Pelvic Health Assessment Allied Health

Pelvic health - Reason for consultation: Postpartum pelvic pain and urinary incontinence - Relevant medical history: History of gestational diabetes - Patient's goals and concerns: Improve pelvic floor strength and reduce urinary leakage Obstetric history: - Labour and delivery details: Vaginal delivery, 8 hours of labor - Postpartum complications or interventions: Episiotomy performed Current symptoms: - Urinary symptoms: Stress incontinence - Urinary habits: Frequent urination - Urinary tract infection history: None - Urine characteristics: Clear - Voiding patterns: Normal - Post-void symptoms: Dribbling Bowel habits: - Bowel movement frequency and consistency: Daily, soft - Abdominal discomfort or pain: Occasional bloating - Stool characteristics: Normal - Gastrointestinal symptoms: None - Relevant medical conditions: None Diet and lifestyle: - Dietary habits: Balanced diet - Fluid intake: 2 liters per day - Alcohol consumption: Occasional - Caffeine intake: 1 cup of coffee per day Sexual health: - Sexual activity status: Active - Sexual discomfort or pain: Mild discomfort - Psychological factors related to sexual health: Anxiety about pain Mental health: - Mood and emotional well-being: Generally positive - Adjustment to motherhood: Well-adjusted - Support system: Strong family support Physical activity: - Exercise goals and preferences: Interested in yoga and pilates - Financial considerations for exercise: Budget for classes - Previous postnatal exercise experience: None Examination findings: - Postural assessment: Slight anterior pelvic tilt - Diastasis recti assessment: 2-finger width separation Management plan: 1. Pelvic floor exercises and core strengthening: - Exercise recommendations: Kegel exercises - Specific exercises suggested: Pelvic tilts - Frequency and consistency goals: Daily 2. Sexual health: - Advice on returning to sexual activity: Gradual resumption - Recommendations for improving comfort during intercourse: Use of lubrication - Suggestions for scar tissue management: Gentle massage 3. Lifestyle modifications: - Dietary recommendations: Increase fiber intake - Nutritional considerations for breastfeeding and recovery: Ensure adequate protein - Specific dietary suggestions: Include leafy greens 4. Exercise programme: - Affordable and modified exercise options: Home-based yoga - Encouragement for current physical activity: Continue walking - Referral considerations for postnatal exercise classes: Local community center 5. Education: - Information on normal postpartum changes: Discussed - Advice on posture and intra-abdominal pressure management: Provided 6. Follow-up: - Timeframe for follow-up appointment: 6 weeks - Contact information for additional support: Provided 7. Referrals: - Consideration for referral to other healthcare providers: Physiotherapist (Note: Patient encouraged to reach out with any concerns or questions.)