Intro to Incontinence and Pregnancy

Stress Incontinence

Urine leaks when the patient exerts pressure on the bladder by coughing, laughing, sneezing, exercising or lifting something heavy

Urge Incontinence

The patient has a sudden, intense urge to urinate followed by an involuntary loss of urine. The patient may urinate frequently, including through the night. May occur due to an infection, neurological disorder, diabetes or age incontinence.

Levator ani

• Creates a superior force towards the heart and a puckering or drawstring motion around the sphincters

• Composed of the pubococcygeus, puborectalis and the iliococcygeus.

What is the recommended amount of weight gain during pregnancy?

• 25 -35 lbs distributed between:

  • Baby

  • Placenta

  • Amniotic fluid

  • Uterus and breasts

  • Blood and fluid

  • Fat stores

How does the uterus change in size during pregnancy?

• Before 2×4 in

• After 10×14 in

• Each ms cell becomes 10x longer

Uterosacral ligaments

Are fibroelastic provide suspensory support for the uterus

How are depth of RR and total lung capacity affected during pregnancy?

Unchanged or slight dec for (TLC)

How are depth of respiration, tidal volume, minute ventilation, and oxygen consumption affected during pregnancy?

Increase

How does the trunk change during pregnancy?

• Ribs flare out as uterus grows

• Chest circ. inc 2-3 in.

• Diaphragm elevated 4 cm

• *Dyspnea present at 20 wks with mild ex.

How much does blood volume inc during pregnancy?

35-50%

During pregnancy plasma increases more than RBC causing physiologic anemia.

True

How does BP change during pregnancy?

Slight in in SBP in early stages and dec (up to 20%) of DBP in early-mid stages

How much does the HR usually inc during full term?

10-20 bpm

Does venous pressure inc in LE during standing while pregnant?

Yes

What are signs of preeclampsia?

• BP over 140/90 on two separate occasions

• Excess protein in urine (proteinuria)

• Severe headaches

• Upper ab pain under R-side

• Changed in vision

• N/V

• Dec urine output

• Dec level of platelets

• Impaired liver function

• SOB due to fluid in lungs

How are vascular structures occluded in supine during pregnancy?

• Dec in venous return → dec cardiac output → causes symptomatic supine hypotensive syndrome

• Pressure on inf vena cava inc in later pregnancy

• Aorta partially occluded in supine

How can occlusion of the aorta be prevented in pregnant women?

Place a folded towel under R-side of pelvis while lying i supine

What changes occur to the musculoskeletal system during pregnancy?

• Ab mms become stretched

• Pelvic floor drops (about 1 in.)

• Thoracolumbar fascia is lengthened

• Hypermobility in wt bearing joints

How can the diastasis recti be monitored?

*Before ab ex

• Patient in hooklying

• Patient raises head and shoulders off surface

• Clinicians fingers placed horizontally across abdomen at umbilicus

• If separation exists, fingers will sink into gap or bulge will be visible between the muscle bellies

How is posture altered during pregnancy?

• COG goes up and forward

• Inc lumbar and cervic lordosis

• Inc thoracic kyphosis

• May or may not self-correct

How is balance affected during pregnancy?

• Pregnant women usually walk with a wider base of support and increased external rotation at the hips than prior to pregnancy

• Center of gravity being higher and more anterior may put the pregnant women at a higher risk for falls.

• They may miss obstacles on the floor

How can the pelvic floor be damaged during birth?

• Stretch and compression of the pudendal and levator ani nerves during labor

• Extreme stretching of the pelvic floor muscles (may require episiotomy-incision or tearing)

Episiotomy degrees

• 1st Degree – only Skin

• 2nd Degree – Includes underlying superficial muscle layer

• 3rd Degree – Extends to anal

  sphincter

• 4th Degree – Tears through anal

  sphincter into the rectum

What are some general guidelines for interventions with pregnant women?

• No > 5min in supine

• Ed. on orthostatic hypotension

• Discourage breath holding

• Avoid high temp and humidity

• Limit single leg wt bearing (risk of SI or pubic symphysis discomfort)

Precaution and contraindication for working with pregnant women

 Persistent pain (esp. chest, pelvic girdle,

low back)

 Leakage of amniotic fluid

 Uterine contractions that persist beyond exercise session

 Vaginal bleeding

 Decreased fetal movements

 Persistent SOB

 Irregular heartbeat

 Tachycardia

 Dizziness/faintness

 Swelling in the calf

 Difficulty in walking

Absolute contraindications for pregnant women in PT

 Incompetent cervix (early dilation)

 Vaginal bleeding in 2nd or 3rd trimester

 Placenta previa (placenta may detach before delivery)

 Multiple gestation with risk of premature birth

 Preclampsia – pregnancy induced hypertension

 Rupture of membranes causing amniotic fluid leak before labor

 Premature labor

 Maternal heart disease, thyroid disease or serious respiratory disease

 Maternal type I diabetes

 Intrauterine growth retardation

Exercise recommendations for pregnant women

• 15-30 min of ex a day (any intensity, 12-14 on Borg for uncomplicated preg)

• No contact sports or wt bearing ex.

• Gradually resume ex postpartum per dr

Recommended ex:

 Posterior pelvic tilt (in a variety of positions)

 Pelvic clock

 Standing push-ups

 Supine bridging

 Modified squatting (wall slides or supported squatting)

 Scapular retraction

 Perineum and Adductor stretching – Knees towards chest and abducted

 Pelvic Floor strengthening exercises (Kegel’s)

What are unsafe ex for pregnant women?

• Bilateral straight-leg raising

• “Fire hydrant” exercise above available range or if patient has history of SI dysfunction

• Quadruped hip extension past available range

• Unilateral weight bearing activities

Cesarean Section

Delivery of baby through an incision in abdominal wall and uterus

Risks:

 Risk of pulmonary, gastrointestinal, or vascular complications

 Risk of infection

 Development of adhesions at incision site

 Faulty posture

 Pelvic floor dysfunction (urinary or fecal incontinence, organ prolapse, hypertonus, poor proprioceptive awareness and disuse atrophy)

 Abdominal weakness, diastasis

What interventions can be used post C-Section?

 Diaphragmatic breathing

 Pelvic floor exercises

 LE AROM, walking

 Postural training

 Pelvic tilts

 Bridging

 Cross-friction massage after incision has healed

**Patient will probably have a lift restriction

of about 10# for 4-6 weeks

How can bed rest affect someone?

• A blood clot in a deep vein, such as a vein in your leg (venous thromboembolism)

• Decreased bone mass (bone demineralization)

• Musculoskeletal and cardiovascular deconditioning

• Stress due to self-blame, child-care issues, and

  concerns about job loss or finances