72 F I S I O T E R A P I E SEPTEMBER 1979 o f the haem olysis in the fetus can be ascertained by m easurin g b iliru b in -lik e pigm ents in the a m n io tic fluid. But th e m ost im p o rta n t in d icatio n fo r am niocentesis is the p rev e n tio n o f re sp ira to ry disease in the n ew ­ born. L iq u o r is usually tak en by su p rap u b ic pun cture, but som etim es u n d er u ltraso u n d guidance; 1 m l liq u o r is m ixed w ith 1 ml alco hol and shaken up. T h e am o u n t o f stable b u b b le fo rm atio n tells us w h eth er the fetus has s u rfa ctan t o r not, w hich w ill p ro tec t it from re s p ira to ry distress syndrom e. F E T A L M O N IT O R IN G A fu rth e r invasion into the privacy o f the fetal w o rld has tak en place in th e la b o u r w ard. T o m ake lab o u r safer fo r m o th er an d fetus, m o n itors have been developed w hich can m o n ito r the m o th e r’s co ntraction s an d reco rd the fetal h e a rt rate continuously. T h e n o r­ m al fetal h e a rt ra te is betw een 120 an d 160 beats ncr m in u te an d th e b aselin e should be changing all the tim e. N o rm ally th e re is no relatio n sh ip betw een the fetal h e a rt an d contractions. T h e follow ing changes arc associated w ith fetal distress. A fetal h e art rate con­ tin u o u sly above 160 (tachycardia), o r a heart rate co ntinuo u sly below 120 (brady cardia), suggests distress A b sence o f baselin e v a ria b ility is an om inous sign O ften, especially n e a r delivery; the fetal heart rate will decelerate w ith the co ntraction , b u t reco ver imme­ diately. T his is due to com pressio n o f the head. H ow ­ ever, w h en th e deceleration continues a fte r the con­ tra c tio n has ended, this is a p a rtic u la rly om inous sign o f fetal distress. W hen the o b stetricia n is w o rried ab o u t the fetal h e a rt r a te p a tte rn , he w ill tak e a sam ple o f blood fro m th e fetal scalp an d estim ate its p H value. I f the p H is below 7,2 this is alm ost alw ays an absolute sign o f a fetal p roblem ; delivery sho u ld be at once expedited, usu ally by caesarean section. REPORT ON CONGRESS PROCEEDINGS IN T RO DU CTO R Y COURS E IN N E U R O D E V E L O P M E N T A L T H E R A P Y 37 m em bers attended this course. T h e lectures an d dem on stratio ns w ere given by m em bers of the South A frican N e u ro d ev elo p m en tal T h erap y A ssociation. T he first session discussed th e properties of spasticity and the problem s w hich spasticity poses to the p h y sio th era­ pist. C u rre n t m ethods o f co ntro lling spasticity were an alysed an d the und erlying philo so p hy o f n e uro dev e­ lopm ental th e ra p y was presented. T h e follow ing session fo rm u late d the role played by the p o stu ral reflex m echanism s in d eterm ining norm al m o to r developm ent. T h e d em o n stratio n w hich follow ed show ed how these p o stural reflex m echanism s can be utilized to obtain specific m ov em ent p a ttern s in p re p a ra tio n fo r fu tu re skills as well as fu n ctio n al sequences o f m ovem ent. T h e second h a lf o f the course was devoted to an alysing th e f u n c tio n a l. pro blem s en co u n tered with sitting standing an d w alking in different types of spastic patients. T his section included an outlin e of how these problem s develop as well as guidelines fo r treatm ent. T h e w o rk sho p o n u p p er ex trem ity function was not held as p la n n ed owing to lack o f su p p o rt from Society m em bers. In stead , an in fo rm al w orksho p was thrown open to o ccupational, speech an d physical th e r a p is ts __ an d also teach ers — an d over 30 p e o p le attended two sep ara te sessions, the first devoted to analysing upper ex trem ity functions in th e n o rm a l as well as in spastic an d ath eto id ch ild re n an d the second to discussing how to establish these functions in spastic ch ildren and in ath eto id children. S. Irw in-C arruthers WORKSHOP ON C L I N I C A L SUPERVISION T h e first session o f th e w o rk sho p w hich was ch aired by M rs. A. M athias, C h ief P h y sioth erapist o f th e J o h a n ­ nesburg H o sp ita l com plex, com m enced w ith g roup fo r­ m ulation of aim s an d objectives of clinical'^supervision. T he m ost im p o rta n t aspect th a t em erged fro m these groups was realisatio n th a t th e clinical situ atio n was th e prim e area fo r g ro w th an d developm ent of th e stu ­ dent. By providing the right clim ate in the clinical situation, the student will be stim ulated to th in k independently, to use h e r initiative an d w ant to p ro b e fu rth e r an d be respon sible f o r h e r ow n learning. By teaching th roug h de m onstratio n, th e sup ervisor will encourag e acceptable standard s o f in te rp e rso n al relationships an d professional values as well as rein fo rce in practice th a t w hich is tau ght in the classroom . I n tw o very co m petent talks given by students fro m th e U niversities o f C ap e T ow n an d Stellenbosch, the need fo r b e tte r co m m unication betw een studen t an d supervisor was stressed. C laire Joh nson urged far grea ter involvem ent of the supervisor in the clinical situ a tio n an d felt th a t the student w ould o nly be able to learn, if she knew w h at was done correctly, w hat was unacceptable an d how this could be changed. C arin H u g o urged grea ter co m m itm ent on the p a rt o f the superviso r to prov id e assistance in a ll aspects o f p atien t handling by dem o n stratio n an d discussion, especially w hen the stu den t is a t the beginning o f her clinical training . T h e studen t has the right to know w h at is goo d o r bad in h er p a tie n t m anagem ent and m ust be given th e chance to co rrect m istakes as well as specify h er ow n problem s. E valuation must be objective an d th o ro u g h an d n o t be just a mark. S h a p lead ed fo r supervisors to be en thusiastic ab o u t th e il p rofession in o rd er to stim ulate the students. I n atte m p tin g to provide a m eaning ful learning e x p erien ce in th e clinical field, certain objectives for clinical supervisors w ere suggested by J. C. Beenhakker. T hese w ere teaching by d e m o n stratio n in all areas of clinical com petencies, co -ordin ating class teaching and clinical practice, setting goals fo r achievem ent in that p a rtic u la r d ep artm en t, developing skills of problem ­ solving an d provid in g co nstant an d constructive feed­ back to th e student. T his feed b ack to the student is to poin t o u t w here h e r strengths an d w eaknesses lie and w h eth er th e stu d en t has fulfilled th e stated goals. The stu d en t sh o u ld also be en courag ed to assess the super­ viso r jn o rd e r to bring ab o u t desirable change. The ideal superviso r should be com petent in he r own field, be available a t all tim es, be ab le to com m unicate with th e stu d en t an d be sensitive to h er needs. I n th e second session u n d e r th e C hairm an sh ip of Miss M. J. R un nalls, H e ad o f the D epartm en t of P h y sio th erap y o f th e U niversity o f Stellenbosch and Tygerberg- H o spital, th e em phasis was on the methods by w hich clinical supervision should be carried out. A lth o u g h P. B ow erbank, C h ief P hy sioth erapist at K a lafo n g H o spital, presen ted h er talk in the form of a R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) SEPTEMBER 1979 P H Y S I O T H E R A P Y 73 skit, th e , un d erlying m essage was a serious one. She stressed th a t the clinical a re a is a co m plem entary p a rt of the teaching situ atio n an d urged fo r g rea ter co­ o peration betw een the supervisors an d th e academ ics. T he skill of caring fo r the p a tie n t m ust be instilled by exam ple and she fe lt th a t im proved supervision w ould be b roug ht ab o u t by g rea ter know ledge o f didactics. Miss R unn alls spelled o u t the need fo r instructing clinical supervisors a t the beginning of each y ear and following this up th ro u g h o u t th e year. T his w ould assist in defining the ro le an d responsibilities o f the superviso r an d provide self confidence by self ev alu atio n and p e er audit. T h e superviso r sh o u ld realize th a t it is a com ­ plim ent to be assigned a student. She suggested th a t th e supervisor should observe a t the first treatm en t session and dem o n strate if necessary an d follow this up at weekly intervals. T h e sup ervisor m ust also check all docum entation an d registers as well as set specific tasks. A form o f ev alu atio n o f studen ts based o n different d a ta bases fo r th ird and f o u rth year studen ts was dis­ cussed. A second session o f discussion by group s was then held to establish m ethods of clinical supervision. F ro m the p ap ers read an d th e ensuing discussion, it was obvious th a t clinical supervision is fa r fro m ,deal. Even w hen objectives have been set b o th fo r the supervisor an d the studen t an d in s tru ctio n in su p er­ vision provid ed, there ap p ears to be a break d o w n in co m m unication between the studen t an d h e r superv isor and the teaching staff. T his m eans th a t eith er the BACKACHE AND T H E L O U ISE H A C K * B.Sc. Few w om en pass th rou g h th e ir pregn an cy and puer- perium w ith o u t som e b ackache sym ptom s. U n fo rtu n a te ­ ly, gynaecologists seem im perv ious to the w o rd “ b ack­ ache” fro m the lips o f a p reg n an t w o m an an d consider it p a rt an d parcel o f having babies. G ynaecologists seldom refer th e ir patients to phy sio therapists, w hich causes a co nsid erable am o u n t o f unnecessary suffering. F o r the p reg n an t p a tien t (and h e r husband) it is very difficult to live w ith backache an d the em otional effect of this co n tin u ed d isco m fo rt can stra in relatio nsh ips w ithin the fam ily. O f course, there is a g rou p o f wom en w ho love th e ir backaches and w o u ld n ’t p a rt Nwith them. T h e y obv iously need a different ty pe o f Jherapy fro m phy sio therapy ! ' T h e causes o f backache w ere discussed, b u t the lecture itself concen trated m a in ly on m echan ical con­ ditions, w h ere the sym ptom s are due to m a lfu n ctio n of the joints and w ill resp ond to treatm en t d irected to­ w ards co rrectio n o f the m echan ical im pairm ent. T he com bined effects o f p o o r p osture and h o rm o n al influences w ere discussed. L igam entou s laxity, d ue to the effect o f horm o nes, such as relax in, occurs du rin g pregnancy an d predisposes tow ards lu m b ar stress and sacroiliac strain . C om bin ed w ith the co m pen sato ry in ­ creased lu m b ar lordosis, d ue to the changed centre o f gravity, the s tra in on these joints and ligam ents is fu rth er increased. M A N A G E M E N T OF BACK ACH E IN P R E G N A N C Y T his was discussed u nd er the follow ing headings: 1. R em ove the cause w here possible e.g. a sagging m attress, high-heeled shoes. * P riv ate P ractitio n er, P re to ria t Sum m ary o f a p a p e r read at C ongress p receding 13th N atio n al C ouncil M eeting 2 3 - 2 7 A p ril 1979. objectives are not realistic o r th a t they have not been und ersto o d by all p arties co ncerned. T o rectify this, fu rth e r w o rk shops should be held w ith p articip ants com ing fro m th e academ ic staff, clinical supervisors, clinicians an d the stu d en t body. A fu rth e r p ro b le m a re a is th e m a n n er of ev aluating clinical com petence. If the clinical situ atio n is the p rim ary one fo r learning of in te rp e rso n al, intellectual and technical com petencies, th e n a d eq u a te and co n ­ tinuous feed b ack is required in all these areas. E ach objective sh ould be assessed an d assistance given in im prov ing weaknesses, to g e th er w ith praise for strengths. T he stud en t m ust also be given the o p p o r­ tunity to pro v id e feed b ack to th e supervisor as regards her m ethods o f supervision in o rd e r to bring ab o u t desirable change. In the final sum m ing up, M r. B. R. Slab b ert, H e ad o f the D ep artm en t of D idactics a t the F a c u lty of M edicine, U niversity o f Stellenbosch, touched upo n three m a in p ro b le m areas. T h e first was the need fo r establishing aim s and objectives by a person w ith th o ro u g h know ledge in the field co ncerned. T hese m ust then be given to the student an d the sup ervisor m ust ensure th a t th ey are u n d ersto od. M o tiv atio n was co n ­ sidered the m ost im p o rta n t co rnerston e o f learning in the clinical field as in an y o th e r field. F in ally it was suggested th a t it is im p o rtan t to ev aluate in the affective dom ain w hich is th e m ost difficult o f the th ree dom ains. J. C. B eenhakker. P R E G N A N T P A T I E N T (Physio), W itw atersrand 2. P o stu re re-edu catio n and strength ening exercises m ust be the first p rio rity a t an te-n atal classes w hen p atients com e w ith backache. T h e basis o f spinal co ntrol is the pelvic tilt. As a p ro p h y lactic m easure, p o stural co ntrol should be tau g h t to all p atients at risk in the first trim ester, i.e. A L L patients w ith a previous history o f backache sym ptom s. S treng then­ ing exercises fo r po stu ral m uscles m ust be taught and practised to prevent too m uch ligam entous stra in as the p regn ancy progresses. I f these patients are tau gh t good po stural co ntro l, chances o f b a ck ­ ache developing are greatly dim inish ed. T h e first line o f defence o f an y jo in t against in ­ jury o r stra in is ligam ento us an d w hen ligam entous su p p o rt is deficient, as m ay occur in pregnancy, the m uscles m ust com plem ent lig am ento us fun ctio n. T he m ost im p o rta n t fa c to r in tre a tin g b ackache du rin g pregnancy, is P R E V E N T IO N . T h e follow ing m uscle group s are exercised fo r this purpose: obliq ue, stra ig h t and transverse ab d o m in a l m uscles; gluteal m uscles; back extensors; psoas and side flexors. E xam ples o f su itab le exercises w ere ex plained w ith atte n tio n being given to pelvic tilt in variou s posi­ tions an d w ith progressions. All pelvic tilt exercises w ere done fro m m id -po sition to backw ard pelvic tilt p o sitio n to prevent facet im pingem ent and disc stress in an alrea d y lo rd o tic lu m b ar spine. M any exam ples o f strengthening exercises fo r postural muscles w ere shown. T h e choice o f starting posi­ tio n an d av o id in g u n ila teral w eigh t-bearin g positions in patien ts w ith sacro-iliac stra in w ere stressed. Exercises to be av oided w ere also shown. Q uadriceps and gluteal exercises w ere included to strengthen the legs, thus prev entin g trau m a to the b a ck in lifting. 3. “ A u to -m a n ip u la tio n ” m ovem ents, w h ere patients do the m ovem ents slow ly and rh y th m ically an d find the ran g e an d r a te o f m ovem ent th a t gives relief. 4. Ice Packs. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 74 F I S I O T E R A P I E SEPTEMBER 1979 5. T h e caring aspect o f m assage was em phasised. 6. U ltraso u n d was th o u g h t co ntro versial in pregnancy. 7. ‘Sam -B row n’ su p p o rtiv e belt could be w orn to su p ­ p o r t the sacro-iliac jo in ts and stab ilise the pelvic ring. 8. M a n ip u la tio n was also th o u g h t to be co ntro versial in pregnancy. 9. E d u ca tio n plays a vital p a rt in the treatm ent routine. P atients m ust be tau g h t ho w to c a rry over co rrect p o stu ral p o sitio n s o f the bod y in everyday activities. T h ey m ust un d erstan d th e an ato m y an d m ovem ents o f th e spinal colum n an d pelvis in o rd er to m inim ise unnecessary stresses an d strains. P atients should be tau g h t how to m ove fro m sitting to standin g, o r fro m lying to sitting; the co rrect sitting p osture, standing p o sition s and m a n n er o f lifting. E d u c a tio n m ust also p re p a re the p a tie n t fo r the p o st-n ata l period. In conclusion positio n s o f op tim al co m fo rt fo r exer­ cise, sleep, relax atio n , first stage la b o u r an d delivery w ere discussed. A th o ro u g h know ledge o f each p a tie n t’s co ndition is essential before exercises are com m enced and the p h y sio th erap ist m ust m ake a d ap tatio n s w here necessary fo r each indiv idual p atien t, alw ays bearing in m ind th a t injud icious exercise will do m ore h a rm than good. V A L U E O F Q U A L I T Y O F M O V E M E N T F O R P R E G N A N C Y M ost people are ig n o ra n t a b o u t th e ir bodies and how they w o rk . M an y peo p le are starved o f m ovem ent as they do n o t p a rtic ip a te in sp o rt o r organ ised exercise a fte r leaving school. V a rio u s occupations, careers and n a tu re en courage laziness o r exercise inactivity. M a r­ riage leaves even less tim e fo r sport. T h u s m ost w om en a re unfit a t th e b eginning o f pregnancy. A dvancing pregnancy leads to in creasing stiffness and unw illingness o r in ab ility to m ove. E xercise classes a re p u t off, es­ pecially if p eo p le co ntinu e w o rk ing. L a b o u r comes as a surprise as it is physically h a rd e r than expected. T h us the m o th er is faced w ith post-natal recovery an d a d ju st­ m ent, flabby muscles, an aching back an d very little tim e. T h is vicious cycle can be preven ted b y organised, co rrect and reg u la r m ovem ent. T o achieve fitness f o r lab o u r, a t least twelve weeks o f an te-natal tra in in g is recom m en ded, usually fro m 24 - 36 weeks, w hich leaves an o th er 4 weeks fo r m ore exercise o r rest, w h ichever is ap p ro p ria te . Once preg ­ n a n t w om en start exercising, they co ntinu e into labour. T h ey feel b e tter as aches and pains d isapp ear, they relax an d look b e tter as they m aster co rrect m ovem ent, becom e co -ordin ate and feel in co ntro l o f th e ir bodies. It is too late to w ait un til la b o u r starts, w hen they feel stiff and in co -o rd in ate an d have difficulty in p er­ fo rm ing the task. A b d o m in a l muscles w o rk at an increasing m echanical disadv antag e in pregnancy, thus exercises are perform ed^ in lying and po sture co ntro l is stressed. One aim s at!| no rm a l m ovem ent checking ab n o rm al o r excessive m o vem ent an d suggesting a su ita b le hom e ro utin e. A ny m ovem ent w hich is painfu l o r un c o m fo rtab le is dis­ co ntinued an d possibly a different startin g p o sitio n is all th a t is required. T h e ex ercise ro u tin e is follow ed by relax atio n tra in ­ ing, norm al b rea th in g changes expected in labour, pushing techniques, advice on b r a ’s an d breast care an d problem s en coun tered on taking th e baby home. P atients are fam iliarised w ith h o sp ita l ro u tin e on ad m ission an d taken on a to u r o f the la b o u r and post­ n a tal w ards. T im e fo r discussion and questio ns con­ trib u tes to relax ation. E xercises to m usic follow ed the sh o rt dissertation. H . B. Kastell R EPO RT ON TH E THIRTEENTH G E N E R A L MEETING O F THE NATIONAL COUNCIL T h e T h irte e n th G en eral M eetin g o f th e S ou th A frican S ociety o f P h y sio th e ra p y was held in th e B eattie com ­ plex o f th e U n iv ersity o f C ape T ow n on \2 6 an d 27 A p ril 1979. F o rty delegates attend ed , the full voting strength being fifty-five. Several observers also attended. T h e C hairm an , M rs. K. M. Levy, w elcom ed delegates an d observers an d gave a special w o rd o f w elcom e to P rofesso r A. J. B rin k, P resid en t o f th e S outh A frican M edical R esearch C ouncil and D ean o f th e F a c u lty o f M edicine at the U n iv ersity o f Stellenbosch, an d to M r. J. J. C raig, P resid en t o f the South A frican Society of P hy sioth erapy. P ro fesso r B rin k gave th e opening address, in w h ich he o utlin ed th e activities o f the M edical R esearch C ouncil an d challenged p hy sio therapists to involve them selves in research projects, p a rtic u la rly in the clinical sphere. In delivering his P resid en tial address, M r. C raig discussed th e im p lic atio n s o f first-con tact p hy sio th erap y p ractice and the im p o rta n ce o f establishin g the p rin cip le o f first-contact practice. M r. C ra ig ’s speech was p u b ­ lished in the Ju n e issue o f th e Jo urn al. In h e r co m prehensive C h a irm a n ’s r e p o rt M rs. Levy com m ented first on the ro le w hich the N a tio n a l C om ­ m ittee of R epresen tatives, w hich m et fo r th e first tim e in J a n u a ry 1976, had played in th e affairs o f the S ociety since its inception. T h e N a tio n a l C om m ittee o f R ep resentatives, as a tru ly representative body, had n o t only acted in an ad viso ry capacity to the N atio n al E xecutive C om m ittee but had been the o rig in a to r of several m otio ns su bm itted to this C ouncil M eeting f o r a final decision. One m a tte r alrea d y passed by p o s ta l v o te h a d enabled th e Special G ro u p s/A sso c iatio n s to' elect represen tatives to an d subm it resolutio n s to C oun­ cil, an d at th is p o in t th e C h airm an w elcom ed the first official representativ es o f the Special G rou ps/A ssocia­ tions. M rs. L evy also stressed the n a tio n a l interest and concern o f the N a tio n a l E xecutive C om m ittee and wel­ com ed the fact that n o m in atio n s fo r th is Com m ittee fo r th e first tim e included the nam es of fo u r nom inees fro m ou tside the T ran sv aal. T h e C h airm an also o u tlin ed th e w o rk o f the P ro ­ fessional B oard over the last two years. E very effort is being m ade to have the p rescrip tio n o f the whole co u n try in respect o f the profession o f p h y sio therapy re-gazetted. T h e list o f acceptable registrab le overseas q u alification s has been com pletely revised and criteria f o r th e acceptance f o r reg istratio n o f ad d itio n a l qualifi­ cations h ave been laid dow n. T h ere is also a m ove to establish a fu rth e r set o f crite ria fo r post-basic courses o f a s h o rter d u ra tio n than one y e ar w hich m ight con­ trib u te tow ards a cred it system recognised by the Public Service C om m ission fo r salary purposes. A lth ough salary scales an d cond itions o f service for p h y sio th erap ists in p ro v in cial em ploy w ere still far fro m satisfactory , th e C h airm an than ked th e D e p a rt­ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )