffing and coughing (the abdomen must be supported by the patient‫י‬s hands and/or towel) 2- Excessive abdominal pain: due to - Wound infection. - Nerve entrapment syndrome (ilioinguinal or iliohypogastric nerve) 3- Deep venous thrombosis: due to hypercoagulability, decrease venous tone. Complications of cesarean section 4. Postpartum haemorrhage (>1000ml) 5. Wound haematoma (increased in patient with large BMI/diabetes/ immunosupressed). ❑ 6. Intra-abdominal haemorrhage ❑ 7.Bladder/bowel trauma (more common in patients who have had previous abdominal surgery) 8.Signs and symptoms of DVT: in about 50% Edematous limb. Erythrocyanotic appearance. Dilated superficial veins. Elevated skin temperature. Prophylactic role to prevent DVT: Early ambulation. Avoidance of pressure under thighs and calves Avoidance of sitting with knees acutely flexed. Deep breathing exercises. Circulatory and leg exercises. 9- Dependent edema. (generalized retention of fluid) aggravated by decreased movements of the lower limb muscles. TO PREVENT DEPENDENT EDEMA: oVigorous foot and ankle exercises. oElevation of L.L. oIf sever apply stoking and intermittent pressure. 10- Intestinal complications. 11- Hemorrhage.  Cesarean hysterectomy It is done when there is inability to stop bleeding from the uterine incision or multiple fibroids in old patient.  Sterilization during C.S. It is an excision of a portion of both fallopian tube. It is done after 3rd or 4th cesarean section.  Hysterectomy Is an operation in which the uterus is removed. The cervix, ovaries and/or fallopian tubes might also be removed. It may be done abdominally or vaginally. Vaginal hysterectomy usually done for some cases of uterine prolapse. Indications of hysterectomy Obstetrical: ▪ Rupture of the uterus. ▪ Uncontrollable post-partum hemorrhage. ▪ Placenta accreta. Gynecological: ▪ Inflammatory: as some cases of genital tuberculosis. ▪ Tumors: - benign (ovarian tumors, fibroids) - Malignant: (cervix, body and ovaries) ▪ Displacement: some cases of uterine prolapse or chronic inversion. ▪ Some cases of dysfunctional uterine bleeding. Types of hysterectomies: 1- Subtotal hysterectomy (partial): Involves removing the body of the uterus, but leaving the cervix in place. Done for post partum hemorrhage and rupture uterus. 2- Total hysterectomy: Involves removing the body of the uterus as well as the cervix, much better than subtotal. 3. Pan hysterectomy Total hysterectomy and bilateral removal of both ovaries 4. Radical hysterectomy Is done specifically in the case of invasive gynecological cancer. Removal of the uterus, both tubes, and ovaries, the upper third of the vagina, the iliac and obtruator lymph gland. 5. Ultra radical hysterectomy Anterior excenteration →Removal of the bladder posterior excenteration →Removal of the rectum Advantages of subtotal hysterectomy It is easier and quicker than total hysterectomy There is less danger of injuring the bladder. Less danger of pelvic infection. The cervix left to act as a support for vagina. The cervix discharge lubricates the vagina ADVANTAGES OF TOTAL HYSTERECTOMY Provides better drainage of the operation area. If the cervix is lacerated or infected, the source of irritant discharge is removed. Role of Physical Therapy post operative case Pre-operative management Post- operative management:  Pre-operative For elective cases, prior to surgery the mother is pain free and alert, to prepare her emotionally and physically for post operative delivery. ❑Pre-operative goals: 1. Improve pulmonary function and prevent post operative pulmonary complications( pneumonia….) 2. Improve circulation and prevent post operative circulatory complications (DVD, edema ….) 3. Prepare patient emotionally and physically ❑Methods: ▪ Discussion to minimize or eliminate negative feeling about delivery. ▪ Demonstrate the patient how to mobilize early with minimum amount of strain or pain. ▪ Teach the patient how to cough and huff to get out of expectoration. ▪ Deep breathing exercises. ▪ Circulatory exercise. Post-operative goals: 1. Improve pulmonary function and prevent post operative pulmonary complications( pneumonia….) 2. Improve circulation and prevent post operative circulatory complications (DVD, edema ….) 3. Decrease incisional pain associated with coughing, movement or breast feeding. 4. Improve healing of incision and prevent adhesion formation. 5. Prevent pelvic floor dysfunction. 6. Improve lactation and prevent sagging of the breast. 7. Correct posture. Physiotherapy Mangement after Cesarean Section Goal: To improve pulmonary function and decrease the risk of pneumonia Breathing instructions should be given. Coughing and / or huffing technique should be taught. Goal: To decrease incisional pain with coughing, movement or breast feeding. Post operative TENS can be given. Ice application. Support incision site with pillow when coughing or breastfeeding. Incisional support with pillows or hands with movement ,education regarding incisional care and risk of injury.  Goal: To prevent post surgical vascular or gastrointestinal complications. Active leg exercises should be taught. Early ambulation should be encouraged. Abdominal massage to peristalsis can be taught. Goal: To enhance incisional circulation and healing; prevent adhesion formation. Gentle abdominal exercise with incisional support should be taught.. scar mobilisation can be done. friction massage can be given.  InGoal: To decrease post surgical discomfort from flatulence,itching or catheter. structions regarding positioning should be given. Goal: To correct posture. Posture instructions should be given, particularly regarding child care. Goal: To prevent injury and reduce low back pain. Instructions regarding incisional splinting and positioning for ADLs should be given. Instructions regarding body mechanics should be given.  Goal: To prevent pelvic floor dysfunction Pelvic floor exercises should be taught. Education regarding risk factors and types of pelvic floor dysfunction should be given. Goal: To develop abdominal strength Abdominal exercise progression , including corrective exercises for diastasis rectii should be taught.  Goal: To improve lactation and prevent sagging of the breast. Arm exercise. Advices about lactation. Physical therapy for early post-operative days: ❖1st day: ✓Breathing ex‫י‬s. ✓Circulatory ex‫י‬s. ✓Leg ex‫י‬s. ✓Static abdominal contraction. ❖2nd day: ✓Repeat previous ex‫י‬s, add the following: ✓Early ambulation to: ✓Prevent muscle wasting. ✓Prevent constipation. ✓Prevent respiratory and vascular complication. ✓Arm ex‫י‬s. ❖3rd day: ✓Repeat previous ex‫י‬s, add the following: ✓Pelvic floor ex‫י‬s ❖4th day: ✓Repeat previous ex‫י‬s, add the following: ✓Pelvic rocking ex‫י‬s ✓Scapular retraction. ❖5th day: ✓Repeat previous ex‫י‬s, add the following: ✓Hip shrugging. ✓Postural correction ex‫י‬s. ❖6th day: ✓Repeat previous ex‫י‬s, add the following: ✓Pelvic rotation ex‫י‬s. ❖7th day: ✓Repeat previous ex‫י‬s, add the following: ✓Lateral flexion (1st step) ✓Trunk rotation (1st step) ✓Trunk flexion (1st step). Electrical modalities for post- operative case: (A) Post-operative pain relief:- ▪Ice packs for 10- 15 min on the treated area, every 8 hours for 72 hours. ▪TENS, Para incisional, pulse width 200us, frequency 2 Hz (burst mood)  Post operative wound healing LASER: IR laser / 904 nm, 10 watt power, reach 20-30 mm. After 24 hour post op. then every other day. Mechanism of action of LASER on wound healing: 1. Immune system, Increase erythrocyte rosette formation, igG and phagocytic index. 2. Accelerate inflammatory phase by alter the level of prostaglandin 3. Enhance protein synthesis through DNA and RNA synthesis 4. Bactericidal effect  Ultrasonic therapy ▪ Intensity (1-2 W/Cm2), for 10- 15min daily ▪ Mechanism of action: ▪ Micro massage effect ▪ Increase temp vasodilatation white blood cells invade microorganisms  UV radiation (UV) ❖Promote healing via stimulate growth of the granulation tissue and prevent infection by destructing surface organisms ❖ non infected open wound non-progressed E1 ❖progressed E1 surrounding skin In case of infected wound Slough fine film of yellowish appearance E3 and surrounding skin received E1 Slough definit layer of yellow or green ues E4 and surrounding skin received E1 Thick dark brown or black scalp E4 DAILY the solugh starts to leave the skin gently cut. High voltage current stimulation (HVCS) For infected wound Dispersive electrode on the back 2 active electrode paraincisional Pulse rate 80-100p/sec for 60 min daily Mechnism of action -Increase circulation -Bactericidal effect. Post operative paralytic ileus: SWD: for 1 hour twice / day Early ambulation Static abdominal ex Postoperative scar adhesion Scar adhesion is defined as an abnormal formation of fibrous tissue between two tissues or two organs. Known postoperative scarring complications include hypertrophic scarring, keloid and scar adhesion, and the incidence of excessive scarring after C-section is reported to be around 41%. Adhesions can occur superficially, at the scar site, and these can result in persistent pain and discomfort in the lower ,limiting range of motion or hip or back pain. Soft tissue release for Postoperative scar adhesion Participants lie supine on the treatment table undress the lower abdominal area so that the C- section scar was clearly visible. placed a pillow under the participants' knees to ease any tension of the tissues surrounding the C- section scar.  Areas worked: fascia, connective tissue Try sliding it up and down and side to side. Notice if it moves more easily in 1 direction than another. Working in 1 direction, slowly move the scar back and forth. You will want to start off gently and gradually move up to a more aggressive massage. Move the scar up and down, side to side, and even around in circles. Small movements are better, but tissue mobilization can be done in all areas of the abdomen. If the scar is painful, stop and try again at a later date. Once you feel comfortable, you can perform this massage once a day. Thank you