Outline the role of transversus abdominis in helping to stabilise Mrs D’s 4.5 cm rectus diastasis (DRAM). (2 marks)
- Transverse abdominis is extremely important in helping stabilise Mrs D’s 4.5cm DRAM as the TA helps to provide stabilisation of the pelvic floor as well as the spine.
- Activating TA creates tension across tissue of the linea alba allowing for optimal loading through the abdominal wall.
- TA helps to increase the control of the lower back, support of the abdominal organs and put help maintain pressure on the pelvic floor.
- By having a strong TA, it means that there is not increase in abdominal pressure
Identify two (2) psychosocial factors from Mrs D’s assessment findings that need to be considered and explain why they are relevant in her postnatal period. (2 marks)
- Anxiety medication/anxiety. Anxiety can be a bladder wall stimulant, thus post postnatally could increase risk of incontinence or leakage
- Single parent, being a single parent with 3 children can cause stress which like anxiety can be a bladder wall stimulant which could increase risks of leakages. Also being a single parent could mean difficulty finding time to adhere to the exercise program that is put in place.
Discuss what exercise advice/guidelines you would recommend for Mrs D from 6 to 12 weeks postnatal. Within your answer, provide two (2) examples of exercise options and outline your clinical reasoning for each exercise. (5 marks)
- PFMT
o 10 reps x 3 second hold pelvic floor exercise, 3 times daily. No info regarding fast contractions so can reassess at next appt and potentially use as a progression. Completed for at least 12 weeks, ideally 6 months. Perform lying on surface or bed that allows for feet to be flat on the surface.
o To help improve PF strength, in turn to reduce IAP and reduce UI - Guidelines:
o Bladder diary and modification of fluid intake, monitoring for continued symptoms of UI
o Info regarding incontinence pads
o Addressing DRAM with garments + education
Ie support Helps resist increased IAP and prevent bulging out
Teaching TA activation. Importance of TA in decreased IAP ie UI. - Exercise:
o Info regarding getting back to exercise. Low impact for 6 weeks, ie bike, yoga or walking progression). Can begin to trial High impact (ie running)
o Addition of gentle exercise - arm, leg and trunk movements (avoid crunches initially), build up to light hand weights. Ie could be dead bugs. Palpate over linea alba to check gap when performing exercise
o To continue strengthening TA a helps reduce IAP and helps provide co contraction of RA which will help with DRAM
Describe two (2) options for pain relief during labour, that are within the scope of practice for a Physiotherapist and explain your clinical reasoning behind each treatment. (4 marks)
- Pain Relief During Labour
o Natural – Endorphins (released by body / natural response to pain)
o Massage (sacrum)
o Obstetric TENS (trial before labour)
o Intracutaneous injections of sterile water (sacrum)
One of the pregnant women attending your class asks the following question “I purchased an obstetric TENS machine and was wondering how to use it in labour?” Outline your answer to this question, to be heard by the whole class. (4 marks)
Obstetric TENS can definitely be used during labour for pain relief. We would trial this before labour, but TENS can help as it is a form of pain relief that doesn’t involve any medications or injections. It also means that you can be mobile as there is not cords or anything attached to machines. Two electrodes are stuck to your skin and connected to a battery-powered machine. The machine delivers small pulses of electrical current to the body. You can adjust the amount of electricity delivered to your body. The pulses feel like tingling sensations on your skin.
Describe how would you educate your patient on the 3B tear she sustained during labour. Your answer must include a lay definition of a 3B tear, and the timepoints at which you recommend the patient books her physiotherapy sessions after leaving hospital until 12 weeks postnatal. (2 marks)
3b tear is a tear to more than 50% External Anal Sphincter. Follow up at 6 weeks and 12 weeks with physio
Your patient is reporting significant swelling over the region of the 3rd degree repair. Suggest four (4) physiotherapy interventions that the patient could use in hospital to reduce this swelling and pain. Your answer must include the clinical reasoning for each treatment. (4 mark)
- Ice
- Lying flat every 1-2hours to stop pooling
- Gentle exercise and PF contraction – 10 x 2 second holds
Based on the patient’s obstetric history, identify four (4) evidence based intrapartum risk factors that are linked to pelvic floor/levator trauma, as outlined in current research. (2 marks)
- Forceps use
- Birth weight of child >4000g
- Prolonged second stage labour – 2 hours
- 2nd/3rd degree tear
Based on Mrs M’s subjective assessment findings, identify four (4) pre-existing risk factors for developing dyspareunia and chronic pelvic pain. Your answer must include the clinical reasoning for each risk factor identified. (4 marks)
- Recurrent UTI’s can be related to chronic pelvic pain
- 2nd degree tear, causing damage and potential sensitivity
- Medications lyrica = hypersensitivity
- Stressful working career – stress can be linked to
a) Men who have undergone radical prostatectomy can often experience incontinence. Outline two (2) factors that might contribute to incontinence postradical prostatectomy. (2 marks)
- Sphincter incompetence – compromised function
- Detrusor overactivity of bladder contraction - reduced storage
b) Describe two (2) methods that can be used to assess pelvic floor function in men and explain what those methods can assess. (2 marks)
- Anal EMG (Electromyography) – can be used to assess activation of urethral muscles
- Transperineal US - measure activation of individual pelvic floor muscles in men during voluntary contraction
- Digital rectal examination - Evaluation of contraction of external anal sphincter and puborectalis, muscle tone, areas of tenderness. Can look at strength, endurance and coordination
- Subjective assessment:
o Can you stop the flow of urine upstream? - Assess the ability to contract
o You have difficulty initiating micturition? – assess for hyperactivity
o Self-palpation
Suggest the likely diagnosis for Mrs C, and identify two (2) findings from the subjective or objective assessment to explain your clinical reasoning for this differential diagnosis. (3 marks)
- SUI
o UI on coughing, increased IAP causing leaking
o Vaginal examination showing weak pelvic floor, thus meaning higher chance of SUI and leakage
b) You determine that Mrs C would benefit from a pelvic floor exercise program. Based on the objective assessment findings above, prescribe a pelvic floor program for this patient. Write your answer in the same format that you would give to Mrs C. (2 marks)
- 5 reps x 2 second holds/lifts
- 2 x 2 fast contractions
- 3 x daily with progression self-according to fatigue
- Completed for a minimum of 12 weeks, ideally 6 months. Program can be completed on bed or any flat surface where you can lie on your back with knees up o the bottom of your feet is on the flat surface
- Continue progressing how many reps and length of contraction/hold
Mrs C is also keen to start a home exercise program to maintain her general strength and health. Describe three (3) home exercises (not including pelvic floor therapy) you would prescribe for Mrs C, including your clinical reasoning. (3 marks)
Swimming - Low impact on IAP
Shallow body weight lunge - Good for strengthening lower body
Nordic walking - Good for overall activity and health
Wall push ups - helps with upper body strength and doesn’t place increased pressure on pelvic floor
Wall sits – squat holds helps with lower body strengthening, maintains correct posture, helps with strengthening core muscles prior to pregnancy
Before prescribing an exercise program for Mrs M, list four (4) subjective or objective assessment points that need to be considered when (or before) prescribing your program. Provide your clinical reasoning for each consideration. (4 marks)
- Pre-pregnancy exercise levels
o To understand what exercises she would like to do and could be capable of doing with regressions in mind if needed for her. - GDM
o Looking at her diet and exercises - Low blood pressure
o More likely to faint while undergoing/performing exercises is. Graded CV approach to ensure no adverse events during exercises - Grade 2 tear
o Risk of infection/pain and limited types of exercises. - SUI
o May occur during exercises,focus on preventing this situation.
o exercise with high IAP may need to be reconsidered
Design a home exercise program that includes two (2) exercises for Mrs M to complete daily, which takes into account her antenatal and musculoskeletal history. For each exercise, please include details of the exercise prescription (e.g. number of sets, repetitions) and provide your clinical reasoning or modifications. (6 marks)
Wall sits with an exercise ball 3 x 30 seconds - Wall sits can help with lower body strengthening and abdominal muscle activation. Abdominal muscle activation is important in maintaining IAP and reducing the risk of UI
sit -to-stands 8 reps, 3 sets, every other day - Strengthens LL, helps stabilise, functionally relevant (common for ADLs)
Wall pushes 8 reps x 3 sets x2/day Good for upper body strength + abdominal muscle contraction
General walking program 20 mins, x2/day She was previous walking and doesn’t increase IAP. Keeps her healthy and similar to pre-exercise activity
Based on the patient’s subjective assessment findings, identify three possible (3) barriers to her management. Using the table below, provide an explanation of how you would address each barrier through physiotherapy and/or multidisciplinary care. (3 marks)
1) Family separation recently Determine how supportive her parents will be, and if she has any close friends that can also help to support her emotionally throughout this time - make sure she has a good supportive network
2) Not interested in exercise due to busy job Explain that exercise is really important for her health and the health of her baby - and this is something that she needs to prioritise and potentially consider taking some time off work if able - taking some time off also might decrease some of her stress
* - Potentially talk about exercise classes?
* - Explain the risks of not exercising
3) Patient not wanting pain relief during labour – set on delivery SVD Determine why this is the case - discuss other potential options for pain relief during labour such as massage. Can consider TENS for pain relief which can alleviate stress as it helps pain and is non-pharmacological.
* - Massage of sacrum
* - Obstetric TENS
* - Sterile water injections
* - Pain/stress relief positions
* - Talk to her about body’s natural response to
pain i.e. release of endorphins
4) Anxiety - psychosocial factors Could potentially try to contact and work with her psychologist or social worker to ensure that she receives appropriate, holistic care
Deep breathing exercises and massage
Explain the role of diaphragmatic breathing in labour, and outline the instructions you would give to your patient to practice this breathing technique at home. (2 marks)
- Deep breathing can cause relaxation and breaks the panic cycle where people tend to hold their breath during the first stage of labour, it is useful to practice in advance
- Diaphragmatic breathing can help supply more oxygen to your baby, and may even decrease the intensity of contractions you may experience during labour
- Breath in deeply from your lower stomach, imagine it filling up like a balloon and expanding outwards, then hold it for a couple of seconds before releasing and slowly letting all of the air out
Describe two (2) pain relief or relaxation strategies during labour that you would teach your patient without a birth partner. Your response should include details of your instructions for your patient about how to perform each strategy. (4 marks)
- Visualisation - think of your happy place where you feel calm and relaxed - close your eyes and picture this place
- Music - play some of their favourite music for them - have a playlist set up beforehand for this would be useful
- Deep breathing - details for doing this as above
- Epidural Injection
- TENS - No medication or noninvasive pain relief. Can be mobile. Helps block pain back to brain through nerve stimulation
Dr Andrews has requested a Physiotherapy review for Mrs D on Day 2. Describe your physiotherapy management plan for the patient (on Day 2), which takes into account her PPH. Your response should also include any further information you may require in order to manage her safely. (2 marks)
- Teach bed mobility - sitting up through log roll - go through everything slowly as they might get lightheaded.
- Need to ensure that they are not a fall risk - once they are sitting on the edge of bed lower it down, so their feet are on the ground. Ensure stable before starting to stand up
- She should sit down in the shower because vasodilation happens in the shower due to heat which increases falls risk.
- When standing or moving, take it slow in case of postural hypotension.
You return to Mrs D’s room on Day 4. She has normal BP and haemoglobin levels. Formulate an initial physiotherapy treatment plan for this patient based on her subjective history and delivery notes. The plan should include three (3) treatments that you would give Mrs D at the end of this assessment. The patient is scheduled to see you for a follow-up assessment in 6 weeks. (3 marks)
- Teach pelvic floor exercises
- Advice and education regarding constipation after C section as common
- Advice and education regarding Breastfeeding positioning
Describe three (3) treatments for Mrs D that you would implement at this stage in her management post-delivery, based on the assessment findings above. Provide your clinical reasoning for each treatment. (6 marks)
1) Pelvic floor exercise program Weakened pelvic floor apparent from PERFECT score. Needed to support pelvic organs and continence
2) Addressing DRAM regarding Garments + education Helps resist increased IAP and prevent bulging out
3) Constipation education and diet management of Fibre Type 1 stool meaning straining, thus increasing IAP and impacting recovery of DRAM
Suggest the most likely cause of Mrs P’s dyspareunia and explain why this cause may be contributing to the patient’s symptoms. (2 marks)
- Episiotomy scar tenderness, incorrect healing can cause sensitivity and pain on scars, which in turn cause dyspareunia.
- Poor repair following perineal trauma causing scar tissue formation
- Dyspanueria is most commonly caused by pelvic floor muscle pain i.e. pelvic floor myalgia
- Pelvic floor muscle pain involves pain in the muscles of the pelvic floor, perineal or levator ani, commonly due to overactive pelvic floor, causing vagina-related pain
- Typically involves overactivity and/or pain of pubococcygeus, iliococcygeus and puborectalis which are all in close proximity to the vagina
When Mrs P’s GP performed the vaginal examination, she mentioned an involuntary spasm at the introitus (vaginal opening), that limited her examination. Suggest the diagnosis of this involuntary spasm, and explain why this may limit the assessment and vaginal examination. (2 marks)
- Diagnosis = Vaginismus
- This can limit the assessment and vaginal examination as it prevents adequate palpation of structures within the vagina. For example, the examiner will have difficulty with inspecting the pelvic floor muscle tones, palpating specific regions (i.e. perineal body and vulval tissue) etc. This prevents the practitioner from making accurate diagnosis and treatment.
