Who is a woman?

An individual of the sex which conceives and brings forth young, or (in a
wider sense) which has an ovary and produces ova. an individual of the
sex that is typically capable of bearing young or producing eggs.

Features
higher percentage of body fat and wider hips.
have a smaller and lighter skeletal structure, particularly in the hips and
pelvic area, to accommodate pregnancy and childbirth. The female pelvis is
wider and more shallow than the male pelvis,
including the vagina, uterus, and ovaries. breasts.

Bartholin's glands
The Bartholin's glands are located on each side of the vaginal opening.
These glands secrete fluid that helps lubricate the vagina. Sometimes the
openings of these glands become obstructed, causing fluid to back up into
the gland. The result is relatively painless swelling called a Bartholin's cyst.

The Bartholin's glands (named after Caspar Bartholin the Younger; also
called Bartholin glands or greater vestibular glands) are two pea
sized compound alveolar glands located slightly posterior and to the left and
right of the opening of the vagina. They secrete mucus to lubricate the
vagina.
They are homologous to bulbourethral glands in males. However, while
Bartholin's glands are located in the superficial perineal pouch in females,
bulbourethral glands are located in the deep perineal pouch in males. Their
duct length is 1.5 to 2.0 cm and they open into navicular fossa. The ducts are
paired and they open on
the surface of the vulva.

Skene's glands
 In female human anatomy, Skene's glands or the Skene glands also known
as the lesser vestibular glands or paraurethral glands) are glands located
around the lower end of the urethra. The glands are surrounded by tissue that
swells with blood during sexual arousal, and secrete a fluid from openings
near the urethra, particularly during orgasm. The Skene's glands are located
in the vestibule of the vulva, around the lower end of the urethra. The two
Skene's ducts lead from the Skene's glands to the vulvar vestibule, to the left
and right of the urethral opening, from which they are structurally capable of
secreting fluid. Although there remains debate about the function of the
Skene's glands, one purpose is to secrete a fluid that helps lubricate the
urethral opening.

Types of pelvis
Ÿ Gynecoid pelvis: This is the most common type of pelvis in women. It has a
rounded shape with a wide pelvic inlet and a generous pelvic cavity, making
it well-suited for childbirth.

Ÿ Android pelvis: This type of pelvis is more common in men but can also
occur in women. It has a heart-shaped inlet with a narrow pelvic cavity,
which can make childbirth more challenging.

Ÿ Anthropoid pelvis: This type of pelvis has an oval-shaped inlet with a narrow
transverse diameter and a long anteroposterior diameter. It is more common
in women and may be associated with easier childbirth compared to the
android pelvis.

Ÿ Platypelloid pelvis: This is the least common type of pelvis and is

characterized by a flat, wide shape with a wide transverse diameter and a
short anteroposterior diameter. It may present challenges during childbirth
due to its shape.

Role of physiotherapy in pregnancy

Ÿ Physiotherapy can help with numerous musculoskeletal changes observed in
women during childbearing months.

Ÿ The therapies are designed to treat issues such as low and mild back pain,
piriformis muscle spasm, rectus diastasis, carpal tunnel symptoms, various
bladder problems, and joint pain.

Ÿ If a woman adopts antenatal physiotherapy, she can enhance normal labour

as well, which will prevent her from the complications of cesarean

Ÿ It will be easier for the mother to recover in the postnatal period due to the
physiotherapy interventions and return back to normal. Moreover, exercise
sessions prevent postpartum problems as well.

Ÿ It can also prevent urinary incontinence that a majority of the women

experience during pregnancy.

Ÿ Physiotherapy also helps a woman to feel energetic and happy with a baby in
the womb as it increases happiness hormones.

Indications for antenatal care:

Ÿ To assess the state of health of the mother and the fetus early in pregnancy.
Ÿ To prepare for labour and prevent unwanted complications of labour or
pregnancy.
Ÿ To prevent maternal and child mortality.
Ÿ To promote and maintain optimal physical and emotional maternal health.
Ÿ To foster good husband, wife and child relationship. Antenatal care
encourages family interactions and bonding between husband, wife and their
baby.
Ÿ To prepare for purperium and child care
Ÿ To prepare and educate mother on mode of delivery, mode of care and place
of delivery
Ÿ To recognize and treat correctly any medical or obstetric complications
occurring during pregnancy
Ÿ To detect foetal abnormalities as early as possible

Routine tests:

Ultrasound scans. You will be offered two scans, one early in pregnancy at
approximately 11–14 weeks and another at 18–21 weeks
Blood group

Iron deficiency anaemia

Prenatal screening

Blood pressure

Blood test

Group B Streptococcus

Hepatitis B

Rubella

Complete blood count

HIV

Syphilis

Urinalysis

Cervical screening

Gestational diabetes
Pregnancy:
Pregnancy is the time during which one or more offspring develops
(gestates) inside a woman's uterus. Pregnancy is the biological process
through which a woman carries and nurtures a developing embryo or fetus
within her uterus until it is ready to be born. It begins with conception, when
a sperm fertilizes an egg, forming a zygote. The zygote then implants itself
into the lining of the uterus, where it begins to grow and develop.

The most important tasks of basic fetal cell differentiation occur during the
first trimester, so any harm done to the fetus during this period is most likely
to result in miscarriage or serious disability. This stage truly ends with the
phenomenon of quickening: the mother's first perception of fetal movement.
It is in the first trimester that some women experience "morning sickness," a
form of nausea on awaking that usually passes within an hour. The breasts
also begin to prepare for nursing, and painful soreness from hardening milk
glands may result. As the pregnancy progresses, the mother may experience
many physical and emotional changes, ranging from increased moodiness to
darkening of the skin in various areas. During the second trimester, the fetus
undergoes a remarkable series of developments. Its physical parts become
fully distinct and at least somewhat operational. As the fetus grows in size,
the mother's pregnant state will begin to be obvious. In the third trimester,
the fetus enters the final stage of preparation for birth. It increases rapidly in
weight, as does the mother. As the end of the pregnancy nears, there may be
discomfort as the fetus moves into position in the woman's lower abdomen.
Edema (swelling of the ankles), back pain, and balance problems are
sometimes experienced during this time period. Most women are able to go
about their usual activities until the very last days or weeks of pregnancy,
including non-impact exercise and work. During the final days, some feel too
much discomfort to continue at a full pace, although others report greatly
increased energy just before the birth. Pregnancy ends when the birth process
begins.
Pregnancy is typically divided into three stages, known as trimesters, each
lasting approximately three months. These stages mark significant
milestones in the development of the fetus and the changes experienced by
the mother's body:

1. **First Trimester (Weeks 1-12):**

- Conception occurs when a sperm fertilizes an egg, forming a zygote. The
zygote undergoes rapid cell division as it travels down the fallopian tube and
implants itself into the uterine lining, becoming an embryo.
- Major organs and structures begin to form during this period, including
the brain, spinal cord, heart, and limbs.
- The mother may experience symptoms such as fatigue, nausea (often
referred to as morning sickness), breast tenderness, frequent urination, and
mood swings due to hormonal changes.
- The risk of miscarriage is highest during the first trimester, particularly in
the early weeks.
Morning sickness, nausea, vomiting, bleeding, spontaneous abortion,
ectopic pregnancy. Btw first and 3rd months

2. **Second Trimester (Weeks 13-26):**

- By the second trimester, the embryo has developed into a fetus, and many
of the major organs and structures are fully formed.
- The fetus continues to grow and mature, and its movements become more
pronounced. Expectant mothers may begin to feel the baby's movements,
known as quickening.
- Pregnancy symptoms such as nausea and fatigue often improve during
this trimester, and many women experience a surge of energy.
- Around the midpoint of the second trimester, usually between weeks 18
and 20, many women undergo a prenatal ultrasound to screen for fetal
abnormalities and determine the baby's sex.

3. **Third Trimester (Weeks 27-Birth):**

- In the third trimester, the fetus undergoes rapid growth and development,
and its organs and systems mature in preparation for birth.
 - The mother's abdomen expands as the uterus continues to grow to
accommodate the growing baby, leading to discomfort and difficulty with
mobility for some women.
- Braxton Hicks contractions, also known as "practice contractions," may
occur as the body prepares for labor.
- Towards the end of the third trimester, the baby typically settles into a
head-down position in preparation for birth.
- Labor may begin spontaneously, or it may be induced if necessary. The
baby is born either vaginally or via cesarean section, marking the
culmination of pregnancy.

Physiological changes :
Pregnancy and the associated changes are a normal physiological process in
response to the development of the fetus. These changes happen in response
to many factors; hormonal changes, increase in the total blood volume,
weight gain, and increase in foetus siz³ as the pregnancy progresses. All
these factors have a physiological impact on the pregnant woman: the
musculoskeletal, endocrine, reproductive , cardiovascular, respiratory,
nervous, urinary, gastrointestinal and immune systems are affected, along
with changes to the skin and breasts. The full gestation period is 39-40
weeks, and a pre-term birth is classed as delivery before 37 weeks gestation,
although there is variation internationally and it is thought that the length of
human pregnancies also vary naturally.

Endocrine System Changes

Pregnancy is associated with changes in hormone levels. These hormones

work together to control the growth and development of the placenta and the
foetus, and act on the mother to support the pregnancy and prepare for
childbirth. Many organs of the body secrete hormones which affect the
expectant mother, although when the placenta is developed it then takes over
the production of many of these hormones, including: oestrogen,
progesterone, human chorionic gonadotrophin (HCG), human placental
lactogen, placental growth hormone, relaxin and kisspeptin.

HCG is the first hormone to be released from the developing placenta and is
the hormone that is measured in a pregnancy test. It acts as a signal to the
mother’s body that pregnancy has occurred by maintaining progesterone
production.

Progesterone is initially produced by corpus luteum, a temporary endocrine

gland found in the ovary. Progesterone maintains the pregnancy, by
supporting the lining of the womb and preventing premature uterine
contractions. It reduces the tone of smooth muscles (causing constipation due
to the water retention in the colon), contributes to breast development,
increases the storage of fat due to its catabolic effect on metabolism and
increases body temperature.

Oestrogen, is also initially produced by the corpus luteum and later by the
placenta. Oestrogen levels rise towards the end of pregnancy. Oestrogen acts
to stimulate the growth of the uterus to accommodate the growing fetus, by
having a vasodilation effect and increasing blood flow to the uterus. It allows
the uterus to contract by countering the effect of progesterone and in this
way, prepares the uterus for labour. Oestrogen also stimulates the growth and
development of the breasts.

Relaxin causes the relaxation of pelvic ligaments and softening of the cervix
at the end of pregnancy, which aids the process of labour.

Reproductive System Changes

During pregnancy, the internal genital tract undergoes anatomical and

physiological changes to accommodate the changes and development of the
foetus.

Uterus
Ÿ With pregnancy progression, the uterus leaves the pelvis and ascends to the
abdominal cavity

Ÿ The abdominal content displaced in response to the increased size of the

uterus which is five times more than normal.

Ÿ This increase in the size of uterus is associated with an increase of blood

supply to the uterus and uterine muscle activity,

Ÿ Uterus increases in size till the 38 weeks after that the fundus level starts to
descend preparing for delivery.

Ÿ Its weight increases from 50mg to 1000mg at 40 weeks and stretches to

accommodate the foetus size, which is associated with an increase in the
thickness and length of the fundus.

Cervix

The enlarged mucus glands of the cervix during pregnancy secrete a mucus,
which
 forms a plug called the “operculum”. This acts as a seal for the uterus and
protects it from ascending infection, and acts as a barrier between the vagina
and cervix. Later in pregnancy before delivery, there is a softening of the
cervix in response to oestrogen and progesterone. Ripening of the cervix
occurs due to the effect of prostaglandin and relaxin as labour becomes
imminent.

Vagina

The muscle layer of the vagina thickens and it becomes more elastic, making
it possible for the vagina to dilate during the second phase of labour. The
number of squamous cells increases, due to glycogen, which predisposes the
vagina towards thrush. [3][4].

Musculoskeletal Changes

Postural Changes

Ÿ The overall equilibrium of the spine and pelvis alters as the pregnancy
progresses

Ÿ The centre of gravity no longer falls over the feet, but instead shift
posteriorly. There is an increase in anteroposterior and medial-lateral sway,
and women may need to lean backwards to gain equilibrium resulting in
disorganisation of spinal curves.

Ÿ Reported postures include: a reduction in lumbar lordosis, an increase in

both lumbar lordosis and thoracic kyphosis, or a flattening of the
thoracolumbar spinal curve.
There will be compensatory changes to posture in the thoracic and cervical
spines, and this combined with the extra weight of the breasts may result in
posterior displacement of the shoulders and thoracic spine, increase anterior
pelvic tilting, and increase of the cervical lordosis.[7]
Ÿ These changes may be still similar for 8 weeks after delivery.

Articular Changes

Ÿ Altered levels of relaxin, oestrogen, and progesterone during pregnancy

result in an alteration to collagen metabolism. This laxity is due to the break
down of collagen in the targeted tissue which is replaced by a modified form
that contains higher water content.
Connective tissue pliability and extensibility increases.
Therefore, ligamentous tissues are predisposed to laxity with resultant
reduced passive joint stability. Ligament laxity reaches its maximum at the
second trimester.

Ÿ The symphysis pubis and sacroiliac joints are particularly affected to allow
for the birth of the baby. Ligamentous laxity may continue for six months
postpartum. Bio-mechanical changes of the spinal and pelvic joints may
involve: an increase in sacral promontory, an increase in lumbosacral angle,
a forward rotatory movement of the innominate bones, and downward and
forward rotation of the symphysis pubis.
Ÿ The normal pubic symphyseal gap of 4–5 mm shows an average increase of
3 mm during pregnancy

Ÿ Pelvic joint loosening begins around 10 weeks, with maximum loosening

near term. Joints should return to normal at 4–12 weeks postpartum.

Ÿ The sacrococcygeal joints also loosen. By the last trimester, the hip
abductors, extensors, and the ankle plantar flexors increase their net power
during gait and there is an increase in load on the hip joints of 2.8 times the
normal value when standing and working in front of a worktop. As the uterus
rises in the abdomen the rib cage is forced laterally and the diameter of the
chest may increase by 10–15 cm.[7]

Neuromuscular Changes
 During pregnancy, the enlarged uterus results in elongation of the abdominal
muscles and separation of the linea alba.

Ÿ Passive joint instability (as seen in pregnancy) alters afferent input from joint
mechanoreceptors and probably affects motor neuron recruitment.

Ÿ A decrease in muscle stiffness and thus active stability of joints may result
from alteration of muscle spindle regulation and this is applicable
particularly to muscles around the pelvic girdle.

Nervous System

Ÿ Fluid retention can compress nerves passing through narrow canals, such as
the carpal tunnel, causing pain, numbness and weakness in the hand.

Cardiovascular changes

Ÿ Cardiac output increases throughout early pregnancy, and peaks in the third
trimester, usually to 30-50% above baseline.

Ÿ Oestrogen mediates this rise in cardiac output by increasing the pre-load and
stroke volume, mainly via a higher overall blood volume (which increases by
40–50%).

Ÿ The heart rate increases, but generally not above 100 beats/ minute.

Ÿ Total systematic vascular resistance decreases by 20% secondary to the

vasodilatory effect of progesterone.
Ÿ All of these cardiovascular adaptations can lead to common complaints, such
as palpitations, decreased exercise tolerance, and dizziness.

Ÿ Women may suffer from supine hypotension due to uterine compression of

the vena cava.
 Respiratory Changes

Ÿ There is increasing oedema in the upper airway tract, and if intubation was
necessary a smaller endotracheal tube would be needed.

Ÿ The diaphragm is elevated by about 4cm due to the enlarged uterus.

Ÿ Ligaments connecting ribs to sternum become lax during pregnancy. The

subcostal angle increases from 68 in early pregnancy to 103 in late
pregnancy. Chest circumference increase from 5-7cm and this is
associated with lower chest compliance.

Ÿ Lung Volumes change as follows; functional residual capacity decreases by

10-25%, expiratory reserve volume 15-20%, residual volume is decreased
by 20-25%, and the total lung capacity decreases. There is an increase in the
respiratory capacity by 5-10%, respiratory rate by 1-2 breaths more than
normal, and tidal volume by 30-50%.

Ÿ We will find an increase in oxygen consumption by 30% and the metabolic

rate by 15% in pregnant women.
Pregnant women are more prone to hypoxia, hyperventilation and dyspnea
than non-pregnant women.

Ÿ In addition to these changes there is an increase in PaO2 to facilitate the

transfer of oxygen from mother to foetus and lower PaCo2 to facilitate the
transfers of carbon dioxide from foetus to mother

Gastrointestinal changes

Ÿ Progesterone causes smooth muscle relaxation which slows down GI

motility and decreases lower oesophageal sphincter (LES) tone.
Ÿ The resulting increase in intra-gastric pressure combined with a decrease in
LES tone leads to the gastro-oesophageal reflux commonly experienced
during pregnancy.

Ÿ Nausea and vomiting of pregnancy, commonly known as “morning

sickness”, is one of the most common GI symptoms of pregnancy. It begins
between the 4 and 8 weeks of pregnancy and usually subsides by 14 to 16
weeks.

Ÿ Constipation and haemorrhoids can occur during pregnancy, and are

attributed to the smooth muscle relaxation, decreased motility of the bowel
and increased water absorption of the colon.

Renal changes

Ÿ A pregnant woman may experience an increase in the size of the kidneys and
ureter due to the increased blood volume and vasculature.

Ÿ Later in pregnancy, the woman might develop physiological hydronephrosis

and hydroureteronephrosis, which are normal.

Ÿ There is an increase in glomerular filtration rate associated with an increase

in creatinine clearance, protein, albumin excretion, and urinary glucose
excretion.

Ÿ There is also an increase in sodium retention from the renal tube so oedema
and water retention is a common sign in pregnant women

Ÿ In the third trimester when the foetus starts to engage in the pelvis, there is
an increased frequency of urination. The uterus compresses the ureters at the
pelvic brim, causing a slowing of urine flow which combined with an
increase in urine output results in frequent trips to the toilet.
Stress and urge incontinence are common amongst pregnant women.
 Skin

Ÿ Pigmentation changes occur during pregnancy including darkening of the

areola on the breasts and the linea nigra, increased colouring on the vulva
and increased facial pigmentation.

Ÿ Stretch marks (striae gravidarum) occur on the abdomen, breasts, thighs and
buttocks to varying degrees. They may occur due to changes in the elastic
fibres and collagen in the dermis, which ruptures and overstretches the
epidermis, causing the scarring.

Ÿ During pregnancy there is a marked reduction in normal hair loss, due to an

increased growth phase of the hair follicles.

Breasts

Ÿ Breast tenderness is common in the early stages of pregnancy due to

enlargement under the influence of relaxin, progesterone and oestrogen.
Breasts increase in weight by aproximately 500-800g.

Ÿ Montgomery's tubercles developing form enlarging sebaceous glands around

the areolar.
Ÿ Immunity

Ÿ Mother has some general depression of immunity so that she does not reject
the foetus

Ÿ Slightly increased risk of latent viruses reactivating e.g. influenza,

pneumococcal pneumonia

Problems may have during pregnancy

Ÿ Pelvic floor dysfunction.

Ÿ Rib pain.

Ÿ Nerve compression syndromes.

Ÿ Carpal tunnel syndrome.

Muscle cramps.

Ÿ Symphysis pubis dysfunction

Ÿ Morning sickness.

Ÿ Edema.

Ÿ Pre-eclampsia

Ÿ Back pain.

Post partum conditions:

cardiopulmonary conditions like hypertension, thrombosis, and heart failure.

Prompt monitoring of blood pressure, especially for postpartum
preeclampsia, is crucial before discharge

Conditions like eclampsia and stroke heighten maternal-fetal risk due to

brain
injury. Obstetric nerve issues also elevate falling risk.

Common birth- and pregnancy-related injuries encompass issues like pelvic

symphysis diastasis and lumbar injuries, which can cause pain, mobility
problems, and challenges with daily activities. These injuries ma include one
or mare of the following;

Ÿ Increased elasticity in ligaments, which can last 4-5 months from labour.
Ÿ Elongation and separation between the two recti abdominis muscles known
as Diastasis recti abdominis[9]

Ÿ Weakened pelvic floor musculature, including weakened perineal muscles

Ÿ

Muscular abnormalities and weakness in the levator ani muscle

Ÿ Urinary incontinence

Ÿ Pelvic organ prolapse

Ÿ Pelvic floor neuropathy

Ÿ Incontinence of stool and flatus

Ÿ Swollen extremities hands, feet, and ankles[14][15]

Ÿ Excessive weight gain

Ÿ Low back pain (LBP)

Around 10% of women experience perinatal mood and anxiety disorders

(PMADs), including depression and anxiety. Factors like single parenthood
and mental health history raise the risk[20]. Screening for mental health
during and after pregnancy can identify those at risk, guiding acute care
occupational therapy to aid recovery and decrease the rate of readmissions.

Complications post pregnancy

Maternal mortality
Ante partum hemorrhage
Anemia
Back pain
AKI
Decreased foetal movt
Cardiac dxs
DVT
High Blood Pressure: High blood pressure, also called hypertension, occurs
when arteries carrying blood from the heart to the body organs are narrowed.
This causes pressure to increase in the arteries. In pregnancy, this can make
it hard for blood to reach the placenta, which provides nutrients and oxygen
to the fetus.1 Reduced blood flow can slow the growth of the fetus and place
the mother at greater risk of preterm labor and preeclampsia.

Women who have high blood pressure before they get pregnant will continue
to have to monitor and control it, with medications if necessary, throughout
their pregnancy. High blood pressure that develops in pregnancy is called
gestational hypertension. Typically, gestational hypertension occurs during
the second half of pregnancy and goes away after delivery.

Gestational Diabetes: Gestational diabetes occurs when a woman who

didn't have diabetes before pregnancy develops the condition during
pregnancy.

Infections : Infections, including some sexually transmitted infections

(STIs), may occur during pregnancy and/or delivery
 and may lead to complications for the pregnant woman, the pregnancy, and
the baby after delivery. Some infections can pass from mother to infant
during delivery when the infant passes through the birth canal; other
infections can infect a fetus during the pregnancy.

Preeclampsia : Preeclampsia is a serious medical condition that can lead to

preterm delivery and death. Its cause is unknown, but some women are at an
increased risk. Risk factors include:

Ÿ First pregnancies

Ÿ Preeclampsia in a previous pregnancy

Ÿ Existing conditions such as high blood pressure, diabetes, kidney disease,

and systemic lupus erythematosus

Ÿ Being 35 years of age or older

Carrying two or more fetuses

Ÿ Obesity

Preterm Labor: Preterm labor is labor that begins before 37 weeks of

pregnancy. Any infant born before 37 weeks is at an increased risk for health
problems, in most cases because organs such as the lungs and brain finish
their development in the final weeks before a full-term delivery (39 to 40
weeks).

Certain conditions increase the risk for preterm labor, including infections,
developing a shortened cervix, or previous preterm births.

Depression & Anxiety : Research shows that as many as 13% of U.S.

women reported frequent symptoms of depression after childbirth, and that
anxiety co-occurs in up to 43% of depressed pregnant and postpartum
women, making pregnancy-related depression and anxiety among the more
common pregnancy complications.8 These medical conditions can have
significant effects on the health of the mother and her child. But the good
news is that these are treatable medical conditions. The NICHD-led Moms’
Mental Health Matters initiative is designed to educate families and health
care providers about who is at risk for depression and anxiety during and
after pregnancy, the signs of these problems, and how to get help.

Pregnancy Loss/Miscarriage : Miscarriage is the term used to describe

a pregnancy loss from natural causes before 20 weeks. Signs can include
vaginal spotting or bleeding, cramping, or fluid or tissue passing from the
vagina. However, bleeding from the vagina does not mean that a miscarriage
will happen or is happening.9 Women experiencing this sign at any point in
their pregnancy should contact their health care provider.

Stillbirth : The loss of pregnancy after the 20th week of pregnancy is called
a stillbirth. In approximately half of all reported cases, health care providers
can find no cause for the loss. However, health conditions that can contribute
to stillbirth include chromosomal abnormalities, placental problems, poor
fetal growth, chronic health issues of the mother, and infection.

Other Complications
Severe, persistent nausea and vomiting. Although having some nausea and
vomiting is normal during pregnancy, particularly in the first trimester, some
women experience more severe symptoms that last into the third trimester.

Iron-deficiency anemia. Pregnant women need more iron than normal for
the increased amount of blood they produce during pregnancy. Iron-
deficiency anemia—when the body doesn't have enough iron—is somewhat
common during pregnancy and is associated with preterm birth and low birth
weight. Symptoms of a deficiency in iron include feeling tired or faint,
experiencing shortness of breath, and becoming pale.
Role of PT in gynecology:

1. Pre and postnatal care: Physiotherapists provide exercises and techniques

to help women prepare for childbirth, manage discomfort during pregnancy,
and recover postpartum, such as pelvic floor exercises and breathing
techniques. Postnatally, physiotherapy aids in recovering pelvic floor
strength and abdominal muscle tone.

2. Pelvic floor rehabilitation: Physiotherapy helps in treating pelvic floor

dysfunction, including urinary incontinence, pelvic organ prolapse, and
pelvic pain. Therapists use exercises, manual therapy, biofeedback, and
electrical stimulation to strengthen and rehabilitate the pelvic floor muscles.

3. Pain management: Physiotherapists can help manage gynaecological pain

conditions such as dysmenorrhea (painful periods), endometriosis, and pelvic
inflammatory disease through techniques like manual therapy, acupuncture,
and relaxation techniques.

4. Pre and postoperative care: Physiotherapy interventions help prepare

women for gynaecological surgeries and facilitate recovery afterward. This
may involve exercises to optimize muscle strength and mobility, breathing
exercises, and pain management strategies.

5. Sexual health: Physiotherapists can address sexual dysfunction and pain

disorders, such as vaginismus or dyspareunia, through pelvic floor
rehabilitation, counseling, and education on relaxation techniques.

6. Scar Management: After gynaecological surgeries, such as C-sections or

hysterectomies, physiotherapy helps manage scar tissue through massage,
stretching, and other modalities to minimize discomfort and improve
mobility.
7. Lymphedema Management: For women who have undergone lymph node
dissection as part of cancer treatment, physiotherapy helps manage
lymphedema through specialized techniques like manual lymphatic drainage
and compression therapy.

6. Education and Lifestyle Modification: Physiotherapists educate women

about their pelvic health, menstrual hygiene, and lifestyle modifications to
prevent gynecological issues and optimize overall well-being.

Gynecological conditions:

1. **Fibroids**: Noncancerous growths in the uterus that can cause pelvic

pain and heavy menstrual bleeding.

2. **Endometriosis**: Condition where tissue similar to the lining of the

uterus grows outside the uterus, causing pain, infertility, and irregular
bleeding.

3. **Pelvic pain**: Pain in the lower abdomen, often associated with

gynaecological issues like endometriosis, fibroids, or pelvic inflammatory
disease.

4. **Polycystic ovary syndrome (PCOS)**: Hormonal disorder

characterized by irregular periods, excess hair growth, acne, and cysts on the
ovaries.

5. **Ovarian cysts**: Fluid-filled sacs on the ovaries, which can sometimes

cause pain or discomfort.

6. **Cancer**: Various types of cancer can affect the female reproductive

organs, including ovarian, uterine, cervical, and breast cancer.

7. **Prolapse**: Descent or dropping of pelvic organs like the uterus,

bladder, or rectum into the vaginal canal.
8. **Menstrual disorder**: Any abnormality in the menstrual cycle,
including irregular periods, heavy bleeding, or absence of menstruation.

9. **Infertility**: Inability to conceive or carry a pregnancy to term, often

due to issues with ovulation, fallopian tubes, or sperm quality.

10. **Menopause**: Natural cessation of menstruation, typically occurring

around age 50, accompanied by hormonal changes and symptoms like hot
flashes and mood swings.

11. **Urinary incontinence**: Involuntary leakage of urine, which can be

caused by weakened pelvic floor muscles or nerve damage.

12. **Dysmenorrhea**: Painful menstruation, often caused by uterine

contractions and hormonal imbalances.

13. **Cervical disorders**: Conditions affecting the cervix, such as cervical

dysplasia or cervical incompetence.

14. **Infections**: Bacterial, viral, or fungal infections of the reproductive

organs, including sexually transmitted infections (STIs) like chlamydia and
gonorrhea.

15. **Uterine bleeding**: Abnormal bleeding from the uterus, which can be
caused by hormonal imbalances, fibroids, or cancer.
16. **Vaginitis**: Inflammation or infection of the vagina, often causing
itching, discharge, and discomfort.

17. **Disorders of the vulva**: Various conditions affecting the external

female genitalia, such as lichen sclerosus or vulvodynia.

18. **Frequent urination**: Need to urinate more often than usual, which
can be caused by urinary tract infections, bladder disorders, or pregnancy.
19. **Adenomyosis**: Condition where the tissue lining the uterus grows
into the muscular wall, causing heavy periods and pelvic pain.

20. **Adnexal tumors**: Tumors arising from the ovaries, fallopian tubes,
or surrounding tissues, which can be benign or malignant.

21. **Painful intercourse**: Discomfort or pain during sexual intercourse,

which can be caused by various gynaecological issues like endometriosis,
infections, or vaginal dryness.

22. **Amenorrhea**: Absence of menstruation, which can be primary

(never starting) or secondary (stopping after already having started).

23. **Female genital tract malformations**: Congenital abnormalities

affecting the structure of the female reproductive organs, such as Müllerian
duct anomalies.

24. **Miscarriage**: Spontaneous loss of pregnancy before the fetus can

survive outside the womb, often occurring in the first trimester.

Labour:
Definition of Labor
Labor is a series of continuous, progressive contractions of the uterus that
help the cervix dilate and efface (thin out). This lets the fetus move through
the birth canal. Labor usually starts two weeks before or after the estimated
date of delivery. However, the exact trigger for the onset of labor is
unknown.

Symptoms of going into labour

Some of the signs and symptoms of going into labour may include:
Ÿ 1. Regular contractions: Contractions become regular, more intense, and
closer together over time. They typically start in the lower back and move to
the front of the abdomen.

Ÿ 2. Bloody show: A small amount of blood-tinged mucus discharge may

occur as the cervix begins to dilate and efface.

Ÿ 3. Water breaking: The amniotic sac may rupture, releasing amniotic fluid.
This can happen as a sudden gush or as a slow trickle.

Ÿ 4. Backache: Some women experience lower back pain or aching, which can
be a sign that labor is starting.

Ÿ 5. Pelvic pressure: Pressure in the pelvic area may increase as the baby's
head descends into the pelvis

Ÿ 6. Nesting instinct: Some women experience a burst of energy and an urge to

clean or organize the home in the days leading up to labor.

Ÿ 7. Diarrhea or nausea: Hormonal changes and the body's natural preparation

for labor can cause gastrointestinal symptoms like diarrhea or nausea.

Ÿ Lightening, also known as "engagement" or "dropping," is a common sign

that labor may be approaching. It occurs in the weeks leading up to
labor,when the baby's head descends into the pelvis, putting pressure on the
cervix and causing it to thin and dilate in preparation for childbirth. This
descent of the baby's head can relieve pressure on the diaphragm, leading to
a sensation of breathing becoming easier for the pregnant person.

Definition
 Labor is a physiologic process during which the products of conception (ie,
the fetus, membranes, umbilical cord, and placenta) are expelled outside of
the uterus. Labor is achieved with changes in
the biochemical connective tissue and with gradual effacement and dilatation
of the uterine cervix as a result of rhythmic uterine contractions of sufficient
frequency, intensity, and duration.

Stages of Labor

First stage of labor

The first stage begins with regular uterine contractions and ends with
complete cervical dilatation at 10 cm. The first stage is subdivided into an
early latent phase and an ensuing active phase. The latent phase begins with
mild, irregular uterine contractions that soften and shorten the cervix. The
contractions become progressively more rhythmic and stronger. This is
followed by the active phase of labor, which usually begins at about 3-4 cm
of cervical dilation and is characterized by rapid cervical dilation and descent
of the presenting fetal part. The first stage of labor ends with complete
cervical dilation at 10 cm.
The first stage of labour involves the thinning of the cervix and its dilation to
around 10 cm. The first stage is made up of three different phases:

Ÿ The latent phase – Generally, this stage is the longest and the least painful
part of labour. The cervix thins out and dilates zero to three centimetres. This
may occur over weeks, days or hours and be accompanied by mild
contractions. The contractions may be regularly or irregularly spaced, or you
might not notice them at all.

Ÿ The active phase – The next phase is marked by strong, painful contractions
that tend to occur three or four minutes apart, and last from 30 to 60 seconds.
The cervix dilates from 3 to 7–8 centimeters.
Ÿ The transition phase – During transition, the cervix dilates from 8 to 10
centimetres (that is, fully dilated). These contractions can become more
intense, painful and frequent. It may feel as though the contractions are no
longer separate, but running into each other. It is not unusual to feel out of
control and even a strong urge to go to the toilet as the baby’s head moves
down the birth canal and pushes against the rectum.

Second stage of labor

The second stage begins with complete cervical dilatation and ends with the
delivery of the fetus. If this is your first baby, the second stage of labor can
last up to 1 to 2 hours, particularly if you have had an epidural. If you have
had a baby before, this stage is often much quicker.

Third stage of labor

The third stage of labor is defined by the time period between the delivery of
the fetus and the delivery of the placenta and fetal membranes. During this
period, uterine contraction decreases basal blood flow, which results in
thickening and reduction in the surface area of the myometrium underlying
the placenta with subsequent detachment of the placenta. The muscles of the
uterus continue to contract to stop the bleeding. This process is always
associated with a moderate blood loss – up to 500 ml. Although delivery of
the placenta often requires less than 10 minutes, the duration of the third
stage of labor may last as long as 30 minutes.
The third stage of labor is considered prolonged after 30 minutes, and active
intervention, such as manual extraction of the placenta, is commonly
considered.
In this stage of labour, one of the potential problems is
excessive bleeding (postpartum hemorrhage), which can result
in anemia and fatigue. This is why the third stage is carefully supervised.

Mechanism of Labor
Engagement

The widest diameter of the presenting part (with a well-flexed head, where
the largest transverse diameter of the fetal occiput is the biparietal diameter)
enters the maternal pelvis to a level below the plane of the pelvic inlet.
Descent

The downward passage of the presenting part through the pelvis. This occurs
intermittently with contractions. The rate is greatest during the second stage
of labor.

Flexion

As the fetal vertex descents, it encounters resistance from the bony pelvis or
the soft tissues of the pelvic floor, resulting in passive flexion of the fetal
occiput. The chin is brought into contact with the fetal thorax, and the
presenting diameter changes from occipitofrontal (11.0 cm) to
suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis.

Internal rotation
As the head descends, the presenting part, usually in the transverse position,
is rotated about 45° to anteroposterior (AP) position under the symphysis.
Internal rotation brings the AP diameter of the head in line with the AP
diameter of the pelvic outlet.

Extension

With further descent and full flexion of the head, the base of the occiput
comes in contact with the inferior margin of the pubic symphysis. Upward
 resistance from the pelvic floor and the downward forces from the uterine
contractions cause the occiput to extend and rotate around the symphysis.
This is followed by the delivery of the fetus' head.

Restitution and external rotation

When the fetus' head is free of resistance, it untwists about 45° left or right,
returning to its original anatomic position in relation to the body.

Expulsion

After the fetus' head is delivered, further descent brings the anterior shoulder
to the level of the pubic symphysis. The anterior shoulder is then rotated
under the symphysis, followed by the posterior shoulder and the rest of the
fetus.

Effects of labour on maternal physiology

Ÿ Hormonal changes: During labor, there is a surge in hormones such as

oxytocin, which stimulates contractions, and endorphins, which help manage
pain and promote relaxation.

Ÿ Cardiovascular changes: Blood pressure and heart rate may increase during
labor due to the physical exertion and stress of contractions. Blood flow to
the uterus also increases to support the delivery process.

Ÿ Respiratory changes: Breathing patterns may change during labor, with

some women experiencing shortness of breath or hyperventilation due to the
intensity of contractions.

Ÿ Musculoskeletal changes: The pelvic bones and ligaments stretch and

widen to accommodate the passage of the baby through the birth canal.

Additionally, the abdominal muscles contract to push the baby out.

Ÿ Temperature regulation: Some women may experience fluctuations in
body temperature during labor, with sweating or feeling cold being common.

Ÿ Fluid and electrolyte balance: Labor can lead to dehydration and

electrolyte imbalances due to sweating, increased respiration, and loss of
bodily fluids during delivery.

Ÿ Gastrointestinal changes: Nausea, vomiting, and changes in bowel

movements can occur during labor due to the pressure on the digestive
organs and hormonal fluctuations.

Ÿ Pain perception: Labor pain is subjective and can vary greatly among
individuals. The body releases endorphins and other natural pain-relieving
hormones to help manage the discomfort.
Ÿ Cervical Changes: The cervix undergoes significant changes during labour,
including dilation (opening) and effacement (thinning). These changes allow
the baby to pass through the birth canal.
Ÿ Uterine Contractions: The uterus contracts rhythmically to push the baby
through the birth canal. These contractions are strong and regular, leading to
cervical dilation and effacement.

Complications during labor

Complications during labor can vary in severity and may include:

1. **Prolonged labor**: Labor lasting longer than usual, which can lead to
exhaustion for both the mother and baby.

2. **Fetal distress**: Signs that the baby is not tolerating labor well, such as
abnormal heart rate patterns.

3. **Malpresentation**: When the baby is not positioned ideally for

delivery, such as breech (bottom first) or transverse (sideways) presentation.
4. **Cephalopelvic disproportion (CPD)**: When the baby's head is too
large to pass through the mother's pelvis.

5. **Uterine rupture**: A rare but serious complication where the uterus

tears during labor, potentially leading to severe bleeding and harm to both
mother and baby.

6. **Placental abruption**: Premature separation of the placenta from the

uterine wall, which can cause heavy bleeding and compromise oxygen
supply to the baby.

7. **Postpartum hemorrhage**: Excessive bleeding after childbirth, which

can occur due to various factors such as uterine atony or retained placental
tissue.

8. **Infection**: Infections can occur in the mother's reproductive tract or in

the baby, especially if the amniotic sac has ruptured for an extended period
before delivery.

9. **Perineal tears**: Tears in the tissue between the vaginal opening and
the anus, which can happen during delivery, especially if an episiotomy (a
surgical cut to widen the vaginal opening) is performed.

10. **Instrumental delivery complications**: If forceps or vacuum

extraction is used to assist with delivery, there can be risks of injury to both
the mother and baby, including bruising or lacerations.

11. **Shoulder dystocia**: When the baby's shoulders become stuck after
the head has been delivered, which can lead to complications such as nerve
damage or fractures.

Roles of physiotherapy in labour

Physiotherapy plays several roles in labor, including:
 1. Prenatal education and preparation: Physiotherapists can educate
expectant mothers on proper body mechanics, breathing techniques, and
relaxation exercises to help prepare them physically and mentally for labor.

2. Pain management: Physiotherapists can provide various pain relief

techniques such as massage, hydrotherapy, TENS (Transcutaneous Electrical
Nerve Stimulation), and positioning to help alleviate discomfort during
labor.

3. Labor progression: Physiotherapy techniques such as movement,

positioning, and exercises can help encourage optimal fetal positioning and
facilitate the progression of labor.

4. Support during labor: Physiotherapists can provide emotional support,

encouragement, and guidance to women during labor, helping them to cope
with the challenges and uncertainties of the process.

5. Postpartum recovery: After childbirth, physiotherapy can aid in

postpartum recovery by addressing issues such as pelvic floor dysfunction,
diastasis recti etc and general strength and conditioning to help women
regain their pre-pregnancy fitness and function.

Types of Pregnancy

The nine types of pregnancy include:

Ÿ Intrauterine pregnancy

Ÿ A typical pregnancy, when the fetus(es) implant inside the uterus, and the
placenta attaches to the uterine muscle inside the uterus

Ÿ Ectopic pregnancy
Ÿ This type of pregnancy occurs when a fertilized egg implants in a location
other than the fallopian tube or uterus, such as such as the neck of the uterus
or the abdomen.

Ÿ This type pregnancy is not viable and usually the body spontaneously aborts
the fetus (miscarriage)

Ÿ This type can rupture and be life-threatening and may require surgery to fix

Ÿ Tubal pregnancy

Ÿ This is a type of ectopic pregnancy

Ÿ This type of pregnancy occurs when a fertilized egg implants in the fallopian
tube instead of the uterus

Ÿ This type pregnancy is not viable and must be terminated if a miscarriage

does not occur naturally on its own.

Intra-abdominal pregnancy

Ÿ These types of pregnancies tend to occur following a previous C-section

Ÿ The C-section scar can weaken and tear, and the fetus may slip into the
abdominal cavity

Ÿ Whether or not the pregnancy is viable depends on the gestational age of the
fetus when the tear occurs

Ÿ Singlet pregnancy

Ÿ This is a pregnancy in which one egg meets one sperm and one fetus
develops
Ÿ Multiple pregnancy (twins, triplets, quadruplets, etc.)
Ÿ This may occur when multiple eggs are fertilized at the same time, or when
two sperm enter one egg or when one egg is fertilized by one sperm that
divides into two zygotes
Multiples may be more likely when fertility treatments are used

Ÿ Lupus pregnancy

Ÿ This is a pregnancy carried by a woman with the autoimmune disease lupus,

in which blood clotting is a complication

Ÿ High-risk pregnancy

Ÿ Pregnancies with an increased risk of complications are considered high-risk

This includes women:

Ÿ Over the age of 35

Ÿ With diabetes

Ÿ With other health conditions that affect pregnancy

Ÿ Pregnancy with multiples

Ÿ Who need to take medications to control medical conditions that could affect
the fetus

Ÿ With a history of previous pregnancy complications

Ÿ Molar pregnancy

Ÿ A complete molar pregnancy occurs as a result of the placenta forming in the

uterus without a fetus to support it.
Ÿ A partial molar pregnancy occurs when two sperm fertilize one egg, but two
fetuses do not develop

Ÿ The placenta is abnormal and the fetus has too many chromosomes which
always results in a spontaneous abortion as the fetus cannot develop safely

Ÿ Chemical Pregnancy
This is the clinical term for the loss of a pregnancy that occurs shortly after
implantation. The egg is fertilized and implanted in the uterus, but it then
stops growing and developing soon after. This loss generally takes place
before an ultrasound can detect the heartbeat of the foetus.

Breech pregnancy
A breech pregnancy occurs when the foetus’s head is positioned at the top of
the uterus, and its feet or bottom are towards the cervix and birth canal
unlike in a normal pregnancy, babies will move with their heads towards the
birth canal to prepare for birth.

The typical uterus

The uterus is a pear-shaped organ located in the female pelvis between
the urinary bladder anteriorly and the rectum posteriorly. The average
dimensions are approximately 8 cm long, 5 cm across, and 4 cm thick, with
an average volume between 80 and 200 mL. The uterus is divided into 3
main parts: the fundus, body, and cervix.
Some of the most common abnormalities are:

Ÿ Bicornuate uterus: A heart-shaped uterus.

Arcuate uterus: Similar to a bicornuate uterus but with less of a dip or heart
shape.

Ÿ Septate uterus: When your uterus is divided into two parts by a membrane.
Ÿ Unicornuate uterus: When you have one fallopian tube and an irregularly
shaped uterus.

Ÿ Didelphys uterus: When you’re born with two uteruses.