Physiotherapy in Obstetrics and Gynaecology

493 Pages·2004·7.12 MB·English

by  Jill Mantle BA GradDipPhys MCSP DipTP, Jeanette Haslam MPhil GradDipPhys MCSP SRP Sen Vis Fellow UEL, Sue Barton MSc DipEd MCSP DipTP DipRG & RT DipTHRF

BUTTERWORTH-HEINEMANN
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© Margaret Polden and Jill Mantle 1990
© 2004, Elsevier Limited. All rights reserved.

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First edition 1990
Second edition 2004

ISBN 0 7506 2265 2

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Dedication

This second edition of Physiotherapy in Obstetrics and Gynaecology is dedicated to the memory of Margaret
Polden, co-author of the first edition, who tragically died in 1998 just as work on this second edition
began.
Margie was renowned internationally for her passion for the promotion of the health and well-being
of women, for her clinical excellence, particularly in the obstetric field, and for her easy style of writing.
The Council of the Chartered Society of Physiotherapy formally recognised this by awarding her the first
posthumous Fellowship in 1999.
Through the first edition of Physiotherapy in Obstetrics and Gynaecology the essential essence of Margie’s
knowledge, wisdom and experience was made available to physiotherapists internationally. The
contributors to this second edition all knew Margie and were influenced by her. They have sought to
revise the text in the light of contemporary evidence, as Margie would have wished, and they offer this
volume as a tribute to her – a true friend, colleague and outstanding human being.

Sue Barton MSc DipEd MCSP DipTP DipRG&RT
DipTHRF SRP
Health Senior Lecturer, School of Health Studies,
University of Bradford, England, UK

Teresa Cook GradDipPhys MCSP SRP
Clinical Specialist, Physiotherapist in Women’s
Health, James Paget Hospital, Great Yarmouth,
Norfolk, England, UK

Jo Fordyce GradDipPhys MCSP SRP
Clinical Specialist, Physiotherapist in Women’s
Health, St George’s Hospital, London, England, UK

Jeanette Haslam MPhil GradDipPhys MCSP SRP
Senior Visiting Fellow, University of East London,
London, England, UK

Jill Mantle BA FCSP DipTP
Senior Visiting Fellow, University of East London,
London, England, UK

Pauline Walsh MCSP SRP
Clinical Specialist Physiotherapist in Obstetrics and
Gynaecology, Mount Alvernia Hospital, Guildford,
Surrey, England, UK; Royal Surrey County Hospital
NHS Trust, Guildford, Surrey, England, UK

vii

Contributors

Since 1995 it has been a great pleasure, privilege
and honour to serve as the President of the
Association of Chartered Physiotherapists in
Women’s Health (ACPWH). This has enabled me to
attend council meetings as well as the Annual
Meeting of the Association on several occasions.
The ACPWH is an active, enthusiastic group of spe-
cialist physiotherapists who promote the impor-
tance of physiotherapy in all aspects of obstetrics
and gynaecology.
It is well recognised that antenatal education
facilitates easier childbirth and a faster return to
‘normal’ in the post partum period. However
many under estimate the value of physiotherapy
throughout a woman’s life in the promotion of
good health by preventing or ameliorating a wide
range of physical problems. For example urinary
incontinence and pelvic organ prolapse are exceed-
ingly common with a life-time risk of approxi-
mately 11% requiring surgery for one or other of
these conditions, a third of whom will require
re-operation. Thus a huge proportion of the adult
female population suffer from symptoms which,
although not life threatening, undoubtedly signifi-
cantly impair quality of life and lead to embarrass-
ment and inability to perform routine activities of
daily living. Approximately two thirds of women
with urinary incontinence will benefit from physio-
therapy and, whilst this may not provide a com-
plete cure, it is likely to avoid or defer the need for
surgery until a suitable time e.g. when a woman’s

family is complete and she is fit and willing to
undergo surgical intervention.
All women with lower urinary tract problems
and pelvic organ prolapse benefit from the advice
of a physiotherapist who can not only provide the
appropriate exercises to strengthen the pelvic floor
but can advise on life style interventions in order to
improve symptoms and help individual women to
lead a normal lifestyle. Unfortunately, at present,
there are not enough physiotherapists trained in
women’s health to take care of the needs of all those
women who would benefit from such advice and
treatment.
The second edition of Physiotherapy in Obstetrics
and Gynaecology is an excellent book written by
dedicated women’s health physiotherapists specifi-
cally for physiotherapists. However it will also be
of use to all midwives, health visitors, obstetricians
and gynaecologists and others who are involved in
the care of women before, during and after preg-
nancy and who share the management of women
with the common sequelae of childbearing. The
text has been written in an ‘easy to read’ style and is
well referenced and will, I am sure, be used as a ref-
erence book for many of us dealing with problems
related to women’s health. I am sure that this book
will continue to be the authoritative work on the
subject until the third edition of Physiotherapy in
Obstetrics and Gynaecology is published!

Linda Cardozo, 2004

ix

Foreword to the second edition

xi

The physiotherapist has been an important member
of the maternity team for years, in fact since at least
1912. Then, the physiotherapist Minnie Randall
together with the obstetrician J. S. Fairbairn at St.
Thomas’ Hospital developed special interests in
the management of pregnancy, labour and the puer-
perium. Later the scope was extended to gynaeco-
logical cases.
Out of this has grown the Association of
Chartered Physiotherapists in Obstetrics and
Gynaecology. Its special contribution was recog-
nised in the joint statement by the Royal College of
Midwives, the Health Visitors’ Association and
the Chartered Society of Physiotherapy.
This recognition makes this new book espe-
cially timely. The training of a physiotherapist
does not necessarily include the role in obstetrics
and gynaecology. The book is a definitive state-
ment. It therefore includes chapters on all aspects
of the physiotherapist’s role in obstetrics and
gynaecology, from the basic sciences through to
incontinence, a symptom which causes great dis-
tress and restriction of life to so many women and
one which can so often be helped by the skills of
the physiotherapist.

On a personal note I am happy to say that
throughout my professional life in obstetrics and
gynaecology I was always conscious of the contri-
bution physiotherapists could bring to our work.
I was privileged to know and to work with Helen
Heardman who did so much to promote prepar-
ation for childbirth and the relief of discomfort.
The obstetric physiotherapist was always a valued
member of the team attending teaching rounds and
of course conducting antenatal classes for mothers,
and fathers. They have a special role which cannot
be properly undertaken by others not trained in
their methods.
I am therefore very glad to welcome this
book with all the care and effort that has gone into
its production, not least in the excellent illustr-
ations and the bibliography which follows each
chapter and which makes it an excellent work of
reference.
The book has a scope and interest far beyond its
authors’ intention.

Dame Josephine Barnes, 1990

Foreword to the first edition

xiii

It gave Margie and me great pleasure to receive
many assurances from colleagues that our ‘off-
spring’ was proving useful. As we travelled the
world we were encouraged by the sight of well-
thumbed copies in departments and libraries, and
we heard our book referred to as ‘the bible’ more
than once.
When in 1994 the publishers first mooted the
desirability of a second edition, we were exercised
as to what to recommend and advise, especially
with respect to physiotherapy in obstetrics. The
publication in 1993 by the Department of Health
(DoH) of the report of the Expert Maternity Group,
entitled Changing childbirth, was followed by a very
unsettled period within the UK Maternity Services
as a variety of new service models were tried. We
were dismayed by the absence of any mention
within the report of the obstetric physiotherapist
and, in the light of an acute shortage of midwives,
we considered the emphasis upon each pregnant
woman having a named midwife to support her
throughout each entire childbearing episode to be
unrealistic.
By 1997, publisher pressure mounted, the book
was still selling well but Butterworth Heinemann
wanted an upgrade and we were increasingly

aware of progressions in knowledge, so once again
we set to work in Margie’s kitchen. Receiving the
news of Margie’s tragic and untimely death on
Monday the 16th March 1998 is etched into the
memory bank of many. All writing ceased and the
second edition went on hold. It has been gradually
resurrected with encouragement from Margie’s
husband, Martin and the family, and from col-
leagues. It has only been actually realised with an
enormous amount of help from colleagues, in par-
ticular Jeanette Haslam, Sue Barton, Jo Fordyce,
Pauline Walsh, Teresa Cook, Elizabeth Crothers,
Morag Thow, Margaret Brownlee, and Deborah Fry,
but also there are many others who responded to
our queries. To all these people I offer my heartfelt
thanks. May this edition enable the memory of
Margie to continue to inspire colleagues to holistic,
up-to-date best practice in this specialty.

Jill Mantle
London, 2004

Reference

DoH 1993 Changing childbirth, Part 1 Report of the Expert
Maternity Group. HMSO, London.

Preface to the second edition

This book was conceived in a coach travelling
between Bristol and Bath, and the first cell divisions
occurred in the humid atmosphere of the Roman
Baths and the Regency Pump Room. Implantation
of the developing morula took place in the offices of
Heinemann Medical Books, then in London, and
the pregnancy was subsequently confirmed.
The gestation proved to be much longer than
originally anticipated. About the length of two ele-
phant’s pregnancies, and a period we will certainly
never forget! The physical stresses – writer’s
cramp, aching bottoms and backs – have been
great, but in no way did they approach the psycho-
logical and emotional traumas to ourselves and our
nearest and dearest. We have used every known
coping strategy and invented several more to cope
with the labour necessary to give birth.
Now in the postpartum period, we are, like all
new mothers, relieved but apprehensive as to how

our offspring will be received. We very much hope
that it will prove to be a useful and valued contri-
bution to society.
We would like to thank all those who gave their
time so freely to answer the numerous queries that
arose in our efforts to make sure that information
in the book is accurate and up to date; our thanks
also to Shona Grant, our illustrator, for her patience,
Ricky Hoole, Margaret Nokes and Sarah Polden,
our long-suffering typists, and most particularly,
our dear husbands who have endured our raised
catecholamine levels over an extended period.
They have suffered, like many pregnant fathers,
and are undoubtedly hoping that life will now ‘get
back to normal’ – whatever that might mean.

Margaret Polden, Jill Mantle
London, 1990

xv

Preface to the first edition

At the start of a new edition, it is inspiring to
review briefly the history of physiotherapists’
involvement in obstetrics and gynaecology. It is
also prudent to take stock of relevant changes in
policy and practice within society and the National
Health Service since the publication of the first edi-
tion, and to reconsider the purpose of this book
and the important issues for physiotherapists in
the specialty now.
In the late nineteenth century the physiother-
apy, nursing and midwifery professions shared a
common rootstock. In the UK, educating more
than just a few privileged women was a new phil-
osophy, and formal and accredited training for
occupations thought suitable for women, such as
nursing and midwifery, was at best elementary. In
addition, professional bodies were only just being
formed. Women who wanted to work outside the
home and were inclined to care for people took
whatever training was offered, first in one aspect
of caring, then in another.
In 1886, Dame Rosalind Paget, a nursing sister
at the London Hospital who was also a midwife,
joined the Midwives Institute, which later became
the Royal College of Midwives (RCM). In 1902 she
was involved in the formation of the Central
Midwives Board and appears as number two on
their list of members. Also in 1886 Dame Rosalind
became interested in a new therapy – Swedish
massage. She, and others like her, underwent
training and then returned to their hospitals to
teach the techniques to their colleagues. However,
through her insistence on high standards and her
anxiety that properly trained, reputable masseuses

should not be confused with those of ‘ill repute’,
she became one of the founding members of the
Society of Masseuses and in 1895 became its first
Chairman of Council. Over the years the group
prospered, extended its focus to include remedial
exercise and electrotherapy, and developed into
the Chartered Society of Physiotherapy (CSP).
Dame Rosalind held membership number one.
Early in the twentieth century, Miss Minnie
Randell OBE, a sister at St Thomas’s Hospital
London, had also trained both as a nurse and a
midwife. She became interested in both the mas-
sage and the remedial exercises being propounded
by the Swede, Per Henrik Ling. She was appointed
as Sister-in-Charge and then Principal of the
School of Massage and Medical Gymnastics at St
Thomas’ Hospital. In 1912, J. S. Fairbairn, a lead-
ing consultant obstetrician at St Thomas’ who
believed in ‘preventive obstetrics’, asked Miss
Randell to devise a system of ‘bed exercises’ for
his postnatal mothers. Because newly delivered
women remained in bed for about 3 weeks at that
time, many problems that are rarely seen today
were rife. The exercises were designed to aid post-
natal physical recovery and to train women to rest
through relaxation. Thus Miss Randell was one of
the first to bring the principles of physiotherapy to
obstetrics. Later, Miss Randell turned her atten-
tion to antenatal instruction, once again urged on
by Mr Fairbairn, who thought that more should
be done preventatively to help pregnant women
(Fairbairn 1923). She was greatly influenced by Dr
Kathleen Vaughan who had noticed, while work-
ing in Kashmir, that women who had a sedentary,

xvii

Introduction

Jill Mantle

confined and inactive lifestyle frequently had more
difficult labours and deliveries than the boat-
women and peasants who led much more active
lives. Dr Vaughan believed that heredity was not
the only factor that determined the shape of the
pelvis and the mobility of its joints and those of the
lower spine – the way women used their bodies in
their everyday lives was also an important influ-
ence. Apart from incorporating squatting into her
antenatal programme as a preparation for labour,
Miss Randell introduced many of the pelvic- and
lumbar-spine-mobilising exercises which were
based on the movements made by Kashmiri boat-
women, and encouraged women to adopt different
positions of comfort in labour.
In 1936 Heinemann published a book entitled
Maternity and Postoperative Exercises; written by
Margaret Morris, an ex-ballet dancer, who had been
one of Miss Rendell’s students. It is of interest that,
in it, women in the puerperium were encouraged to
practise repeated ‘pelvic floor tensing’, trying ‘to
invert the sphincters…until it becomes habitual’; it
was recommended that this be performed to the
strains of Schubert’s waltzes 16, no. 2 (Morris 1936).
In her book, Fearless Childbirth published by
Churchill in 1948, Minnie Randell explained that
the purpose of the tensing was to prevent and treat
symptoms of urine leakage and prolapse (Randell
1948). It is important to appreciate that in the early
part of the twentieth century far fewer books were
published than today and women authors were
rare. Yet these pioneers started a tradition that has
continued, and has promoted and enriched the spe-
cialty down the years.
In the 1930s Dr Grantly Dick-Read was a further
notable source of influence on Miss Randell with
his theory of the fear–tension–pain cycle in labour.
Fearful women who expected to feel pain became
tense as labour began. This led to tension in their
minds and, according to Grantly Dick-Read, in
their cervices too. This, he claimed, gave rise to
more pain, which in turn increased their fear. He
encouraged his labouring mothers to relax and
breathe deeply through their contractions, a system
which Miss Randell built into her antenatal classes.
In the late 1930s, Margaret Morris, suggested to
Miss Randell that women should actually rehearse
labour antenatally in the same way that dancers
rehearse for a performance.

It was another physiotherapist, Helen Heardman,
who in the 1940s drew together the threads of
relaxation, breathing and education for childbirth
into antenatal preparatory courses for labour and
parenthood (Heardman 1948). Before her tragic
death in 1949, she was instrumental in gathering
together the group of like-minded physiothera-
pists from around the UK who formed the
Obstetric Physiotherapist’s Association in 1948. It
was one of the first special interest groups of the
CSP, and in 1961 became the Obstetric Association
of Chartered Physiotherapists. Antenatal classes
mushroomed through the 1950s, often taken
entirely by so called ‘obstetric physiotherapists’,
and women were routinely offered postnatal exer-
cise sessions and advice postnatally during their
5–7-day hospital stay. Midwives were invited to
contribute and gradually have become the domi-
nant profession in this aspect of care.
In the 50 and more years since then, much has
changed in obstetric physiotherapy, midwifery and
obstetrics, and many dedicated physiotherapists
have added their expertise to the specialty. In 1963
Laura Mitchell introduced her method of relaxation,
which has been used extensively ever since. In 1977
Dorothy Mandelstam was invited to be the first non-
medical member of the International Continence
Society and her name will always be associated with
the ending of the taboo on incontinence. Together
with Shelia Harrison, she worked tirelessly through
the 1970s to encourage OACP members to expand
the field to include gynaecology and the treatment
of incontinence. In 1978 the Association adopted the
title of the Association of Chartered Physiothera-
pists in Obstetrics and Gynaecology (ACPOG). In
the late 1980s there was further international pres-
sure to think holistically of women’s health issues,
which led to another change of title in 1994 to
the Association of Chartered Physiotherapists in
Women’s Health (ACPWH) and to physiotherapists
employed in the field being called ‘women’s health
physiotherapists’.
The Association is one of the largest clinical
interest groups in the CSP and, down the years, it
has played the lead role in developing postregis-
tration courses for physiotherapists wishing to
specialise in the field. It is regrettable that, despite
the fact that half the UK population is female and
childbearing is the norm for the majority, the basic

INTRODUCTION
xviii

physiotherapy training contains very little specific
material to prepare physiotherapists to assist
women in pregnancy and the puerperium. Neither
does it enable them to take informed account of
the effects of childbearing when treating patients
with pathologies. There is also a deficit in basic
training regarding the promotion of continence
and the treatment of incontinence. This is largely
due to the fact that obstetric, gynaecological and
urogynaecological placements for students are
optional and there are very few university staff
with expert knowledge of these areas. It is also
true that few physiotherapy managers have in-
depth specialist knowledge or experience of the
specialty. Consequently it has fallen to the specific
interest group to provide appropriate training and
this responsibility it has faithfully discharged for
more than half a century, often with tutors giving
their time gratis. Today there are courses accred-
ited and run by universities and shorter courses
organised by ACPWH and by individuals – see
contact details at the end of the chapter. Fortu-
nately it is now more widely recognised by other
health professionals that specialist physiothera-
pists are to be preferred throughout obstetrics,
gynaecology and urogynaecology.
This book was designed to assist the following
categories:

• physiotherapy students making their first con-
tact with this field or whose training has failed
to include needed information

• newly qualified physiotherapists on obstetric
and gynaecological rotations

• physiotherapists embarking on relevant spe-
cialist postregistration training

• physiotherapists who are actively involved in
the specialty (as a resource book).

The Association is fortunate to count among its
members, both past and present, many women
who have reached the top of their profession
as specialist clinicians, educators, authors and
researchers. They have gained the respect, not only
of their colleagues, but also of the members of the
midwifery, health visitor and medical professions.
This mutual respect among individuals led ACPOG
into increasing dialogue and collaboration with the
RCM and the Health Visitors’ Association (HVA).
The result was the publication of the following

statement, negotiated by ACPOG with the RCM
and the HVA, and endorsed by the CSP in March
1987, and further confirmed in 1994, entitled
Working Together in Psychophysical Preparation for
Childbirth. This statement was endorsed by the CSP
at its Council meeting on 11 March 1987. It was
revised in 1994 and is published by CSP as
Information paper no. PA13:

Midwives, Health Visitors and Obstetric Physio-
therapists all have important specialist contribu-
tions to make in preparation for childbirth and
parenthood. This contact with parents also pro-
vides a valuable opportunity for more general
health promotion, health education and preven-
tative medicine. In the delivery of such a service
in a locality, it is important that the professional
team demonstrates a flexible approach and takes
account of the views and needs of all parents.

The midwife
The role of the midwife is that of the practitioner
of normal midwifery, caring for the woman
within the hospital and community throughout
the continuum of pregnancy, childbirth and the
puerperium. She has an important contribution
to make in health education, counselling and
support. In this context her aim is to facilitate the
realization of the woman’s needs, discuss expec-
tations and air anxieties. She has the responsibility
of monitoring the woman’s physical, psycho-
logical and social wellbeing and is in a unique
position to be able to correlate parent education
with midwifery care.

The health visitor
The role of the Health Visitor in this field is to offer
advice to the parents-to-be on the many health,
psychological and social implications of becoming
parents and the development of the child. She is in
a very special position in the family scene to
inform them of the services available and encour-
age them to use them. The health visitor should
always have a participatory role within the team
to provide continuity of care to the family.

The obstetric physiotherapist
The role of the Obstetric Physiotherapist is to
promote health throughout the childbearing

Introduction
xix

period and to help the woman adjust advanta-
geously to the physical and psychological changes
of pregnancy and the post-natal period so that
the stresses of childbearing are minimised. Ante-
natally and post-natally she advises on physical
activity associated with both work and leisure
and is a specialist in selecting and teaching
appropriate exercises to gain and/or maintain
fitness including pelvic floor education. Where
necessary she gives specialised treatment e.g.
therapeutic ultrasound post-natally to alleviate
perineal discomfort. She also assesses and treats
musclo-skeletal problems such as backache and
pelvic floor muscle weakness. In addition she is
a skilled teacher of effective relaxation, breathing
awareness and positioning and thus helps the
woman to prepare for labour.

Liaison
In order for the services of the team to be of max-
imum benefit to parents there should be a close
liaison between members. Liaison, planning and
shared learning sessions help to ensure that tech-
niques and advice are consistent, up to date,
related to current practice and meet the needs
of parents. This is particularly important when
there is no available member of one of the spe-
cialist professions. Where this is the case, advice
should be sought from the relevant professional
body. To enhance continuity of care, new mem-
bers of the team must always have a period
of inter-disciplinary induction. The Midwife,
Health Visitor and Obstetric Physiotherapist
should be in regular contact and operate an effec-
tive referral system.

The aims of parenthood education

• To enable parents to develop a confident and
relaxed approach to pregnancy, childbirth
and parenthood.

• To enable parents to be aware of the choices
in care based on accurate and up to date
information.

• To provide continuity of high quality care as
previously defined to parents by means of
team collaboration and co-operation between
professionals including specialised treatments
where needed.

• To ensure that appropriate, consistent and
clear advice is given with full cognisance of
safety factors.

• To promote health and preventative medicine.

Frequently new methods of education in parent-
hood are introduced e.g. aqua-natal and fitness
classes. In such instances it is necessary for guid-
ance to be sought on appropriate exercises from
the local obstetric physiotherapist or alternately
the Chartered Society of Physiotherapy, and fur-
ther training may be required.

Since the publication of the first edition of this
book in 1990 there have been several government-
funded developments of relevance to the specialty
and the demand, particularly within the conti-
nence services, for specialist physiotherapists has
risen steeply. In 1992, the Continence Foundation
was established as an umbrella organisation that
has provided a focus for all those individuals and
organisations concerned to improve the quality and
availability of services for sufferers with contin-
ence problems. The Foundation, initially govern-
ment funded but now a charity, seeks to raise
awareness, foster education and research, provide
information, advice and expertise and influence
policy makers and providers.
As the result of much collaboration and lobbying
at all levels of government, a great deal has been
achieved in 10 years. Conferences and literature, for
example, Guidelines for Continence Care (ACA 1993),
Incontinence: Causes, Management and Provision of
Services (RCP 1995), raised awareness. This culmi-
nated in 1998 in the formation of a multidisciplinary
expert working group (including a physiothera-
pist), by the Parliamentary Under Secretary of State
for the Department of Health (DoH). The brief of
the working group was to look at continence serv-
ices and advise on how they might be improved.
Their report Good Practice in Continence Services was
published in 2000, highlighting the problems and
making strong recommendations. Although not
mandatory, it clearly maps out the envisaged serv-
ice, the professionals needed to provide the serv-
ice and the priority groups to be served. The
Continence Foundation speedily published two
supporting publications Incontinence: a Challenge
and an Opportunity for Primary Care (CF 2000a) and

INTRODUCTION
xx

Making the Case for Investment in an Integrated
Continence Service (CF 2000b) designed to raise
awareness of the government guidelines and of
the need for better services. In 2001/2 research,
jointly funded by the Continence Foundation and
the Royal College of Nursing, took place to survey
continence service commissioning and provision
across England. A further aim of this research was
to encourage those engaged in the management of
people with incontinence to work towards provid-
ing the best possible services (CF 2002).
In 1997 the report of the Pennell Initiative for
Women’s Health, funded jointly by the government
and by the pharmaceutical company Wyeth and
chaired by Dame Rennie Fritchie, was published.
The objective was to gain an overview of what was
known about women’s health in later life (45–105�)
and to explore the positive steps that could be taken
to improve every woman’s prospects of living well
into a healthy old age. Recommendations were
made for policy makers, for health-care profession-
als, and for women and representative organisa-
tions. The recommendations prioritised education,
better early preventative care and prompt assess-
ment and treatment of problems as they arose.
The National Service Framework for Older People
(DoH 2001) reflects thinking from the Pennell
report (1998) and Good Practice in Continence Services
(DoH 2000) requiring identification of those with
osteoporosis and those at risk of falls, and setting
the target for an integrated continence service by
2004. In addition, the requirement for evidence-
based practice throughout the National Health
Service (NHS) has produced a plethora of research,
especially related to continence care. ‘Quality of
life’ has become a valued outcome measure.
Conservative treatment has returned to favour as
the first line of treatment for many with continence
problems and consequently specialist physiothera-
pists have been in greater demand.
Progress in the maternity services has been less
positive. In 1993 the DoH published the report of
an expert committee entitled Changing Childbirth.
The committee, which did not include a physio-
therapist, was chaired by Julia Cumberlege,
Under-Secretary of State for Health. In essence,
the recommendations were that the service should
ensure that the woman and her partner felt sup-
ported and fully informed throughout pregnancy

and were prepared for the birth and the care of the
baby. The committee recommended that women
should be able to book with a midwife for the
entire episode of care, including delivery. There
followed a very unsettled period, particularly for
midwives, as a variety of service provision models
were tested. There was much talk of ‘informed
choice’ for and ‘empowerment’ of mothers-to-be.
The combination of an acute shortage of midwives,
most pregnant women also being employed, and
the need to hold down NHS costs, made these rec-
ommendations virtually impossible to achieve. As
two leaders in the midwifery field wrote:

It is almost impossible for women to have a
decent discussion on options… in a one off visit,
with a stranger they may never see again, in a
busy maternity clinic…While we espouse the
right of informed choice, we are giving the
women of Britain a clear message; it is alright for
you to have informed choice so long as you
choose hospital birth, caesarean section, epidural
anaesthesia and active management.
(Page & Penn 2000)

The concern with the rising caesarean section rate
continues with the 2000/1 figure for England and
Wales at 21.3% (DoH 2002), and questions are now
being asked as to whether women are made aware
of the risks and disadvantages of caesarean
section. Statistics are now being collected of the
number of ‘normal births’, that is, spontaneous
onset, and without regional anaesthesia, augmen-
tation of labour or episiotomy. Data prepared by
BirthChoiceUK.com (Dodwell 2002) from DoH
statistics for England suggest a patchy picture and
a fall in ‘normal births’ from 60% in 1999 to 41.5%
in 2001. The debate regarding home delivery as an
option for mothers-to-be is being clouded by the
unaffordable insurance premiums being demanded
of independent midwives.
Changing Childbirth failed to mention physio-
therapists, and did not address the health needs of
mothers in the puerperium and beyond. These
needs were powerfully exposed by MacArthur et al
(1991). Many of the problems highlighted could
possibly be prevented by early intervention by a
physiotherapist specialising in women’s health
and, if problems arise, would probably benefit
from assessment and treatment by one. To cut costs

Introduction
xxi

and to reduce the risk of hospital-based infections
being passed to mother or infant, women now are
discharged within 1–4 days of delivery into the
hands of community midwives. Shortages of mid-
wives, holidays, sickness and urban road conges-
tion make this service problematical. More recently
the fact that postnatal women are not happy with
their care has been raised (Singhe & Newburn 2000).
Women now work through pregnancy, often right
up to delivery. Antenatal class attendance is poor,
and early discharge after delivery leaves physio-
therapists struggling to deliver an effective service,
even to those at risk.
Support from research and expert opinion for
providing routine input to modern maternity care
by women’s health physiotherapists is weak; that
for prevention, assessment and treatment of condi-
tions like symphysis pubis dysfunction and incon-
tinence is stronger (Fry 1992, Morkved 2001, Reilly
et al 2002). Attempts to show benefit from antenatal
class attendance has been disappointing. To deal
with this uncertainty, a well-constructed body of
research is needed. This is unlikely to be of interest
to obstetricians and midwives. Women’s health
physiotherapists are the affected group and those
in post must take up the challenge. The collabora-
tive multicentre approach and carefully planned
auditing would provide first stage evidence on
which to base more detailed studies.
When preparations for the first edition of this
book were under way, physiotherapists in urogyn-
aecology felt they were struggling and were under-
valued. What a dramatic change has occurred!
Now it is those in obstetrics who are constantly
being required to argue their case for existence.
Hopefully this book will offer support, informa-
tion and ideas. The motivation of those who have

collaborated to produce this second edition is a
deep conviction that thorough and effective phys-
iotherapy is essential in this field, and that physio-
therapists are the most appropriate professionals
to carry it out. There is no better forum for health
education, in its widest sense, than is offered by the
contact between the whole obstetrical health-care
team and women experiencing pregnancy, labour
and the puerperium; and the benefits go on and
on, into later years. The knowledge so gained radi-
ates out, like the ripples from a stone tossed into a
pool, and influences whole families and the wider
community. The physiotherapist has a great deal to
offer in this field, particularly in terms of fitness,
coping with stress, wise back care and the promo-
tion of continence.
We have tried not to perpetuate information
that has been stated and restated in other textbooks
without proper testing, and have been very careful
not to dictate prescriptions for treatment, as careful
educated assessment is the key to appropriate ther-
apy. In a book of this size we have had to set limits
on what is included and the depth at which it is
covered; some knowledge is assumed. We have
tried to write clearly and simply, with a minimum
of jargon, explaining underlying physiology and
the reasoning behind certain approaches. We
include references for further reading in each
aspect of the subject. Cross-references have been
used extensively, but, in places, material has been
repeated to avoid an irritating break in the reader’s
train of thought caused by having to turn to
another page. We hope that other physiotherapists
will be infected by our enthusiasm for the spe-
cialty, and will enjoy, as we do, working with our
midwifery, health visitor and medical colleagues,
for the benefit of women of all ages.

INTRODUCTION
xxii

References

ACA (Association for Continence Advice) 1993 Guidelines
for continence care. ACA, London.
CF (Continence Foundation) 2000a Incontinence: a challenge
and an opportunity for primary care. Continence
Foundation, London.
CF (Continence Foundation) 2000b Making the case for
investment in an integrated continence service.
Continence Foundation, London.

CF (Continence Foundation) 2002 Good, better and best
Practice. Continence Foundation, London.
CSP (Chartered Society of Physiotherapy) 1994
Working together in psychophysical preparation
for childbirth. Information paper no. PA13. CSP,
London.
Dodwell M 2002 BirthChoiceUK.com: introduction to birth
statistics. New Digest, August, p 8–9.

Introduction
xxiii

DoH (Department of Health) 1993 Changing childbirth, part
1 and 2. HMSO, London.
DoH (Department of Health) 2000 Good practice in
continence services. DoH, London.
DoH (Department of Health) 2001 The national service
framework for older people. DoH, London.
DoH (Department of Health) 2002 NHS maternity statistics,
England and Wales. 1998–99 to 2000–01. Stationery
Office, London.
Fairbairn J S 1923 Introduction. In: Liddiard M The
mothercraft manual, Churchill, London.
Fry D 1992 Diastasis symphysis pubis. Journal of the
Association of Chartered Physiotherapists in Obstetrics
and Gynaecology 71:10–13.
Heardman H 1948 A way to natural childbirth. Livingstone,
London.
MacArthur C, Lewis M, Knox E 1991 Health after childbirth.
HMSO, London.
Morkved S, Salvesen K A, Scheil B et al 2001 Prevention of
urinary incontinence during pregnancy – a randomised

controlled trial of primiparous women. International
Urogynecology Journal 12:S1.
Morris M 1936 Maternity and postoperative exercises.
Heinemann, London, p 109–111.
Page L, Penn Z 2000 Informed choice has become a hollow
phrase. New Generation, June: 12.
Pennell Initiative 1998 The Pennell Report on Women’s
Health 1998. Health Service Management, University of
Manchester, Manchester, p 64–65.
Randall M 1948 Fearless childbirth. Churchill, London.
RCP (Royal College of Physicians) 1995 Incontinence: causes,
management and provision of services. RCP, London.
Reilly E T C, Freeman R M, Waterfield A E et al 2002
Prevention of post partum stress incontinence in
primigravidae with increased bladder neck mobility; a
randomised controlled trial of antenatal pelvic floor
exercises. British Journal of Obstetrics and Gynaecology
109:68–76.
Singhe D, Newburn M. 2000 Women’s experiences of
postnatal care. National Childbirth Trust, London.

Further reading

Continence Foundation 2000a Incontinence: a challenge and
an opportunity for primary care. Continence Foundation,
London.
Continence Foundation 2000b Making the case for
investment in an integrated continence service.
Continence Foundation, London.
Continence Foundation 2001 Good, better and best practice.
Continence Foundation, London.

DoH (Department of Health) 1993 Changing childbirth, part
1 and 2. HMSO, London.
DoH (Department of Health) 2000 Good practice in
continence services. DoH, London.
DoH (Department of Health) 2001 The national service
framework for older people. DoH, London.
NCT 2002 Evidence based briefing. Caesarean section – Part 1.
New Digest Edition 19, National Childbirth Trust, London.

Useful websites

Association of Chartered Physiotherapists in Women’s Health –
www.womensphysio.com
Association for Continence Advice – www.aca.uk.com
Chartered Society of Physiotherapy – www.csp.org.uk
Continence Foundation – www.continence.foundation.org.uk

International Continence Society – www.ics.org.com
Royal College of Midwives – www.rcm.org.com
Royal College of Obstetricians and Gynaecologists –
www.rcog.org.com
Royal College of Physicians – www.rcplondon.ac.uk

Further training for physiotherapists in the specialty

ACPWH c/o Chartered Society of Physiotherapy, 14
Bedford Row, London WC1R 4ED

1

Chapter 1

Anatomy

Jeanette Haslam

CHAPTER CONTENTS

The pelvis 1
The pelvic floor and muscles of the pelvis 5
The perineum 10
The abdominal muscles 11

The breast 12
The reproductive tract 13
The urinary tract 18
The anorectal region 22

THE PELVIS

The pelvis provides a protective shield for the important pelvic contents;
it also supports the trunk, and constitutes the bony part of the mechanism
by which the body weight is transferred to the lower limbs in walking,
and to the ischial tuberosities in sitting. The pelvis consists of the two
innominate bones and the sacrum to which the normally malleable coc-
cyx is attached. The innominates and the sacrum articulate at the symphy-
sis pubis, and at the right and left sacroiliac joints, to form a firm bony
ring. They are held together by some of the strongest ligaments in the
body (Fig. 1.1). The ring of bone is deeper posteriorly than anteriorly and
forms a curved canal. The inlet to this canal is at the level of the sacral
promontory and superior aspect of the pubic bones. The outlet is formed
by the pubic arch, ischial spines, sacrotuberous ligaments and the coccyx.
The enclosed space between the inlet and outlet is called the true pelvis,
with the plane of the inlet being at right angles to the plane of the outlet.
The female true pelvis differs from the male in being shallower, having
straighter sides, a wider angle between the pubic rami at the symphysis
and a proportionately larger pelvic outlet. The ideal or gynaecoid pelvis
is recognised by its well-rounded oval inlet and similarly uncluttered
outlet (Fig. 1.2c).