Postnatal Pelvic Floor Physiotherapy Assessment

Patient Details Jane Doe 15 May 1990 07700 900300, jane.doe@example.com Dr. Sarah Smith Marketing Manager 1 November 2024 6 months postnatal Subjective Assessment Obstetric History * Two pregnancies, two live births. * First delivery: Vaginal, minimal labial tear, baby weight 7lb 5oz. * Second delivery: Assisted with forceps, episiotomy, baby weight 8lb 2oz. No reported complications. Current Concerns * Main goal: Return to running without leakage. * Urinary symptoms: Occasional stress urinary incontinence with coughing/sneezing, mild urgency. * Bowel symptoms: Occasional straining, feeling of incomplete emptying. * Prolapse symptoms: Sensation of vaginal heaviness when on feet for extended periods. * Pain symptoms: Mild lower back discomfort, particularly after lifting her baby. * Sexual function concerns: Mild discomfort with intercourse, reduced confidence. Bladder Function * Urinary frequency: 7-8 times daily. * Nocturia: 1-2 times per night. * Leakage details: Small amounts (dribbles) with strong coughs or sneezes, sometimes with urgency before reaching the toilet. * Urgency symptoms: Present, but able to usually hold. * Fluid intake information: Approximately 1.5 litres of water daily, 2 cups of coffee. Bowel Function * Bowel movement frequency: Every 1-2 days. * Stool type: Bristol Stool Chart Type 3-4. * Straining: Occasional, especially if not well-hydrated. * Incomplete emptying: Sometimes. * Pain during bowel movements: No. Sexual Function * Pain with intercourse: Mild dyspareunia at entry. * Vaginal dryness: No significant issue, uses lubricant. * Confidence returning to sexual activity: Low. Exercise And Activity * Current activity level: Daily walks with pram, light core exercises from an app. * Pre-pregnancy activity level: Ran 5k three times a week, attended Pilates classes. * Exercise goals: Return to running 5k, restart Pilates, be able to lift baby without back pain. * Barriers to exercise: Lack of time, fear of leakage, fatigue. General Health * Sleep quality and patterns: Interrupted due to baby, generally feels tired. * Mental health status: Reports feeling a bit overwhelmed at times, but no formal diagnosis of PND. * C-section scar issues: Not applicable. * Current medications: Multivitamin, Iron supplement. Consent Internal Exam Consent Obtained: yes Chaperone Offered: declined Objective Assessment Posture And Breathing * Postural alignment observations: Mild anterior pelvic tilt, slight kyphosis. * Rib cage position: Flared. * Breathing pattern: Predominantly apical, struggles with diaphragmatic breathing on command. * Ability to coordinate breath with movement: Poor during lifting tasks. Abdominal Assessment * Visual assessment findings: Mild abdominal distension. * Doming or coning observations: Minimal doming with crunch, more evident with sustained abdominal effort. * Tissue quality: Soft, some tenderness on palpation of lower rectus abdominis. * Palpation findings: No obvious hernia. * Diastasis recti width: 2 finger widths at umbilicus, 1 finger width above and below. * Depth and tension: Moderate depth, soft tension. * Location: At and slightly above umbilicus. C-Section And Perineal Scar * Scar healing status: Episiotomy scar well-healed. * Mobility: Good. * Sensitivity: No hyper or hypo-sensitivity. * Presence of adhesions: No palpable adhesions. Pelvic Floor Assessment * External observation findings: Good resting tone. * Perineal movement with cough: Minimal lift. * Ability to contract and relax the pelvic floor: Can initiate contraction, but relaxation is incomplete. Internal assessment tone recorded as normal. Power: 3/5 Endurance: 5 seconds Repetitions: 3 Fast: 2 Elevation: yes Co-Contraction: yes Timing On Cough: slow * Relaxation ability: Difficulty achieving full relaxation. * Prolapse assessment: POP-Q Stage I anterior and posterior wall prolapse. Functional Assessment * Squat: Good depth, some valgus knee movement at end range. * Single leg balance: Fair, sways slightly. * Lunge: Good form, but reports mild pelvic floor sensation. * Load transfer: Struggles with controlled transfer from floor to standing. * Impact tolerance: Not yet assessed for running. * Return-to-run readiness assessment findings: Not yet ready due to reported symptoms and objective findings. Assessment Summary * Key findings: Mild stress urinary incontinence, feeling of incomplete bowel emptying, stage I pelvic organ prolapse, weak pelvic floor muscles with poor endurance and relaxation, mild diastasis recti, suboptimal breathing pattern, and poor core engagement. * Clinical reasoning: Symptoms are likely multifactorial, related to childbirth trauma, prolonged intra-abdominal pressure, and deconditioning of core and pelvic floor postnatally. * Identified impairments: Pelvic floor muscle weakness, impaired coordination, incomplete relaxation, poor core stability, suboptimal breathing mechanics. * Rehabilitation priorities: Improve pelvic floor strength and endurance, enhance relaxation, optimise breathing, improve core stability, and progress functional movements. Treatment Plan Education * Pelvic floor function education: Explained anatomy, role in continence and support, importance of full relaxation. * Pressure management education: Strategies for managing intra-abdominal pressure during daily activities and exercise. * Bladder and bowel habits education: Discussed fluid intake, regular emptying, and optimal toileting posture. Exercise Programme * Pelvic floor training exercises: Isolated contractions focusing on lift and squeeze, then full relaxation. * Core rehabilitation exercises: Transverse abdominis activation, gentle spinal mobility. * Functional strength exercises: Modified squats and lunges, hip hinge exercises. * Mobility work: Thoracic spine mobility, hip flexor stretches. Lifestyle Advice * Lifting technique advice: Demonstrated safe lifting techniques for baby and household items. * Return to exercise guidance: Graded return to impact activities, starting with walking and gradually progressing. * Toileting posture advice: Emphasised elevated feet and relaxed posture. Goals * Short-term rehabilitation goals: Reduce urinary leakage to less than once per week, improve awareness of pelvic floor relaxation, perform 10 efficient pelvic floor contractions with 5-second holds. * Long-term rehabilitation goals: Return to pain-free running for 30 minutes, no prolapse symptoms, comfortable sexual activity. Follow-Up Plan * Review timeframe: In 4 weeks. * Progression markers: Reduction in leakage episodes, improved confidence in pelvic floor control. Email Summary Dear Jane, It was a pleasure to meet you today. This email is a summary of our session. Key Findings And Reassurance It was good to discuss your symptoms today. We found that you have some weakness and difficulty relaxing your pelvic floor muscles, which is very common after childbirth, especially with two vaginal deliveries and an episiotomy. You also have a mild separation of your abdominal muscles (diastasis recti) and a slight feeling of heaviness from your vagina, known as a Stage 1 prolapse. These findings are all very common after pregnancy and birth, and importantly, they are highly treatable with physiotherapy and consistent exercises. Advice Points * Remember to drink plenty of water throughout the day to keep your bowels regular. * Aim for good toileting posture by elevating your feet on a small stool when having a bowel movement. * Practice safe lifting techniques when picking up your baby or other heavy items, bending from your knees and keeping the load close to your body. * Gradually increase your activity levels, starting with walking and gentle core exercises before thinking about higher impact activities like running. Your Exercise Programme Please perform these exercises as discussed. Focus on the quality of the contraction and, just as importantly, the full relaxation afterwards. * Pelvic Floor Lifts: * Gently lift and squeeze as if stopping wind and urine. * Hold for 3-5 seconds. * Fully relax for 10 seconds. * Repeat 10 times. * Perform 3 times a day. * Quick Pelvic Floor Flicks: * A quick lift and squeeze, then immediate relaxation. * Repeat 10 times. * Perform 3 times a day. * Diaphragmatic Breathing: * Lie on your back with one hand on your chest and one on your belly. * Breathe deeply, aiming for your belly hand to rise more than your chest hand. * Practice for 5 minutes, twice a day. I look forward to seeing you for your review in 4 weeks. Please keep a note of your symptoms in the meantime. Best wishes, Dr Thomas Kelly Physiotherapist