Mummy MOT Pelvic health Assessment Notes (Allied Health)

Pelvic health - Visit date: 1 November 2024 - Practitioner: Dr. Emily Carter - Patient DOB: 15 March 1990 - Concerns: Pelvic pain and urinary incontinence - Goals: Improve pelvic floor strength and reduce incontinence - Time postpartum: 6 months - Baby details: Baby Oliver, DOB: 1 May 2024, Weight: 3.5 kg General Medical History: - Current medications: None - Gastrointestinal history: Occasional constipation - Neurological history: No significant history - Cardiovascular history: No significant history - Respiratory history: No significant history - Dermatological history: No significant history - Mental health history: Mild postpartum anxiety - Gynecological history: History of PCOS - Urological history: Recurrent UTIs Obstetric history: - First baby - Labor and delivery details: Vaginal delivery, baby weight 3.5 kg, 39 weeks gestation - Postpartum complications: None Current symptoms: MSK: - Aches and pains: Lower back pain Urological: - Urinary symptoms: Stress incontinence - Urinary habits: Frequent urination - Urinary tract infection history: Recurrent UTIs - Urine characteristics: Clear - Post-void symptoms: Dribbling Bowel habits: - Bowel movement frequency and consistency: Once daily, soft - Abdominal discomfort or pain: Occasional bloating - Stool characteristics: Normal - Gastrointestinal symptoms: Occasional bloating - Relevant medical conditions: None Diet and lifestyle: - Dietary habits: Balanced diet - Fluid intake: Adequate - Alcohol consumption: Occasional - Caffeine intake: Moderate Sexual function: - Sexual activity status: Active - Sexual discomfort or pain: Mild discomfort - Psychological factors related to sexual health: Anxiety Mental health: - Mood and emotional well-being: Mild anxiety - Adjustment to motherhood: Good - Support system: Strong family support Physical activity: - Exercise goals and preferences: Increase core strength - Financial considerations for exercise: Limited budget - Previous postnatal exercise experience: None Examination findings: Active assessment: - Postural assessment: Mild lumbar lordosis - Breathing assessment: Normal - Active pelvic floor assessment: Weakness noted - Forward flexion test: Limited lumbar mobility Passive assessment: - Rib flaring or diaphragm tension: None - Cesarean scar assessment: Not applicable - Diastasis recti assessment: 2 cm gap - External pelvic floor activation: Weak - Coordination of pelvic floor muscles: Poor Internal pelvic floor examination: - Verbal consent gained - Observation of external tissue and vulva: Normal - Ability to perform fast internal pelvic floor contractions: Weak - Assessment of bladder and cervix: Normal Management plan: Pelvic floor exercises and core strengthening: - Exercise recommendations: Kegel exercises - Specific exercises suggested: Pelvic tilts - Frequency and consistency goals: Daily Sexual health: - Advice on returning to sexual activity: Gradual - Recommendations for improving comfort during intercourse: Use of lubricant - Suggestions for scar tissue management: Not applicable Lifestyle modifications: - Dietary recommendations: Increase fiber intake - Nutritional considerations for breastfeeding and recovery: Adequate hydration - Specific dietary suggestions: Include more fruits and vegetables Exercise programme: - Affordable and modified exercise options: Home-based exercises - Encouragement for current physical activity: Walking - Referral considerations for postnatal exercise classes: Recommended Education: - Information on normal postpartum changes: Provided - Advice on posture and intra-abdominal pressure management: Provided Follow-up: - Timeframe for follow-up appointment: 6 weeks - Contact information for additional support: Provided Referrals: - Consideration for referral to other healthcare providers: Physiotherapist Note: Patient advised to monitor symptoms and report any changes.