Preparation For Childbirth by Physiotherapy

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Canad. M. A. J.
Aug. 1952, vol. 67 NICHOLSON AND SIMPSON: PHYSIOTHERAPY 145
PREPARATION FOR CHILDBIRTH
BY PHYSIOTHERAPY
HELEN- M. NICHOLSON, M.C.S.P.,
C.P.A.* and
GEORGE A. SIMPSON, M.D., C.M.,
F.R.C.O.G., F.A.C.S.,t Montreal
THE FOLLOWING PAPER is an outline of the ap-
proach made to the problem of helping civilized
woman to meet the difficulty of childbirth
through her own understanding and co-opera-
tion. The aims underlying this treatment are
three: (1) the reduction of fear; (2) the promo-
tion of relaxation; and (8) the maintenance of
good body mechanics. The approach to each of
these objectives has been as follows.
1. REDUCTION OF FEAR
The results of this project have confirmed the
teachings of Dr. Grantly Dick Reid, Miss Minnie
Randell and Mrs. Heardman to the effect that
the reduction of fear on the part of the pregnant
woman is of prime importance. This result has
been obtained through the discussion of an out-
line of the physiology and mechanics of her
pregnancy and labour.
Previous experience of pregnancy has not al-
ways released a patient from fear of labour, and
it has been noted that the multipara has shown
as much interest as the primipara in these dis-
cussions. It has also been noted that some pa-
tients with experience of previous confinements
under the influence of sedation during the first
stage have not been satisfied with the results.
Although modem science has made painless
labour possible, some women still feel a pride
in performing their own natural functions and
require only a very little guidance in order to
produce a concentration of their whole will to
this end.
The most efficient results in reducing the sen-
sations of pain are obtained through mental and
physical relaxation and the patient should be
attended, during her confinement, by someone
conversant with it herself and with the relaxation
procedure she has been taught during her preg-
nancy. This advantage has not been made avail-
able to the patients discussed in this paper and
these have therefore been trained how to over-
come extraneous interference.
*Assistant Director, School of Physical and Occupational
Therapy, McGill University, Montreal.
tAssistant Professor of Obstetrics and Gynecology, McGill
University; Obstetrician and Gynaecologist, Royal Victoria
Hospital,
Patients have not been told that relaxing will
make the process painless, but rather that the
contractions will not reach a degree of intensity
beyond their tolerance. As a result, those with
excellent relaxation are delighted- with their
success while those less successful are not dis-
appointed. At no time have we suggested that
sedation be withheld or that anaesthesia in the
second stage of labour is not the accepted pro-
cedure. It is suggested to them, however, that
relaxation be given a trial before accepting seda-
tion, with the explanation that it will be found
difficult to relax when the effects of the injection
wear off because they have been prevented from
building up a gradual tolerance to the intensity
of the contractions, also, that the attainment of
such tolerance would normally have increased
their confidence in their own capabilities. Some
patients have voiced indignation that sedation
was offered even before they asked for such
relief, feeling that the offer undermined their
confidence and yet hesitating to refuse lest it
might not be repeated when the real need for
sedation occurred.
A description of the Maternity Unit and of the
arrangements made by the hospital for the pa-
tients' comfort and security has proved to be of
further assistance in aiding relaxation. Most
patients who are admitted to other departments
of the hospital are given a day in which to be-
come accustomed to their surroundings. Women
in labour have no such advantage and much un-
easiness may be avoided by giving them this
information. The supervision of labour by an
intern is a frequent cause of worry unless assur-
ance is given that the patient's own doctor will
be available.
2. PROMOTION OF RELAXATION
If relaxation can be maintained during the
pains, cramp of the voluntary muscles is not
superimposed on the severity of the uterine
contractions and much discomfort is avoided.
Patients are taught lying on a hard surface, upon
which it is easier to obtain a more complete
understanding of the relaxed state. Deep breath-
ing is tiring and inhibits full relaxation, if pro-
longed. A feeling of deep relaxation usually takes
quite a considerable time to be appreciated but,
once achieved, practice should be directed at
reaching this condition as soon as possible. It is
not sufficient to be able to relax only under
favourable circumstances. The next step, in
146 NICHoLsON AND SIMPSON: PHYSIOTHERAPY
preparation for the noise and bustle of the labour
room, is to be able to repeat the exercises in the
presence of an irritating noise until the latter is
no longer impressed on the conscious mind. A
radio playing too loudly on a distasteful -pro-
gram is excellent for this purpose. As a pro-
gression, the body must remain relaxed while
the mind is actively occupied in listening to a
conversation or to a program. If this control is
attained, visits by doctors and nurses during
labour will be less likely to spoil the continuity
of the relaxation rhythm, for important benefits
can be derived when these exercises can be put
into effect in times of emotional stress and strain.
It is also essential that relaxation may be
achieved in positions other than on the back. The
latter position is not always tolerable during the
approach to full term and pillows must be placed
under the knees in order to obtain a feeling of
relaxation in the adductors and the pelvic floor.
Lying on the side, with two pillows placed under
the upper knee to retain the correct postural
alignment for the upper leg, is often a very ac-
ceptable position and relieves the back con-
siderably. Encouragement is given to spend time
in these positions and to practice changing from
one to the other so that the patient may be inde-
pendent when in hospital, and move as she
wishes. The utilization of hospital furniture to
advantage is also taught in an endeavour to find
a position in which relaxation and maximum ease
may be attained before it is necessary for the
patient to remain in bed.
We are trying by these means to give pregnant
women sufficient confidence and understanding
to help them to conduct the first part of their
labour without the constant attendance of a
doctor, physiotherapist or,nurse to offer en-
couragement.
3. MAINTENANCE OF GOOD BODY MECHANICS
The- maintenance of correct muscle balance
and of individual control of muscle groups of the
abdominal back and pelvic floor muscles is of
paramount importance. A patient has little hope
of being able to relax and co-operate in the later
stages of labour if the latter has been neglected.
A few very simple exercises are all that is re-
quired to allow the spine to remain flexible,
allow walking with the least dilculty and permit
the patient to relax and move to or from any
position, even at full term. It cannot be over-
stressed that the greatest hindrance to correct
Canad. M. A. J.
Aug. 1952, vol. 67
posture and muscle balance during pregnancy
is the wearing of a maternity corset, unless
secondary symptoms are deemed by the doctor
to warrant its prescription.
ANALYTICAL REPORF
One hundred and ten patients have been
treated from April 1, 1949 until May 24, 1951.
Reports Ifave been received from 87 of these;
19 in 1949; 41 in 1950; and 27 in 1951. Reports
on a similar number of patients, chosen at
random, who have received the same pre-natal
care, but no relaxation, from Dr. Simpson, have
also been analyzed. The average time of labour
is shown on these reports to have been as
follows:
TABLE I.
Year
1949
With relaxation.........Without relaxation.......
Difference in total time ...
__ Primipare Multipare
Hour. in Hours in
hospital Total hours hospital Total hours
hours snins. hours mins. hours mins. hours mins.
8 32 13 17 6 42 8 50
.14 43 18 16 9 54 16 414 59 7 51
1950
With relaxation .......... 10 10 15 50 4 24 7 05
Without relaxation ....... 15 36 20 45 8 42 12 16
Difference in total time.... 4 55 5 11
1951
With relaxatioa .......... 8 36 10 55 6 34 10 17
Without relaxation....... 8 11 15 29 14 49 18 52
Difference in total time... 4 34 8 35
In view of the fact that the total hours of
labour have ranged from 53 hours 41 minutes
down to 3 hours 17 minutes there appears to be
a striking constancy in the final averages. There
is also an approximately similar reduction in the
average number of hours, in all but one group,
that the patients have spent in the hospital prior
to delivery. It would be interesting to know
whether this eases the financial burden and the
staff problems of the hospital administration.
It would appear from the evidence of our
present lists, that the amount of analgesics re-
quired by the patients has not been greatly de-
creased, although by their own reports, some
have been given sedation prior to their immedi-
ate need or wishes, as already mentioned in this
report. However, it would seem to be the opinion
of-those of the medical and nursing staff with
whom the matter had been discussed, that pa-
tients practising relaxation are more controlled,
quieter and much more co-operative. This in
itself is a definite point in favour of these
techniques.
Throughout the ages it has been recognized
II
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Canad. M. A. J. TuPPER: PELVic ABSCESSES 147
Aug. 1952, vol. 67 T
that women in labour must relax in order to
avoid a long confinement and the unnecessary
exaggeration of pain by fear. Even today, with
the added benefit of analgesics, relaxation is still
desired. Although a short involuntary relaxation
and relief may be gained by the patient if she
follows the doctor's instructions to take short
breaths or to scream, she is usually not recipient
to the command to relax, having no knowledge
of how this may be achieved, unless she has
received prior training. Such training is the aim
of our program, in which we try to prepare
pregnant women beforehand, to interpret and
co-operate with the doctor's requests. It is re-
grettable therefore, that so many doctors do not
avail themselves of this successful program and
of the services of physiotherapists in administer-
ing it. It is particularly regrettable because most
doctors have not the time to spend several ses-
sions in the teaching of basic relaxation, whereas
the medical profession has for many years past
stressed the necessity for such relaxation.
A NEW METHOD OF TREATING
PELVIC ABSCESSES*
W. R. CARL TUPPER, M.D., Halifax
OUR MANAGEMENT of pelvic abscesses in this
institution up until the past three years has been
to use conservative therapy (i.e., rest, heat, anti-
biotics and blood transfusions) until definite
localization and softening occurred. If, at this
point, the abscess seemed accessible from below,
a needle was inserted into its cavity and an in-
cision made along it through which a T-tube
could be inserted. Drainage was allowed for
from 8 to 10 days and if then, temperature, pulse,
etc., had settled to normal the tube was removed.
In reviewing the patients treated by this tech-
nique, several points came to the fore. (1) The
insertion of a T-tube into a small opening in the
pouch of Douglas was difficult and there was
always danger to the bowel in making the in-
cision. (2) There often remained a draining sinus
that could cause a profuse discharge. This was
associated with bouts of fever, chills and gen-
eral malaise from absorption when it did not
drain well. This state of things could only be
cured by removal of the pus sac, which meant
removal of, the pelvic organs-a formidable
operation. (3) The hospital stay was long-often
lengthening into months.
Antibiotics were given intramuscularly in the
more recent cases, and were found quite useful,
but in no case of pelvic abscess did we find them
to be curative in themselves. The evidence of
peritonitis would disappear, the cellulitis would
*From the Victoria General Hospital, Halifax, N.S.
Read at the Annual Meeting of the Royal College of Phy-
sicians and Surgeons of Canada, Quebec, September, 1951.
tend to localize, but we would still be left with a
low grade fever, general malaise and a marked
tendency to exacerbation of symptoms. In the
March issue, 1951, of the American Journal of
Obstetrics and Gynxcology, Stevenson et al.,
from Detroit, Mich., reporting 15 cases of pelvic
inflammatory disease with abscess formation
confirmed the above, but reported excellent re-
sults using chloramphenicol by mouth. Nine of
their 15 cases were cleared up sufficiently to
have laparotomy performed within three to eight
weeks, and the offending tube or other diseased
tissue removed.
We wish to present 14 cases of pelvic abscess
treated by simple aspiration of the purulent ma-
terial through the pouch of Douglas and injec-
tion into the cavity of one million units of peni-
cillin and 2 gm. of streptomycin. The procedure
is simple. Following the usual vaginal prepara-
tion, the posterior lip of the cervix is grasped
with a tenaculum and pulled forward exposing
the pouch of Douglas and lateral fornices
through which an 18 gauge needle six to eight
inches long is inserted into the abscess cavity.
The purulent material is then aspirated com-
pletely. We feel it is important to get the abscess
cavity as empty as possible before injecting the
antibiotics. These are injected into the cavity in
as small a volume as possible. The needle is then
withdrawn. There is little or no danger in the
procedure. In addition to the above, these pa-
tients received intramuscular penicillin and
streptomycin before and after the aspiration.
The ages of the patients varied from 20 to 43
years.
There were some extremely ill patients, whose
condition on admission was so critical that we