Introduction To Pelvic Obstetric And Gynaecology

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INTRODUCTION TO PELVICOBSTETRIC ANDGYNAECOLOGYPHYSIOTHERAPYAn Educational ResourcePublished by the Pelvic, Obstetric and Gynaecology PhysiotherapyContact: POGP Administration, Fitwise Management Ltd., Drumcross Hall, Bathgate, WestLothian EH48 4JT T: 01506 811077 E: info@fitwise.co.uk or visit the POGP websitewww.pogp.org.uk for further information. POGP 2015 for review 2018

ContentsCCCCCIntroduction .3Core skill framework.4Obstetrics.5Urology, Gynaecology and Colorectal.8Breast Oncology . . . . .17Appendices1. Obstetric abbreviations .192. Obstetric terminology .203. Urology/ Gynaecology terminology . .264. Gynaecology surgery terminology . .295. Colorectal terminology . . 316. Advanced clinical objectives for performing internal examinations .34Contents1

THREIntroductionIt is acknowledged that physiotherapists may become involved in the management of pelvic,obstetric and gynaecology patients with differing expertise; diverse skills and varying accessto learning support. This aim of this handbook is to guide the learning of physiotherapists toextend knowledge and skills within this speciality.This handbook covers all aspects of the expanding role of the physiotherapist within thisspecialist area. You can select areas that are relevant to your current practise.The handbook is divided into sections; it identifies learning objectives for each subspecialism that maybe included within your scope of practice. It has references to relevantresearch material; patient information and course details that you can access.As an associate member of POGP we hope you find this resource valuable in validating yourcontinued professional development and hope that you are aiming to become a member.There are four ways to achieve membership pogp.csp.org.uk- membership2

Suggested POGP education routesPOGP Educational progressionServicedevelopmentAssigning amentorClinicalSupervisionWomen’sHealth OGPmembershipShort rpointsIcsp3InformalLearning3 years

Core Skill FrameworkAvailable Learning Resources1. Understand normal posture and muscle functionWebsites2. Consider the application of general exercise physiologyto the pelvic floor muscles.www.pogp.csp.org.ukwww.nice.org.uk3. Consider the different exercise methods such as Corestability, MSK techniques, Pilates and hydrotherapywww.rcog.org.uk4. Understanding the roles of the MDT in your specificareaSuggested reading5. Demonstrate an understanding of cultural, social, ethnicand religious variation needs and adapt professionalinteraction to facilitate care6. Demonstrate appropriate skills in communication invarying environments with particular attention togaining informed, valid consent; the use of a chaperoneand motivating patients to be compliant.7. Demonstrate professional behaviour skills in empathyand sensitivity especially where problems mayberegarding bereavement or of a personal, social orintimate nature knowing who to refer to if furtherexpertise is required.8. Apply skills in accurate record keeping maintainingconfidentiality9. Understand the role of the physiotherapist inpreventative care4pogp.csp.org.uk The Role of theWomen’s Health PhysiotherapistJournal of the Association ofChartered Physiotherapists inWomen’s Health (ISSN 13677845)Royal College of Obstetriciansand Gynaecologists (RCOG)GuidelinesCourses University of Bradford PGCert: Physiotherapy inWomen’s health University of Bradford PGCert: Continence forPhysiotherapists

ObstetricsObstetrics is the field of medicine that deals with pregnancy, delivery of the baby and thefirst six weeks after delivery. The role of the physiotherapist may vary considerably inobstetrics from face to face contacts; triage; parentcraft classes, hydrotherapy in inpatientand outpatient environments.Learning objectives:1. Understand normal posture and muscle function2. Investigate the physiological and physical changes that occur in pregnancy; deliveryand in the year following childbirth3. Investigate the reasons which contribute to musculoskeletal dysfunction in obstetrics4. Consider the effects of different exercise methods in pregnancy such as Pilates,hydrotherapy5. Knowledge of red flags that may affect patients care- pre eclampsia, placenta previa6. Select appropriate assessment and examination techniques for the musculoskeletalsystem and apply clinical reasoning skills to direct intervention7. Develop and adapt therapeutic management skills including appropriatemusculoskeletal techniques8. Develop insight into the effects of obesity in the pregnant women on her health andthe health of the unborn child. How can physiotherapists be proactive in themanagement of maternal obesity.5

Available Learning ResourcesAntenatal period Leaflets available throughpogp.csp.org.ukConsider the health promotion aspect of care toantenatal women especially to women with elevatedbody mass index and those with pre-existingmusculoskeletal dysfunction.Investigate methods of educating women in the antenatalperiod including face to face, patient information leafletsand internet resources.Fit for pregnancyFit and safe, for physiotherapists:Exercises in the Childbearing yearFit for birth Investigate the role of the “core muscles” in maintainingposture and function in the antenatal period.Pregnancy related Pelvic Girdlepain (PGP) – for healthProfessionals Review the factors which may contribute to pregnancyrelated low back pain and Pelvic Girdle Pain.Pilates in women’s healthphysiotherapy Investigate common musculoskeletal conditions that aremanaged by physiotherapists including carpal tunnelsyndrome and rib flareThe Mitchell method of simplerelaxation Explore the differential diagnosis of musculoskeletal painsuch as avascular necrosis and metastatic spinal diseaseand complications of pregnancy that influence care. Evaluate the ways physiotherapy treatment may beprovided such as telephone triage, classes, hydrotherapyetc. Investigate the role of physiotherapy in preparation forchildbirth including positioning, relaxation techniquesand pain management. Investigate bladder and bowel management in pregnancy Consider how you may develop services for antenatalwomen Review the Patient Information literature available towomen in the antenatal period.6Aquanatal Guidelines: guidanceon antenatal and postnatalexercises in waterACPWH guidance on the safe useof transcutaneous electricalnerve stimulation (TENS) formusculoskeletal pain duringpregnancyExercise and advice after the lossof your babyFit for the futureSuggested readingMantle J, Haslam J, Barton S(2004) Physiotherapy inObstetrics and Gynaecology 2EdVleeming A, Albert H.B, OstgaardH.C, Sturesson B, Stuge B.2008European Guidelines for thediagnosis and treatment of pelvicgirdle pain. European SpinalJournal 17(6):794-819

Delivery Understand the progress of normal labour andrecognise deviations from the normal and how thiswould need to be managed in the postnatal period.Identify the risks associated with delivery and howthese can be preventedPOGP workshopsPhysiotherapy assessment andmanagement of pregnancyrelated musculoskeletalconditionsThe unique role of the women’shealth physiotherapist inantenatal carePostnatal period Consider appropriate advice that would benefit allwomen in the postnatal period and how this should beconveyed to include those women who haveexperienced the death of a baby. How would this information need to be modified forwomen who had experienced a complicated delivery Recognise pelvic muscle trauma and post-partumbladder and bowel dysfunction and devise appropriatemanagement plans Identify what musculoskeletal dysfunction can occur asa result of the antenatal period or delivery Investigate the methods by which you may managewomen with musculoskeletal dysfunction in the postnatal period such as Diastasis Rectus Abdominis andcoccydynia7

Methods of enhanced learningSuggested observations Antenatal clinicAntenatal wardCommunity midwifeUltrasound departmentMidwife classesPhysiotherapy classes Physiotherapy assessment andtreatment of musculoskeletal painincluding carpal tunnel syndromeEarly antenatal sessionAquanatal classFull course parentcraftPartner’s/companion’s session(s)Young (teenage) classRefresher/multiparae classPre-operative preparation forcaesarean sectionUse of pelvic support beltsTENSWitness normal delivery/waterbirth/ repair of third degreetear/ forceps delivery/ ventousedelivery/ multiple delivery/suturing of perineum/ caesareansectionPostnatal wardPostnatal groupAssessment and treatment ofpregnancy related problems :Perinealoedema/bruising/haematoma/Third or fourth degree tear/Haemorrhoids/ Woundinfection/delayed healing/Urinary/defaecation problems/Low back and pelvic girdle pain/Coccygeal pain/ Divarificaton ofrectus abdominus 8

Urology, gynaecology and colorectalservicesThe areas of paediatric continence; urology; gynaecology; urogynaecology and colorectalphysiotherapy exist in many diverse settings but are often interlinked.Learning objectives:1. Understand normal bladder and bowel function and how this is maintained in thehealthy adult2. Identify the factors that may contribute to urological, gynaecological and or colorectaldysfunction3. Investigate the physiological and physical dysfunctions of the urological, gynaecologyand colorectal systems including incontinence; sexual function, pain and prolapse4. Understand the physiology and muscle function of the pelvic floor and associatedstructures5. Assess relevant subjective and objective information6. Investigate how pelvic floor dysfunction is managed including exercise; lifestyleadvice; group therapy and electrotherapy/ biofeedback7. Investigate the role of the physiotherapist when a patient is admitted for surgicalmanagement of urological, gynaecology and colorectal problems9

Paediatric continence POGP.csp.org.uk- leafletsIdentify factors which maycontribute to childhoodincontinence. Identify the common paediatricbladder and bowel dysfunctions Consider the health promotionaspect of care to children withlong term conditions that affectbladder dysfunction such as cysticfibrosis. Personal training for your pelvicfloorFit following surgery: advice andexercise following majorgynaecology surgeryPilates in Women’s HealthPhysiotherapyPelvic floor Muscle Exercises (forMen)Evaluate methods of treatingchildren with bladder dysfunctionincluding face to face; patientinformation leaflets and internetresources.Pelvic floor Muscle Exercises (forWomen)Promoting Continence withphysiotherapyInvestigate the role of the pelvicfloor and abdominal muscles inmaintaining posture and bladderfunction. Review the Patient Informationliterature available to children withincontinence. Investigate the value of usingmedication in childhoodincontinenceDo you have a problem with yourbladder or pelvic floor?Female Urinary Continence Identify factors which maycontribute to female urinaryincontinence. Identify the common femaleurinary dysfunctions Consider the health promotionaspect of care to women in the10

antenatal and postnatal periodand with long term conditions thataffect bladder function such asneurological conditions,bronchiectasis and diabetes. Investigate the role of the pelvicfloor and abdominal muscles inmaintaining posture and bladderfunction. Evaluate methods of educatingwomen with bladder dysfunctionincluding face to face; grouptherapy; patient informationleaflets and internet resources. Review the Patient Informationliterature available to women withincontinence. Suggested readingPOGP statement re: ES forwomen with recent abnormalcervical cytologyHaylen B. T, De Ridder d,Freeman R.M, Swift S.E,Berghmans B, Lee J, Monga A,Petri E, Rizk D.E, Sand P.K, SchaerG.N 2009 An InternationalUrogynaecological Association/International Continence SocietyJoint Report on the Terminologyfor Female Pelvic FloorDysfunction. Neurology andUrodynamics. 29:4-20CSP Information paper –PD092Pelvic floor examination-CSPexpectationsInvestigate the value of usingmedication in female urinaryincontinenceCSP Information paper-PD104ERUS-IP 24 Chaperoning andrelated IssuesInvestigate the surgicalmanagement of urinaryincontinence in womenEuropean Association of Urology2012. Pelvic floor function andchronic pelvic pain; Guidelines onchronic pelvic painIdentify appropriate advice andexercises to be given to women inthe pre/post-operative periodUrinary Incontinence: themanagement of urinaryIncontinence in Women-UpdatedNICE guideline. Clinicalguidelines, CG171. September2013Menopause Identify the biochemical andmetabolic changes that occur inthe perimenopause; menopauseand postmenopausal periods Identify how health education canassist women in the menopause Investigate the beneficial effects of11

exercise and the types of exercisefor women in the menopause Investigate the beneficial effects ofacupuncture to menopausalwomen Investigate the use of medicationin managing menopausalsymptomsAppendicesAdvanced clinical objectives forperforming internal examinationsPOGP workshopsPhysiotherapy assessment andmanagement of female urinarydysfunctionUnderstanding pelvic organprolapse- assessment andconservative managementPhysiotherapy and managementof anorectal dysfunctionVaginal Prolapse Identify factors which maycontribute to developing vaginalprolapse in women.ResourcesIcsp- assessment formsIdentify the types andclassification of prolapse. Investigate the symptoms ofprolapse. Consider the health promotion towomen regarding constipation;heavy lifting and a caring role. Investigate the role of the pelvicfloor and abdominal muscles inmanaging the symptoms ofprolapse. Assess and provide pelvic floormuscle exercises to women withprolapse. Evaluate methods of educatingwomen with lifestyle advice, pelvicfloor and posture advice includingface to face; group therapy;patient information leaflets andinternet resources.Blogs/ Twitter/ FacebookPOGP/ Sandy Hilton/ Sue Croft/Jessica Drumond/ Fiona Rogers/Jo Milos/ Tracey Sher/ JaneAppleyard/ Alyssa Tait/ RamonaHorton/ Diane Lee/ Sherrie Palm/Teresa Costello/ Julie Wiebe/Michelle Lyons12

Review the Patient Informationliterature available to women withprolapse. Investigate the value of usingpessaries and medication inprolapse Investigate the surgicalmanagement of prolapse inwomen Identify appropriate advice andexercises to be given to women inthe pre/post-operative periodMale Urinary Continence Review the male urogenital system Identify the common malecontinence dysfunctions and thefactors that contribute to itsdevelopment Consider health promotion to men Investigate the role of the pelvicfloor in male bladder and erectilefunction. Evaluate methods of educatingmen with bladder and erectiledysfunction including face to face;group therapy; patient informationleaflets and internet resources. Review the Patient Informationliterature available to men withpelvic floor dysfunction. Investigate the value of usingmedication in male urinary13

incontinence and erectiledysfunction Investigate the role ofphysiotherapy in the surgicalmanagement of prostatedysfunction Investigate the role ofphysiotherapy in overactive pelvicfloor functionBowel Continence Identify normal anatomy andphysiology in normal bowelfunction including storage anddefecation Consider the health promotion ofbowel function. Investigate the reasons andcontributing factors for alteredbowel function such as slowtransit, constipation, irritablebowel syndrome Identify the common boweldysfunctions Evaluate the assessment of pelvicfloor function related to anorectalstructures Investigate the role of the pelvicfloor in maintaining bowelfunction and use of techniquessuch as biofeedback. Evaluate methods of educatingpatients with bowel dysfunctionincluding face to face; group14

therapy; patient informationleaflets and internet resources. Review the Patient Informationliterature available to patientswith bowel incontinence. Investigate the value of usingmedication in bowel incontinence Suggested ReadingChronic Pelvic Pain andDysfunction: Practical PhysicalMedicine. Leon Chaitow L, Jones RJanuary 2012Heal Pelvic Pain. Stein A.September 2008Investigate the role of the MDT inmanaging bowel incontinenceRCOG Chronic Pelvic Pain, InitialManagement (Green-top GuidelineNo. 41 May 2012Engeler D, Baranowski AP, Elneil S,Hughes J, Messelink EJ, Oliveira P,van Ophoven A, de C. Williams AGuidelines on Chronic Pelvic Pain.February 2012Chronic pelvic pain Identify musculoskeletal factorsthat may contribute to chronicpelvic pain including pudendalnerve neuropathy Define Vaginismus and Vulvodynia Reflect on approaches topersistent pain management Investigate theories for improvedpatient education Investigate methods of managingCPP including downtraining thepelvic floor; acupuncture;biofeedback; relaxation;Neurostimulation and injection Surgical management of CPP15

Methods of enhanced learningSuggested observationsInpatients Observation in theatre: Totalabdominal hysterectomy; Vaginalhysterectomy; Pelvic floor repair;Urethral sling procedure; fistularepair; TURP Pre-operative/pre-admissionsession Post-operative careOutpatients: Urology/ Gynaecology clinic Urodynamics Continence adviser Nurse specialist Vulvodynia clinic Specialist Paediatric continenceservices Bladder retraining Vaginal examination Anorectal examination; Treatment modalities including:Lifestyle advice; Pelvic floorexercises; Posture re-education;Biofeedback; Neuromuscularstimulation; Manual Therapy;Devices e.g cones Group therapy Pessary clinic16

Breast OncologyLearning objectives:1. Investigate the lymphatic system2. Understand breast cancer pathogenesis3. Investigate the treatment of breast cancer to include surgical, radiological andchemotherapy4. Identify the physiotherapy role in the management of patients in the surgical,radiological and chemotherapy environments to include manual therapy and exerciseand identify the clinical considerations of care such as pain and fatigue5. Investigate reducing oedema and fibrosis following medical management of breastcancer17

Breast surgerySuggested ReadingObserve the procedures used in breastcancer and reconstructive surgeryAssociation Oncoplastic breastsurgery –A guide to goodpracticeExplore the role of the physiotherapistwithin the surgical Multidisciplinary teamNICE guideline CG80 Early andadvanced breast cancer diagnosisand treatment 2012Discover the psychosocial impact of breastcancer and its treatmentNeely ML, Campbell KL , RoweBH, Klassen TP, Mackey JR,Courneya KS. Effects of exerciseon breast cancer patients andsurvivours: a systematic reviewand meta analysis. CMAJ 2006:175:34-41Identify the non-musculoskeletal andmusculoskeletal complications aftersurgeryIdentify the primary and secondaryinduced health problems associated withchemotherapy; radiotherapy andhormone therapyMarkes M, Brockow T, Resch KL,Exercise for women receivingadjuvant therapy for breastcancer. Cochrane database Systrev 2006 Oct 18; (4): CD005001Investigate lymphoedema and itsmanagement through exercise, pressuregarments and complex decongestivetherapyExplore how pain and cancer relatedfatigue may be managed via medication,physiotherapy and complimentarytherapiesGoomide LB, Matheus JP,Candidodos Reis FJ. Morbidityafter breast cancer trea

2 T H R E It is acknowledged that physiotherapists may become involved in the management of pelvic, obstetric and gynaecology patients wi

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