September, 1969 P H Y S I O T H E R A P Y Page 3 A Gynaecologist's View point By B E O R N U Y S , M .B ., B .C h ., M .R .C .O .G . T h e p ro p e rly -tra in e d p a tie n t will co m e in to la b o u r c o nfident in h e r ow n ab ility to cope w ith th e stringencies o f this event, a n d e m o tio n a l b re a k d o w n is very ra re . A s w ith a n y o th e r s tu d e n t, she co m es to lo o k fo rw a rd to h e r “ final e x a m in a tio n ” as a tim e w hen she can p rove herself, w hen she will see a successful c u lm in a tio n o f her p e rio d o f p re p a ra tio n a n d stu d y ; a n d th e th o u g h t o f fa ilu re does n o t seem to e n te r h e r h e a d . T ru e e n o u g h she w o n d e rs w h e th er she will re m e m b e r e v erything she h a s been ta u g h t a t the c ritical m o m e n t, b u t she c a n be re assu red th a t the vital e lem ents o f c onfidence a n d c o n tro l will re m a in . T h u s d u rin g h e r la b o u r she will be largely self-sufficient a n d will place h e r confidence in h e r o w n a b ilities ra th e r th a n leaning heavily o n th e m edical p ra c titio n e r o r m idw ife a tte n d in g her. T h e n eed fo r d rugs is a lm o st in v ariab ly less th a n in th e u n tra in e d p a tie n t a n d d osages c a n be k e p t well w ithin th e safe lim it. H e r c o n c e n tra tio n in re m e m b e rin g w h a t she is to d o a n d in p u ttin g this in to pra ctic e serves to k eep her m in d fro m w a n d erin g in to d a rk alleys o f a p p reh e n sio n . N o t o nly a re th e tec h n iq u es o f re la x a tio n a n d c o n tro lle d b re ath in g very effective in dim in ish in g the a m o u n t o f p a in g e n era te d by u terin e c o n tra c tio n a n d cervical d ila ta tio n b u t she is a ble to c o p e w ith th e p a in a ctu ally e x perienced w ith fo rtitu d e . She has been to ld d u rin g a n te n a ta l in stru c tio n th a t d u rin g th e e arlie r stages o f la b o u r sittin g o r w alking is o ften p re fe r­ a ble to lying d o w n a n d th e re a so n s fo r this have been ex plained. She h a s c om e to a p p re c ia te th a t la b o u r is n o t ju s t “ so m e th in g th a t h a p p e n s to h e r” b u t a n a ctive process w hose p ro g ress she c a n facilitate a n d she will v o lu n ta rily w alk o r sit up a n d ta k e p rid e in h e r ab ility to d o so. She will be inte rested in th e pro g ress o f th e la b o u r a n d will w a n t to k n o w w h a t stage she h a s reached. T h e a bsence o f fe a r is re m a rk a b le ; it is very tru e to say th a t a n a d u lt will seldom scream fro m p a in b u t will d o so fro m fe a r o r p a n ic . In p ro p e rly tra in e d p a tie n ts o n e will p e rh a p s e n c o u n te r g ru n tin g a n d g ro a n in g b u t extrem ely seldom will hear scream ing w hich occu rs all to o o ften in th e u n tu to re d p a tie n t w ho is a p t to lose c o n tro l o f h e rself w hen the going gets tough. T h e d o c to r h a s th e tre m e n d o u s a d v a n ta g e w ith a tra in e d p a tie n t o f a la b o u r w hich is u sually sh o rte r a n d sm o o th e r a n d o f d e aling w ith a ra tio n a l p a tie n t w ho u n d e rsta n d s w h a t is h a p p e n in g to h e r a n d c a n c o -o p e ra te fully. S h o u ld he need to a d m in iste r a d rip , a p p ly fo rcep s o r c a rry o u t any o f th e o th e r c o m m o n p ro c e d u re s he kno w s th a t this will n o t th ro w the p a tie n t in to c o n ste rn a tio n b ecause th e re aso n s for these m ea su re s have b een ex p la in ed to h e r in th e c ourse o f g ro u p lectures. T o see a p a tie n t e n joying h e r la b o u r a n d delivery is a n experience w hich n o d o c to r c an re ad ily forget. B A C K A C H E A N D P E L V IC P A IN B a ck a ch e d u rin g a n d a fte r pre g n an c y c a n arise from several different so u rces a n d c auses b u t the c o m m o n e st is u n d o u b te d ly th e a ch in g o f lu m b a r a n d low er th o ra c ic spinal m uscles fro m in co rre ct p o stu re a n d w eakness o f th e re ctu s a b d o m in is g ro u p . I t m u st be carefully ex p la in ed to the p a tie n t h o w d ro o p in g a n d p o o r to n e o f h e r a b d o m in a l m uscles re su lts in hig h er pelvic in c lin a tio n a n d lu m b a r lo rd o sis a n d in tu rn in a g re a te r lo a d being th ro w n o n the a b d o m in a l m uscles ra th e r th a n o n the pelvis. I t is distressing to see h o w o ften a p a tie n t will e n te r h e r second pre g n an c y w ith re c tu s m uscles still stre tc h e d a n d w eak fro m h e r first p re g n an c y ; she s ta rts w ith a b u ilt-in d isab ility a n d will o ften c o m p la in b itte rly o f b a c h a c h e in th e la te r m o n th s unless her pro b lem c a n be c o rre c te d e arly o n by m ea n s o f v ig o u ro u s exercises a n d p o stu ra l in stru ctio n . P e rh a p s even w orse is to see th e a p p a llin g p o stu re ex h ib ited by m a n y teenagers a n d to envisage th e tro u b le they a re g o in g to e n c o u n te r b e arin g even th e ir first child. O n e is te m p te d to th in k th at th e early m o n th s o f th e first pre g n an c y is to o late a tim e for in stru c tio n to begin a n d th a t p re n a ta l classes sh o u ld begin a t school, b u t p e rh a p s u n d e r a different n a m e ! L ow b a ck a ch e is a very c o m m o n a n d d istressing a ilm ent in w om en in th e ir late forties, a n d beyond, a n d is a source o f d e sp a ir to th e fam ily d o c to r a n d o rth o p a e d ic surgeon. T h is is all to o o fte n a la te legacy o f p re g n an c y due to c orrect p o stu re n o t h a ving b een re sto red p o stn a ta lly . I t has p e rh a p s n o t b e en sufficiently em p h a sise d in the p a st th a t p o stn a ta l p o stu ra l exercises d o n o t a p ply on ly fo r a m o n th o r tw o a fte r th e b a b y is b o rn b u t sh o u ld c o n tin u e fo r th e re st o f th e life span. (In cid e n ta lly a n o th e r c o m m o n a fte rm a th o f in a d e q u a te p o stn a ta l exercise is p ro la p s e o f th e u te ru s a n d vagina, m anifesting itself usually a fte r the m en o p a u se ). P a in will o ften arise in one o r b o th sa croiliac jo in ts a n d /o r the sym physis p u b is d u rin g pre g n an c y o r so o n a fte r delivery. T hese jo in ts a re n o rm a lly com pletely rig id a n d w ith o u t m ovem ent in th e n o n -p re g n a n t sta te , b ut d u rin g p regnancy u n d e r th e influence o f h o rm o n e s c o n sid era b le slackening o f th e ligam ents s u rro u n d in g these jo in ts tak e s p lac e a n d c o n se q u en tly m o v em e n t can o c c u r a n d p a in m ay result. T h e m in o r form s o f sa c roiliac s tra in are fo rtu n a te ly usually tra n s ie n t a n d a re n o c o n tra in d ic a tio n to th e c o n tin u a tio n o f p re n a ta l exercises. P a rtic u la r a tte n tio n sh o u ld be p a id to the q u e stio n o f pelvic tilt as a n e ar-v e rtic al p o sitio n o f the pelvic b rim will a g g ra v a te th e lo a d o n the sa croiliac while a m o re h o riz o n ta l in c lin a tio n will relieve th e stra in . W h e n m o re th a n n o rm a l re la x a tio n o f th e pelvic jo in ts occu rs th ere is excessive se p a ra tio n o f th e sym physis pubis a n d ex ag g e rate d m o v em e n t a t th e sa croiliac jo in ts . T his c o n d itio n h as b een te rm e d pelvic a rth r o p a th y o f pregnancy a n d c a n lead to severe p a in . T h e p a in m a y be o f su d d e n onset a n d c a n be in ca p ac ita tin g , m ak in g even w alking extrem ely difficult a n d p a in fu l. O ccasionally severe pain m akes its a p p e a ra n c e o nly a fte r lab o u r. P a tie n ts suffering fro m th is c o n d itio n c a n obviously n o t c o n tin u e w ith n o rm al pre- a n d p o stn a ta l exercises. T h e re co m m e n d e d tre a tm e n t is rest, m ild m u sc le -to n in g exercise a n d s u p p o rt by a surgical belt, a lth o u g h th e la tte r m ea su re is difficult to ap p ly a n d o ften u n sa tisfac to ry . A t th e p re sen t tim e n o re a so n is evident for th e excessive degree o f re la x a tio n o f th e pelvic jo in ts ex h ib ited by som e p a tie n ts a n d n o specific tre a tm e n t is k n o w n . P o s itio n d u rin g la b o u r is im p o rta n t for th em a n d excessive flexion a n d p a rticu la rly th e lith o to m y p o sitio n are to be avoided. C A E S A R E A N S E C T IO N O v er recent years th e re has b e en a c h a n g e in a p p ro a c h to c ae sa rea n section. N o lo n g er is it a n o p e ra tio n o f last re so rt w hen vaginal delivery is im possible o r excessively d a n g e ro u s. M o re a n d m o re it is b e ing realised th a t cae sa rea n se c tio n is p re fa ra b le fo r b o th m o th e r a n d b a b y to a difficult o r p ro lo n g ed la b o u r. O ne has o n ly to exam in e a p a tie n t a fte r a difficult delivery a n d c o n tra s t th e sta te o f th e pelvic o rg a n s w ith th o se o f a w o m a n w h o h as h a d a cae sa rea n se c tio n to a p p re c ia te ho w m u ch less tissue tra u m a is involved in th e la tte r p ro c e d u re . A p a tie n t w ho h a s h a d a section will o ften have less p a in a n d d isc o m fo rt p o st-delivery th an o ne w h o is left w ith a b ru ise d pelvic floor a n d a n extensive e pisiotom y. It is in evitable a n d rig h t th a t c a e sa re a n section will be m o re a n d m o re freely e m ployed in th e future. T h is m a tte r affects fairly p ro fo u n d ly th e a n te n a te tra in in g o f th e p a tie n t. W ith intensive in stru c tio n a n d e n co u ra g em e n t th e p a tie n t com es to lo o k fo rw a rd to her la b o u r a n d to “ being p re se n t” a t th e delivery o f h e r baby. It becom es in a sense a s ta tu s sym bol fo r h e r to d o well in h e r la b o u r a n d she c an be intensely d isa p p o in te d if she is d e p riv e d o f th is im p o rta n t event in her life. I t is extrem ely difficult to k n o w h o w to p re p are th e p a tie n t fo r th e possibility th a t a cae sa rea n se c tio n will be necessary. I n th e p a tie n t w ith a b o rd e rlin e pelvis a trial la b o u r is 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. ) Page 4 P H Y S I O T H E R A P Y September, 1969 c o n d u c te d , w hich m ean s th a t la b o u r is a llow ed to progress fo r so m e 8 to 12 h o u rs befo re a decision is m a d e as to d o in g a c a e sa rea n se c tio n o r a llow ing la b o u r to pro ceed a n d achieve vaginal delivery. I f o n the o n e h a n d the p a tie n t is to ld in the last few w eeks o f h e r p re g n an c y th a t she is to h ave a trial la b o u r a n d th a t a se ction m ay be necessary sh e will b e in so m e u n c e rta in ty a n d will n o t e n te r la b o u r w ith full confidence th a t la b o u r will progress in the n o rm al w ay in w hich she h a s been in stru cte d . O n the o th e r h a n d if she is n o t to ld o f th e possibility b e fo re h a n d a n d is then to ld a fte r som e h o u rs o f la b o u r th a t she n ow re q u ire s a se ction she is a p t to im agine th a t so m e serious c o m p lic a tio n h as su d d e n ly arisen a n d h ow ever m u c h she is re a ss u re d she will be a p p reh e n siv e a b o u t the o u tc o m e fo r h e r baby. T h e e m o tio n a l sta te o f la b o u r is n o t c o nducive to h e r being a ble a t th a t stage to a cc ep t a ra tio n a l e x p la n a tio n o f w hat is h a p pening. A re w a rd in g a spect o f a n te n a ta l in stru c tio n is th a t the p a tie n t w ith a definitely c o n tra c te d pelvis fo r w h o m vaginal delivery is n o t safe a n d w ho is to ld a t 38 w eeks th a t a cae sa rea n se ction is definitely necessary will som etim es ask th a t sh e be allo w ed to have som e h o u rs o f la b o u r first. T h ro u g h the m ed iu m o f h e r in stru c tio n she has com e to lo o k fo rw a rd to the experience o f la b o u r a n d the o p p o rtu n ity o f p roving h e rself a n d a lth o u g h she realises th a t se ction is in evitable does n o t w a n t to b e de p riv e d c o m pletely o f the lab o u r. I n som e c en tres in th e U n ite d S ta te s a n d C a n a d a th ere has in re c e n t y e ars b een a s tro n g sw ing to w a rd s n a tu ra l c h ild b irth , so m u c h so th a t o b ste tric ia n s have c o m p la in e d th a t w here c a e sa re a n section becom es necessary they can h ave th e u tm o st difficulty in p e rsu a d in g th e p a tie n t to accept this. T h e answ er to th e p ro b le m m u st lie in in stru c tin g p a tie n ts a t p re n a ta l classes th a t c a e sa re a n se c tio n is n o t u n d e rta k e n as a last d e sp e ra te m ea su re b u t ra th e r as a m ea n s o f fore­ stalling c o m p lic a tio n s a n d a v o id in g tra u m a to m o th e r a n d b a b y . T h ey sh o u ld a lso be m a d e a w a re th a t th e ir p re n a ta l tra in in g w as n o t w asted sh o u ld they n o t be a b le to deliver vaginally b u t th a t la b o u r a n d delivery fo rm b u t o n e p a rt o f the p re n a ta l c o u rse a n d they will still have the ad v an tag e s o f p o stu re , p ro p e rly to n e d u p m uscles, c o rre c t b re a th in g in th e late r m o n th s o f p regnancy a n d a n u n d e rsta n d in g o f m an y a spects o f c h ild b e arin g . T hey s h o u ld also n o t lose sight o f the fact th a t p o stn a ta l exercises a re as im p o rta n t a fte r se c tio n as a fte r vaginal delivery. I f th e p a tie n t h a s th is k n ow ledge a n d .h as confidence th a t h e r d o c to r will c h o o se th e rig h t c o u rse fo r her, little difficulty sh o u ld be e n c o u n te re d in p e rsu a d in g h e r th a t c a e sa rea n se ction is the rig h t c o u rse fo r her. T H E S E X U A L A S P E C T T h ere a re m an y a spects o f p re - a n d p o stn a ta l in stru c tio n w hich a re b e tte r im p a rte d to a g ro u p th a n to a n individual as the p a tie n t will th en feel th a t th e re m a rk s a re n o t being a d d ressed to her pe rso n ally a n d so she is a ble to assim ilate the k n ow legde w ith o u t e m b a rassm en t. T h is is p a rticu la rly tru e o f m a tte rs re la tin g to sexual a d ju stm e n t. T h e delivery o f a h e a d o f som e 4 inches d ia m e te r th ro u g h the uro g e n ital h ia tu s w hich n o rm a lly is o f 1£ in ch diam e te r will in evitably re su lt in stre tc h in g o f th e v a gina a n d o f the m uscles a n d ligam ents s u rro u n d in g it. T h e le v a to r m uscle will n o t sp o n ta n e o u s ly re tu r n to its fo rm e r sta te b u t p ro v id ed th a t it h a s n o t been o v e rstre tc h e d o r to rn it can be re sto re d to n o rm a l by m ea n s o f a ssid u o u sly -p ra ctised p o stn a ta l exercises. D u rin g delivery o f the first in fa n t e p isio to m y is freq u e n tly c a rrie d o u t as a m eans o f av o id in g o v e rstretch in g o f th e m uscle, b u t this leaves a sc a r w hich displays residual ten d e rn ess fo r som e weeks o r e v en m o n th s a fte r delivery. A s sexual sa tisfac tio n a n d o rg a sm in th e fem ale a re largely d e p e n d e n t o n th e in te g rity o f the lev a to r m uscle it is h a rd ly su rp risin g th a t th e p a tie n t w ith a stre tc h ed a n d relatively a to n ic le v a to r a n d a te n d e r sc a r to b o o t will n o t find m u ch jo y fro m the re s u m p tio n o f sexual re la tio n s w hen h e r b a b y is a m o n th o r 6 w eeks old. A d d e d to these difficulties are the fact t h a t h e r in te rest h a s becom e very largely c e n tre d o n th e b a b y a n d th a t she is so m e w h a t e x h a u ste d by the d e m a n d s he m ak e s o n her. It is th e re fo re n o t very su rp risin g th a t even th e p a tie n t w h o h as e n joyed g o o d sexual responsiveness b e fo re her delivery will o ften c o m p la in o f loss o f interest, p a in a nd a bsence o f o rg a sm a fte rw a rd s. F re q u e n tly sh e will b e shy even to m en tio n these difficulties to h e r d o c to r a n d m ay th e n n ever recover th e n o rm a lity she knew befo re in this re g ard . F o r the p a tie n t w ho w as h a v in g difficulties before her pre g n an c y the p ro b le m is a p t to be m agnified ten fo ld . T h e re a re a lso su b tle h o rm o n a l c h anges th a t ta k e place d u rin g pre g n an c y w hich m ay result in loss o f sexual res­ ponsiveness a t th a t tim e a n d th e re is freq u e n tly fear in the u n tu to re d th a t in te rc o u rs e m ay be h a rm fu l to th e baby. T h e e n fo rc e d ab stin e n ce d u rin g the last m o n th o f p regnancy a n d fo r the first m o n th a fte r delivery can also cause a d is ru p tio n in m a rita l re la tio n s w hich is difficult to overcom e. A d d e d to these fa c to rs th ere m ay be th e fe a r th a t a n o th e r pre g n an c y m ay e n su e so o n e r th a n is desired. F o r these v a rio u s re a so n s loss o f lib id o (n o rm a l sexual desire) is one o f th e c o m m o n e st a n d m o s t try in g o f p o stn a ta l c o m p li­ catio n s. P a rt o f th e answ er lies in p ro p e r p re n a ta l in s tru c tio n as to the harm lessness o f in te rco u rse d u rin g pregnancy, e m p h a sis o n pelvic flo o r exercises p re- a n d p o stn a ta lly , a h e alth y division o f in te rest betw een h u s b a n d a n d b a b y a fte r c on fin e m e n t a n d p ro p e r c o n tra c e p tiv e advice. T h e re s p o n ­ sibility fo r th ese m ea su re s lies jo in tly w ith th e d o c to r a n d th e p h y sio th era p ist. T hese m easures a lo n e m ay be in a d e q u a te a n d th e n m o re de ta ile d h elp m u st be given a n d p e rh a p s the help o f a psychologist so u g h t. Psychological Principles A p p lie d to Antenatal Training By A L M A E. H A N N O N , (M .A .) Psychology D ivergence o f o p in io n exists a m o n g s t th e p ro p o n e n ts o f a n te n a ta l tra in in g as to w h a t c o n stitu te s a com pletely sa tisfa c to ry p ro g ra m m e fo r th e p re p a ra tio n o f c h ild b irth . Successful p e rfo rm a n c e d u rin g la b o u r is co n sid ere d th e c rite rio n fo r “ sa tis fa c to rin e ss” . U n til a c o n tro lle d in vestiga­ tio n is u n d e rta k e n w here th e re su lts d e m o n s tra te a definitive re la tio n s h ip b etw een m e th o d o f tra in in g a n d p e rfo rm a n ce d u rin g la b o u r no claim s fo r th e su p e rio rity o f o n e m e th o d o ver a n o th e r c a n b e m ade. R e se arc h in th e efficacy o f these different p ro c ed u re s w o u ld p ro v e extrem ely la b o rio u s a n d a lm o st since c o n tro l o f all th e v ariab les re la te d to successful p a rtu ritio n w o uld b e difficult. H o w th e n c a n we assess th e in trin sic value o f a n y o n e o f th e tra in in g p ro c e d u re s? W e m ay be p re p a re d t o a sse rt t h a t if it w orks, th e n it is successful. T h is is p u re em piricism . S u ch a n .a p p r o a c h is p e rm itte d in a scientific discipline b u t it c a n p ro v e sterile w h e re th e g e n e ra tio n o f new co n ce p ts, h y p o th esis o r a th eo re tic al m odel a re c o n ce rn ed . T h e q u e stio n sh o u ld be “ w h a t m ak es it w o rk ? ” T h is becom es a q u e st fo r th e a n te ce d e n ts o f the o b se rv ed b e h av io u r. “ H o w d oes it w o rk ” o n th e o th e r h a n d im plies a q u e st fo r law s g o v e rn in g b e h a v io u r. I f such a n a p p ro a c h is a d o p te d , we n eed e x p lo re n o fu rth e r, as the p rin cip les g o v erning b e h a v io u r a re a lre a d y k n o w n to us. W h a t we need to d e te rm in e is h o w a d eq u a te ly th ey are a p p lie d to th e a r e a o f a n te n a ta l c a re o r train in g . A n te n a ta l tra in in g c a n be divided in to th re e categ o rie s: P hysical tra in in g th ro u g h exercise a n d b re a th in g ; re la x a tio n ; a n d e d u c a tio n in th e p h y siology a n d m echanics o f c h ild b irth a n d la b o u r. A ll th re e categ o rie s sh o u ld be c overed in th e p re p a ra tio n fo r c h ild b irth . T h e ra tio n a le fo r any a n te n a ta l p ro c e d u re sh o u ld be to eq u ip th e w o m a n w ith responses 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. )