There is no one single ethical protocol that can cover these situations. The following considerations, however, offer a direction for difficult decisions. First, there is no clinical or moral obligation for physicians and family to adhere to a treadmill of increasing therapy and diminishing returns for a patient who will, in all probability, never be freed from a regimen of intensive care. Second, there is no ethical difference, and it is also increasingly recognized that there is no legal difference, between not starting and stopping life-prolonging treatment. Third, the purpose of resuscitation, respiratory support, and other emergency and intensive care measures is to return a person in acute collapse to some reasonable measure of normal human life. Intensive care treatment has reached its limits when its only result is to entrap a patient into permanent bondage and residency in an intensive care unit. Intensive care has reached its limits, and may be stopped, when it can do little more than totally tie the patient’s time and energy to the procedures of survival. Fourth, it is not always possible, but it sometimes happens that patients are able to understand their predicament and are able also to help family and physicians with the difficult decisions that have to be made.

Case study A 10-year-old boy, neurologically damaged but cognitively unimpaired after an automobile accident, had already suffered several episodes of respiratory failure and would continue to do so indefinitely. This little boy, while still on respirator after his last respiratory arrest, clearly told his parents and doctor that he wanted to go home and was altogether too fatigued by the whole process to ever want to be resuscitated again. Nancy, B., a 25-year-old woman in Quebec, afflicted with extensive muscular atrophy resulting from Guillain-Barre syndrome, initiated the discussion and deliberation that eventually elicited Superior Court agreement with her request to stop the respirator on which she would be dependent for breath and life for the rest of her life.

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In this section, the futility of an intervention is to be judged in terms of the clinical goals for each individual patient. The central question is: will the intervention benefit the patient as a whole? Antibiotics will clear up a pneumonia in a patient locked into a persistent state of unawareness. That effect can be achieved. Because this effect can be achieved, some physicians believe antibiotic therapy in this situation is not futile, and hence obligatory. However, what is the goal of treatment for a patient who will never regain consciousness? If the clinical goal of this treatment is to return the patient to even a minimum of intellectual and relational capacity, then this treatment for patients in this state is indeed futile and non-obligatory, for those patients will never return to consciousness and awareness.

It is essential to distinguish and even separate two components in the concept of futility: the component of physiological effect and the component of benefit. Some treatments are futile because they cannot produce a desired physiological effect for a particular patient or a particular category of patients. For example, the probability of chemotherapeutically halting a metastatic process may, on the basis of clinical trial results or on the basis of accumulated clinical experience, be nil or so low as to constitute the rare and unpredictable exception.

Other treatments may be futile because they are useless in attaining the clinical goals of care, even if they can have the effect of prolonging biological life. If the goal of clinical treatment is to restore a patient to a measure of independent life, then treatments are futile if they only prolong a dying process, or preserve the patient in a permanent state of unconsciousness, or tether the patient indefinitely to life-support machines in an intensive care unit.(
Consideration of each individual patient in his or her body and biography, the total patient, is the key to proper use of futility as a criterion for withholding or discontinuing advanced or even basic life support. Prolonging a dying process may be justifiable if the patient and family need that extra time to achieve important personal goals.

Case study One man in an irreversible and advanced stage of leukaemia returned to a hospital time and again for blood transfusions. Some members of the clinical team accused others of excessive agressivity in their treatment of this man. They came to think differently, though, on the day the man returned to hospital one last time, this time to die. He explained that, though he knew the treatments would never cure him, they at least gave him the time to complete the porch he was building around the house for his wife. In a quite different situation, a physician aggressively maintained life support for a severely brain damaged teenager so that the mother and father could synchronize their schedules of grief. The father, unrealistically expecting his son’s return to conscious life, was accusing his more realistic wife of abandoning hope, of abandoning their son. The marriage and the equilibrium of the surviving 9-year-old brother were in danger. The physician, a neurologist, worked carefully and sensitively with the father who, 5 months later, came to the hospital with his wife and son. He apologized to his wife in the presence of the doctor and both husband and wife requested that no further efforts whatsoever be continued to prolong the biological shell of their child. Efforts to prolong the life of a non-salvageable child can be justified, within reasonable limits, if they contribute to the healing of an endangered family life.

Treatments of the most varied sorts are means to ends and the futility of treatments in clinical practice should be judged in terms of how likely it is that any given treatment will obtain the current clinical goals for this patient now.

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It was on the basis of a proportionality judgment that the court supported a mother’s and grandmother’s refusal of additional chemotherapy treatment for Carole Couture-Jacquet’s saccrococcygeal teratoma. This little girl, under 5 years old, had already suffered greatly from the side-effects of previous chemotherapeutic regimens. The suffering included constant nausea, loss of at least 50 per cent of kidney function, and a significant diminishing of hearing function. Physicians estimated that a renewed chemotherapy regimen had a 10-20 per cent chance of arresting the advance of Carole’s cancer.

The Quebec Court of Appeal did not find the mother’s and grandmother’s refusal of additional chemotherapy for Carole to be unreasonable. That refusal, rather, was seen as based on reasonable proportionality judgment that the low probability of success did not justify submitting Carole to more of the intolerable suffering she had already endured.(

Case study: A 42-year-old man, severely handicapped intellectually, and with multiple metastases to the brain, presented his two sisters and a clinical team with a choice initially found by all involved to be most difficult. The treatments available at the time would probably prolong this man’s life for a period of 6 months to 1 year beyond the time he could be expected to live without treatment. Yet these treatments required the patient’s collaboration, and he could not collaborate. He didn’t understand what doctors and nurses and hospitals were, and had no concept whatsoever of disease, treatment, and side-effects. He was a powerfully built person and still capable of quite devastating resistance to anyone he thought threatening or harmful. He also had lovely hair, and prized this personal characteristic above everything. He would spend hours grooming himself and admiring himself in the mirror, and would glow when complimented about his hair.

How, his sisters and physician asked, would he react to the hair loss and other side-effects of his treatment? Would he resist treatment if he made the connection between his hair loss and what doctors were doing to him? Would it not be better for our brother, the sisters asked, if he could have a relatively comfortable 8 months of life rather than 11 months or so of life filled with losses, complications of daily living, and misery he could never understand? This is how the sisters and the clinical team came to understand the choice they had to make for this man, and they judged aggressive antitumour treatment as being out of keeping with what this patient could tolerate, as likely to cause this man harm out of all proportion to the good it would bring him.

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When patients refuse treatment

If confusion, the undue influence of other persons, and pathologic depression can be excluded, many hold to the principle that ‘the will of the patient, not the health of the patient, should be the supreme law’ governing decisions about initiating or discontinuing life-prolongation measures. A classic expression of the principle of self-determination is Justice Benjamin Cardozo’s 1914 statement: ‘Every human being of adult years and sound mind has a right to determine what shall be done with his own body’.( In the same vein, the Law Reform Commission of Canada has proposed an amendment to the Criminal Code of Canada to prohibit any relevant paragraph of the code from being interpreted as requiring a physician ‘to continue to administer or to undertake medical treatment against the expressed wishes of the person for whom such treatment is intended’.

This clear and reasonable principle may conflict sharply with strongly held clinical perceptions and certain dominant values in our culture. People increasingly give public support to patient autonomy and to the value of self-determination against the potential abuse of medical technology. However, it is not always easy to live according to the same categories in which we think. People can generally agree on the justification of abandoning life-prolonging procedures when a patient’s loss of consciousness is irreversible. Many, however, experience a strong visceral opposition to discontinuing or withholding life-prolongation treatmentwhether this be respiratory support, chemotherapy, or total parenteral nutritionfrom an intelligent, conscious, and lucid patient.

This spontaneous opposition may be reinforced by bonds to the patient forged during the earlier fight for life. Decisive and distressed family members may also intensify the difficulty of respecting a patient’s refusal of life support. Moreover, although the principle of autonomy or of self-determination may be easy to state, it is often very difficult to ascertain whether some patients who are speaking coherently are not perhaps so dominated by a particular state of mind, such as a depression, that they really are unable to make decisions on their own behalf.

Case study Several years ago, a 27-year-old woman entered a hospital with leukaemia. She had been abandoned by her parents shortly after her birth, and subsequently lived in one foster home after another. Through adolescence she lived a wild sex and drug life and came to despise herself at the age of 19. At this time she met a couple who had never had children, and they offered her a room in their home. She gradually became their own child in fact, if not by law, and this young woman, highly intelligent, went on to finish her schooling, her university undergraduate studies, and had dreams of becoming an architect.

Her leukaemia was diagnosed at this point in her life. A young physician was very supportive, assuring this young woman that effective treatments were available, and that she had every chance of pursuing her professional dream. When he outlined the treatment plan, the young woman agreed to everything except the blood transfusions. She could not accept transfusions she said, because her new parents’ Jehovah’s Witness faith had become her own. She didn’t want to die but could not accept a treatment that for her was tantamount to betrayal of her faith, and to a betrayal of the parents and extended family who had given her a new life.

The physician opposed her refusal, insisted that she was not going to enter the cemetery because of some silly belief, and that she was totally wrong in refusing a treatment, when that refusal was, in his view, equal to a choice of death. When he threatened to force treatment on the young woman, the relationship broke down, and another, older physician entered the scene. He spoke to the younger physician, reminding him of their shared religious beliefs, some of which were looked upon as bizarre and even foolish by some of their very bright and competent colleagues. The older physician said ‘It’s not for us to judge her faith but to make sure she is really speaking her own mind and is not being pressured by others.’

It became quite clear over several considerations that this young woman was quite thoroughly independent, was not being pressured by family or friends, and held the Jehovah’s Witness belief as her very own. Her refusal of transfusions was then respected by the entire clinical team, with the young physician maintaining a very reluctant silence.

After the young woman’s death and funeral, that reluctant silence exploded in rage directed against the older physician who had orchestrated respect for the young woman’s decision. The young physician’s accusation? ‘If it were not for you and your ethics, doctor, she’d be at the university now, and probably dancing on Saturday. Now she’s dead, and you seduced me into betraying my basic mission as a doctor, which is to save life. I could have saved hers.’ The older physician’s response? ‘Do you think it is your mission to save life at all costs? Even at the cost of crushing a patient’s liberty? If you do, you’re wrong. At times liberty is a value higher than health or even life.’

This one case illustrates how difficult it can be at times to respect an instance of human freedom that is highly conscious of itself, superbly capable of self-expression, and articulating itself in a choice that affronts a dominant value or moral persuasion. This case also illustrates how the whole biography of this young patient, not only her clinical condition and the treatments available, entered into the deliberation required to reach a clinical decision. Many, but not all, would argue that the decision reached in this case, matched the full particularity of this young woman. For that reason, it was the right decision. However, if principles can be generalized, specific clinical-ethical decisions cannot.

Case study The clinical circumstances of the following case are quite different from those of the young woman with leukaemia, just discussed. This woman, 53 years old, entered a hospital in a state of renal failure. She was accompanied by her husband and her adult daughter. The physician explained to the woman that she would have to start dialysis, but she refused, stating that it was time for her ‘to go into the arms of God’. Over lengthy conversations that afternoon, the woman’s refusal of dialysis was persistent, and her refusal was strongly supported by her husband and daughter. She appeared lucid and coherent, but fatigued and withdrawn. She insisted on leaving the hospital and returning to her village many miles away, to be cared for by her doctor there, and basically to let nature take its course.

Her son, however, arrived at the hospital late in the afternoon, before her departure, and explained that his mother had been depressed over the last 10 years and had never, in his opinion, been adequately diagnosed or treated. Supported by her son, and against her protests and those of her husband and daughter, the doctor had the woman admitted to hospital and dialysis was started. The woman also received psychiatric attention. Over months she improved and changed her mind thoroughly about the dialysis, with which she collaborated enthusiastically, and about wanting to live. As she gradually rediscovered her former better self, she took up activities and re-established friendships she had long abandoned. Her husband and daughter changed too, recognizing in her the woman they had once loved but who, over years of depression, had become for them a constant source of stress and even a symbol of death.

It was not immediately obvious to the doctor, even after a lengthy conversation that afternoon, that this woman’s depression, not her genuine self, was refusing treatment and seeking death. This case illustrates a situation in which respect for a patient’s self-determination requires clinical opposition to a patient’s and to her family’s refusal of treatment.

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Although saving lives always has been, and will ever remain, a primary goal of clinical practice, the initiation and continuation of intensive life-prolonging procedures may result in little more than a stretching out of the dying curve, or in the extension of an unbearable and unrelentingly miserable life. Over the last 20 years or so, patients, families, nurses, doctors, and people from all walks of life have been asking whether extension of life to the bitter biological end is the right thing to do, particularly when the sick and the dying find the physical, emotional, and personal costs of such treatment to be hardly bearable. A trend has developed over more than two decades, and its direction is away from an ethic of prolonging life at all costs towards an ethic emphasizing the quality of life and of dying over the duration of life taken as an absolute value. This trend, as evidenced in a line of court cases and in a voluminous literature in medicine, nursing, ethics, and law, is against the tethering of people with advanced, irreversible illness to life-prolonging treatments and technologies, particularly when the underlying disease is progressing and cannot be halted; and when the life extended is only marginally bearable or definitely miserable.

This consensus regarding withholding or withdrawing life-prolonging treatments has crystallized around seven basic considerations.

First, decisions about withholding or discontinuing life-sustaining treatments cannot be made adequately on the basis of a pre-determination that some treatments are extraordinary and others are ordinary. The real clinical-ethical issue is whether any treatment, be it technically simple or complex, be it an instrument of basic or of advanced life support, is in keeping with the current clinical goals for each individual patient. For this reason, the distinction between extraordinary and ordinary means has given way to the more meaningful distinction between proportionate and non-proportionate treatments.

Second, the proportionate/non-proportionate distinction implies that there are no intrinsic moral or ethical imperatives attached to different categories of treatment, such as cardiopulmonary resuscitation, ventilatory support, dialysis, medication such as vasopressors, antibiotics, and insulin, and the provision of assisted nutrition and hydration. Decisions to use, to forego, or to discontinue any of these and other kinds of treatment should be taken as a function of, and not in isolation from, the clinical goals of the total treatment plan for each patient.

Third, binary thinking that would set sacredness of life in opposition to quality of life, so that respect of the one would require abandonment of the other, is not the way to reach ethically sound clinical decisions.

Fourth, quality of life decisions are inescapable in clinical practice because physicians and clinical teams are ethically and professionally obligated to gauge the consequences of their work on the bodies and lives of the people they are professionally presuming to help. Yet, the quality of human life varies from person to person, and, indeed, varies for each person across the ages of the life cycle. The ethical danger in ‘quality of life’ decisions is that some lives may be judged as not worth living because they will never match up to some inflexible notions or scales, inevitably culturally conditioned, of what worthwhile human living means. Thinking of quality of life in absolute rather than in relative terms risks the mistake of ignoring that a meaningful human life is possible even far-out from the centers of biological, psychological, and intellectual normalcy.

Fifth, an ethical danger also lurks within any absolute emphasis on the sacredness of life. Since the introduction of powerful life-prolonging technologies in hospitals, people have feared being technologically tethered to the biologically living relic of the persons they once were, and can never be again. They have feared being clinically forced into the extension of a life now irreversibly damaged by disease, depleted of energy, and intolerant of enjoyment. In such and similar circumstances, it is now widely recognized as being ethically erroneous to read the sacredness of life principle as compelling absolute persistence in extending life by all means and at all costs, right up to the moment when a patient’s biology has utterly lost all capacity to respond. To insist on the contrary would be equivalent to insisting that a sick person’s biology is more sacred than their person.

Sixth, the emphasis in the contemporary consensus, at least within the countries and culture of the West, is on shared decision-making between physician and patient, with the patient holding primacy of power to decide. This emphasis comes to expression, to cite one example, in an amendment to the Criminal Code of Canada, proposed some years ago by the then existing, and now disbanded, Law Reform Commission of Canada. The amendment was designed to prohibit any relevant paragraph of the code from being interpreted as requiring a physician ‘to continue to administer or to undertake medical treatment against the expressed wishes of the person for whom such treatment is intended’.

Seventh, it would be a mistake to read the contemporary emphasis on self-determination as implying that there is no place in the contemporary consensus for withholding or discontinuing life-prolonging treatment when patients can no longer express their will and never expressed any thought about these matters before falling gravely ill. There is general agreement that incompetent patients have the same rights as competent patients. There is also general agreement that doctors and clinical teams should not be bound by law to administer treatments that are therapeutically useless and not in the patient’s best interests.

Physicians, clinical teams, and family members do not, of course, always agree on what are the best interests of irreversibly ill or dying persons. Moreover, some family members, when speaking with doctors about discontinuing life-prolonging treatments, may not have the best interests of a dying person as their decisive priority. These situations, as will be considered below, may provoke intensely difficult scenes at the bedside.

The contemporary clinical-ethical consensus about withholding or discontinuing life-prolonging treatments may simply fail to operate when there is no continuing communication among doctors, nurses, patients, and families; when doctors and nurses are not educated to attend both to the body and to the biography of patients; and when the organization of care in hospitals promotes the unreflective use of technology rather than the careful mastery of technology in the service of the patients’ goals and aspirations. When these failures occur, a technologically and bureaucratically dominated system tends to take charge, and that system may not know when or how to stop life-extending treatments, in great part because that system is not in intimate contact with the sick and dying people it is meant to serve.

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The starting point of clinical ethics, as also of clinical practice, is the consideration of patients in their full particularity, what Charles Fried has called the principle of personal care. The complete palliative physician holds together two seemingly incompatible excellences: sensitivity to signals of the patient’s body and receptivity to the messages of a life in crisis at the crossroads or at the terminus of a personal history.

The clinical goals to be pursued for each patient, and the requirements of clinical care, inevitably change along the continuum of disease. While diseases vary considerably both as to rate and as to continuity of evolution, the evolution of disease is also always unique to each individual patient. It is the nature of a patient’s response to treatment plans that indicates when the times arrive to down-regulate intensive life-prolonging care and up-regulate palliative care. The shift is rarely abrupt or of the on-off, binary kind of change. Moreover, certain interventions, such as radiotherapy or surgery, may serve curative clinical goals for some patients and palliative goals for others. Along this continuum of evolving disease and correspondingly changing clinical goals, moments are reached when it is clinically, ethically, and legally justifiable to withhold or to discontinue clinical treatments, such as resuscitation procedures, respiratory support, dialysis, antibiotics, chemotherapy, surgery, and assisted hydration and nutrition; the discontinuance of this last-mentioned intervention being still very controversial.

The kinds of decisions that have to be taken for and with gravely ill and dying persons are not purely technical. These decisions become an intrinsic component of the event of dying. Depending on the content of these decisions, and on the way they are made, some people will have the chance to die well, masters of their dying, not alone and not lonely. Others may die before their time, without a chance to live their dying through. Others may die too late, reduced to biological systems that have to be tended. Some may die uninformed and unenlightened, caught trying to play ’scene two’ when life’s drama is in fact about to close. Still others may die, who could have lived.

Decisions having such consequences demand that comprehensive attention be given to patients in their full particularity; that attention is focused on the unique biology, clinical condition, needs, desires, life plans, hopes, sufferings, strengths, vulnerabilities, and limitations of this particular person now. Decisions of this kind, and they are the primary outcome of clinical ethics in palliative medicine, cannot be deduced from any one principle or set of principles. These decisions result rather from a process of highly practical reasoning. The method of clinical ethics in palliative medicine is inductive. It works by passing the existing principles of the philosophical and religious moral traditions through the grid of particular personal and clinical histories to learn gradually what these principles command, prohibit, or tolerate. This knowledge is not all worked out in advance, completed, and awaiting to be applied. The clinical ethical order within these principles is, to use an expression of David Bohm, an implicate order. An implicate order cannot be made explicit as a whole. It is manifested slowly and only partially as it is worked out in the case-by-case practical judgments reached at the bedsides of utterly unique persons as their disease advances and their biographies come to a close.

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This consideration of withholding or withdrawing life-prolonging treatment and of euthanasia opens with a brief discussion of clinical ethics, the primary perspective of the entire chapter. Of course, what happens at the bedsides of sick and dying people happens also within hospitals and health care institutions, and these are societal institutions. So the ethical issues raised by the withholding of life-prolonging treatment and by euthanasia and physician-assisted suicide could be analysed and discussed by focusing attention on the ethics of a health care institution, or on the ethics of the medical and nursing professions, or more broadly, on the public ethics of a given society. However, the choice taken here is to consider withholding treatment and euthanasia primarily from the perspective of clinical ethics, a specialization of ethics that is not to be identified with, although it inevitably intersects with, the ethics of an institution, of a profession, of a religion, or of the public ethics of a society.

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Nerve compression syndromes may also occur in the lower extremities because of the weight of the fetus, fluid retention, hormonal changes, or circulatory compromise.

Interventions
Typical protocols include postural correction exercises, manual techniques, ergonomic assessment, and modalities. Splints may be used in the treatment of carpal tunnel syndrome. Carpal tunnel surgery in the pregnant population is rare, as symptoms generally resolve soon after delivery; a longer course of the problem has been noted in women who breastfeed.

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Interventions
• Exercise modification. Teach the woman safe exercises to perform during the childbearing year, including modification of exercises to decrease excessive joint stress

• Aerobic exercise. Suggest nonweight-bearing or less stressful aerobic activities such as swimming, walking, or biking, particularly for women who were relatively sedentary before pregnancy.

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Positioning
• Left side-lying to prevent vena cava compression, enhance cardiac output, and decrease lower extremity edema

• Pillows between the knees and under the abdomen

• Supine positioning for short periods, with a wedge placed under the right hip to decrease inferior vena cava compression

• Modified prone positioning (side-lying, partially rolled toward prone, with pillow under abdomen) to decrease low back discomfort and pressure

Range of Motion (ROM)
• Active ROM of all joints.

• Motions should be slow, nonstressful, and through the full range if possible.

• Teach in a gravity-neutral position if antigravity ROM is too stressful.

• Individualize the number of repetitions and frequency to the woman’s condition.

• Include the following exercises with the patient supine (with wedge under the right hip) or side-lying:
  • Alternate knee to chest
  • Ankle pumping and ankle circles
  • Shoulder, elbow, and finger flexion and extension; reach to ceiling; arm circles
  • Unilateral straight-leg raise in supine or side-lying position
  • Unilateral active ROM in diagonal patterns for the upper and lower extremities
  • Lower extremity abduction and adduction
  • Pelvic tilt, bridging, gluteal setting
  • Abdominal exercises (check for diastasis); these should be very low intensity and closely monitored.
  • Pelvic floor exercises
  • Neck motions: look up/down, turn head left/right.
  • Backward shoulder circles

Ambulation/Standing
• Almost always contraindicated; when allowed, usually will be only to use the bathroom
• Good posture in ambulation
• Tip-toe or heel walking
• Gentle, partial-range squatting
• Lower extremity rotation

Relaxation Techniques, Bed Mobility and Transfer Activities
• Relaxation as in the uncomplicated pregnancy
• Moving up, down, side to side in bed
• Log rolling: incorporate neck, upper and lower extremities to aid movement
• Supine to sitting: use log roll technique assisted by arms

Preparation for Labor
• Relaxation techniques
• Modified squatting: supine, sitting, or side-lying with knees to chest
• Pelvic floor relaxation
• Breathing exercises: minimize forced abdominal exhalations

Postpartum Exercise Instruction
Instructions are the same as previously described in the uncomplicated pregnancy section.

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Characteristics
Varicosities can present in the first trimester, and are more prevalent with repeated pregnancies. They can occur in the lower extremities, the rectum (hemorrhoids), or vulva. Symptoms usually include heaviness or aching discomfort, especially with dependent leg positions; intensity may become severe as the pregnancy progresses. In addition, pregnant women are more susceptible to deep vein thrombosis

Interventions
• Exercise modification. If there is discomfort, exercises may need to be modified so that minimal dependent positioning of the legs occurs.

• External support. Elastic support stockings should be worn to provide an external pressure gradient against the distended veins, and the woman should be encouraged to perform lower extremity exercises and to elevate the lower extremities as often as possible Vulvar varicosities may benefit from use of a perineal pad or belt that provides counter-pressure and support to the tissues.

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Develop good rapport with the patient and instill trust. Closely monitor the patient during all activities; re-evaluate her after each treatment and note any changes. It is also important to teach the patient self-monitoring techniques so that she will be alert to adverse reactions and respond appropriately.
• Prolonged static positioning is a primary concern. The position of choice for the high-risk patient is left side-lying, which is optimal for reducing pressure on the inferior vena cava and for maximizing cardiac output, thereby enhancing maternal and fetal circulation.

• Some exercises, especially abdominal exercises, may stimulate uterine contractions. If this occurs, modify or discontinue them.

• Monitor and report any uterine contractions, bleeding, or amniotic fluid loss.

• Do not allow the Valsalva maneuver to occur. Avoid any activities that increase intra-abdominal pressure. Body mechanics and postural instruction will stimulate abdominal contractions, so be sure the patient does not strain and closely monitor for adverse symptoms.

• Keep the exercises simple. Have the patient do them slowly, smoothly, and with minimal exertion.

• Many high-risk pregnancies result in cesarean deliveries, so educate the woman about cesarean delivery rehabilitation.

• Incorporate maximum muscle efficiency into each movement.

• Teach the patient self-monitoring techniques.

Management Guidelines-High-Risk Pregnancy

Potential Impairments and Functional Limitations:

Primary functional limitation is inability to be out of bed and prolonged static positioning which contributes to the following:

Joint stiffness and muscle aches

Muscle weakness and disuse atrophy

Vascular complications including risk of thrombosis and decreased uterine blood flow

Decreased proprioception in distal body parts

Constipation caused by lack of exercise

Postural changes

Boredom

Emotional stress; patient may be at risk of losing the baby

Guilt from the belief that some activity caused the problem or that the patient did not take good enough care of herself

Anxiety about her home situation, older children, finances or the impending birth

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Interventions
Pelvic girdle and sacroiliac symptoms are treated via modification or elimination of activities that may further aggravate sensitive tissue, stabilization exercises, and the use of belts and corsets to provide external support to the pelvis.

• Activity modification. Daily activities should be adapted to minimize asymmetrical forces acting on the trunk and pelvis. For example, getting into a car is done by sitting down first, then pivoting both legs and the trunk into the car, keeping the knees together; side-lying is made more symmetrical by placing a pillow between the knees and under the abdomen, and sexual positions are altered to avoid full range of hip abduction. Single-leg weight bearing, excessive abduction and sitting on very soft surfaces should be avoided. In addition, caution patients to avoid climbing more than one step at a time, swinging one leg out of bed at a time when getting up, or crossing the legs when sitting.

• Exercise modification. Exercise must be modified so as not to aggravate the condition. Avoid exercises that require single-leg weight bearing and excessive hip abduction or hyperextension. Teach the patient to activate the pelvic floor and transverse abdominals when transitioning from one position to another in order to stabilize the pelvis.

• External stabilization. Use of external stabilization such as belts or corsets designed for use during pregnancy helps reduce posterior pelvic pain, expecially when walking.

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Incidence
Back pain is reported by 50% to 70% of pregnant women at some point during pregnancy; this condition contributes to lost work days and decreased functional ability. In addition, symptoms may continue in the postpartum period, with a prevalence in up to 68% of women, for as long as 12 months after delivery.

Characteristics
The symptoms of low back pain usually worsen with muscle fatigue from static postures or as the day progresses; symptoms are usually relieved with rest or change of position. Women who are physically fit generally have less back pain during pregnancy.

Interventions
Low back pain symptoms can be treated effectively with many traditional low back exercises, proper body mechanics, posture instructions, improvement in work techniques, along with superficial modality application. The use of deep-heating agents, electrical stimulation, and traction is generally contraindicated during pregnancy.

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Premature onset of labor. Labor that begins before 37 weeks of gestation or before completion of fetal development is considered premature. Fetal life is endangered if delivery occurs too early.

Incompetent cervix. An incompetent cervix is the painless dilation of the cervix that occurs in the second trimester (after 16 weeks’ gestation) or early in the third trimester of pregnancy. This may lead to premature membrane rupture and delivery of a fetus too small to survive.

Placenta previa. The placenta attaches too low on the uterus, near the cervix. As the cervix dilates, the placenta begins to separate from the uterus and may present before the fetus, thus endangering fetal life. The primary symptom is intermittent, recurrent, or painless bleeding that increases in intensity.

Pregnancy-related hypertension or pre-eclampsia. Characterized by hypertension, protein in the urine, and severe fluid retention, pre-eclampsia can progress to maternal convulsions, coma, and death if it becomes severe (eclampsia). It usually occurs in the third trimester and disappears after birth. The cause is not understood.

Multiple gestation. More than one fetus forms. Complications of multiple gestation include premature onset of labor and birth, increased incidence of perinatal mortality, lower birth weight infants, and increased incidence of maternal complications (e.g., hypertension).

Diabetes. Diabetes can be present before pregnancy or may occur as a result of the physiological stress of pregnancy. Gestational diabetes, which presents in pregnancy, affects 4% to 7% of pregnant women and usually disappears after pregnancy, but there remains a greater tendency for development of the disease at some future time.

Unlike many of the previously discussed high-risk conditions, women with gestational diabetes may be appropriate candidates for more traditional physical therapy treatment. Supervised, individualized exercise programs are excellent options for the woman with gestational diabetes. Exercise may actually prevent gestational diabetes in obese pregnant women. In particular, recumbent bicycling or arm ergometer exercises have been shown to stabilize and lower glucose levels.

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Patient position and procedure: Hook-lying. Have the patient slowly raise her head and shoulders off the floor, reaching her hands toward the knees, until the spines of the scapulae leave the floor. Place the fingers of one hand horizontally across the midline of the abdomen at the umbilicus. If a separation exists, the fingers will sink into the gap between the rectus muscles. The number of fingers that can be placed between the muscle bellies is then documented. A diastasis recti can also present as a longitudinal bulge along the midline. Because this condition can occur above, below, or at the level of the umbilicus, test for it at all three areas.

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• Pelvic tilting and/or bridging. These can be done in conjunction with massage.

• Bridge and twist. Have the patient maintain a position of bridging while twisting her hips to the right and left. This position may also facilitate air embolism and therefore should be used with caution in the early postpartum period.

• Partial abdominal curl-up. Avoid strain to the linea alba.

Scar Mobilization
Cross-friction massage should be initiated around the incision site as soon as sufficient healing has occurred. This will minimize adhesions that may contribute to postural problems and back pain.

High-Risk Pregnancy
A high-risk pregnancy is one that is complicated by disease or problems that put the mother or fetus at risk for illness or death. Conditions may be pre-existing, induced by pregnancy, or caused by an abnormal physiologic reaction during pregnancy. The goal of medical intervention is to prevent preterm delivery, usually through use of bed rest, restriction of activity, and medications, when appropriate. Various factors may lead to high-risk pregnancies; specialized care is required for successful outcomes.

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Diastasis Recti

Diastasis recti is separation of the rectus abdominis muscles in the midline at the linea alba. The etiology of this separation is unknown; however, the continuity and integrity of the abdominal musculature are disrupted. Any separation larger than 2 cm or two fingerwidths is considered significant.

Incidence
The condition is not exclusive to childbearing women but is seen frequently in this population. In one study, Boissonnault and Blaschak tested 89 women for separation of the rectus abdominis muscles. The sample included women who were not pregnant, one group for each trimester of pregnancy, and two postpartum groups. The incidence in this study ranged from 0 in the nonpregnant and first trimester women, to 27% in the second trimester, to a high of 66% in the third trimester. Also of interest is that 36% of the women between 5 weeks and 3 months postpartum continued to display a separation. A second study, done by Bursch, found a significant diastasis in 62.5% of postpartum women tested within 92 hours of delivery.

• Diastasis recti may occur in pregnancy as a result of hormonal effects on the connective tissue and the biomechanical changes of pregnancy; it may also develop during labor, especially with excessive breath-holding during the second stage. It causes no discomfort.

• It can occur above, below, or at the level of the umbilicus but appears to be less common below the umbilicus.

• It appears to be less common in women with good abdominal tone before pregnancy.

• Clinically, a diastasis may be found in women well past their childbearing years and also in men. Routine assessment for this condition is highly recommended and can easily be done in conjunction with abdominal strength testing.

Significance
The condition of diastasis recti may produce musculoskeletal complaints, such as low back pain, possibly as a result of decreased ability of the abdominal musculature to stabilize the pelvis and lumbar spine.

Functional limitations. Functional limitations can also occur, such as inability to perform independent supine to sitting transitions because of extreme loss of the mechanical alignment and function of the rectus muscle. Again, this finding is not exclusive to childbearing patients.

Decreased fetal protection. In severe separations, the remaining midline layers of abdominal wall tissue are skin, fascia, subcutaneous fat, and peritoneum. The lack of muscular support provides less protection for the fetus.

Potential for herniation. Severe cases of diastasis recti may progress to herniation of the abdominal viscera through the separation at the linea alba. This degree of separation requires surgical repair. Rehabilitation following this type of repair may include components of C-section rehabilitation, with specific precautions and input from the referring surgeon. There may be a need for very slow progression depending on the severity of the diastasis and how it was repaired.

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Risk of pulmonary or vascular complications

Postsurgical pain and discomfort

Development of adhesions at incisional site

Faulty posture

Pelvic floor dysfunction
  • urinary or fecal incontinence

  • organ prolapse

  • hypertonus

  • poor proprioceptive awareness and disuse atrophy

Abdominal weakness, diastasis recti

Coughing or Huffing
Coughing is difficult because of incisional pain. An alternative is huffing. A huff is an outward breath caused by the upper abdominals contracting up and in against the diaphragm to push air out of the lungs. The abdominals are pulled up and in, rather than pushed out, causing decreased pressure in the abdominal cavity and less strain on the incision. Huffing must be done quickly to generate sufficient force to expel mucus. Instruct the patient to support the incision with a pillow or the hands and say “ha” forcefully and repetitively while contracting the abdominal muscles.

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Neuromuscular Re-education
Neuromuscular re-education is essential, as many women have significant disuse and proprioceptive deficits of the pelvic floor muscles. Internal techniques of assessment and treatment are often indicated for optimal patient outcomes. For example, manual stretch facilitation (a Proprioceptive Neuromuscular Facilitation technique) to the levator ani can be a very effective treatment option. Initially, emphasis on isolated contractions of the pelvic floor is needed because many patients will exhibit excessive accessory muscle recruitment such as the gluteals, hip adductors, and abdominals. Once coordination has improved, the patient progresses to integration of pelvic floor activity with ADLs, lumbar stabilization, and other functional exercises.

Exercise and Biofeedback
The use of exercise and biofeedback, including surface electromyography (SEMG) for treatment of pelvic floor dysfunction in a female population is well supported. SEMG allows for immediate visual and/or auditory feedback to the patient, enhancing motor learning and proprioceptive improvements. It is particularly invaluable for pelvic floor re-education owing to lack of knowledge of the muscles’ existence, let alone their function and importance.
 

Manual Treatment and Modalities
Manual treatment and modalities, including intravaginal and intrarectal techniques, also play a role in the treatment of pelvic floor symptoms, particularly pelvic pain syndromes. Advanced training is necessary for true expertise with internal techniques.

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• Instruct the woman during her pregnancy in all appropriate exercises, if she is able.

• Instruct the woman to begin preventive exercises as soon as possible during the recovery period.
  • Initiate ankle pumping, active lower extremity ROM, and walking to promote circulation and prevent venous stasis.

  • Initiate pelvic floor exercises to regain tone and control of the muscles of the perineum.

  • Deep breathing and coughing or huffing is used to prevent pulmonary complications

• Progress abdominal exercises slowly. Check for diastasis recti and protect the area of the incision to improve comfort. Initiate nonstressful muscle-setting techniques and progress as tolerated, based on the degree of separation.

• Teach posture correction as necessary. Retrain postural awareness and help realign posture with indicated therapeutic exercise. Develop control of the shoulder girdle muscles as they respond to the increased stress of caring for the new baby.

• Reinforce the value of deep diaphragmatic breathing techniques for pulmonary ventilation, especially when exercising, and relaxed breathing techniques to relieve stress and promote relaxation.

• The woman should wait at least 6 to 8 weeks before resuming vigorous exercise. Emphasize the importance of progressing at a safe and controlled pace and not expecting to begin at her prepregnancy level.

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Significance to Physical Therapists
Cesarean section (C-section) delivery is now at an all-time high in the United States. In 2004, the rate was 29.1% of births, totaling 1.2 million deliveries. The cesarean birth rate in the United States has fluctuated greatly over the last three to four decades, in part depending on the type of hospital and the population it serves. Since the early 1990s, the American College of Obstetricians and Gynecologists (ACOG) has discouraged repeat C-sections as routine practice; however, historically more than 33% of all Cesareans are repeat procedures. The Vaginal Birth After Cesarean (VBAC) movement has been quite visible, as historically more than one-third of all C-sections are repeat procedures. Recently, the perceived “convenience” of a C-section is becoming a factor, leading to increases in not only repeat but also elective C-sections. In addition to the appeal of scheduling a delivery date, there is some evidence that cesarean delivery may aid in prevention of future pelvic floor dysfunction. Although the overall number of women choosing Cesarean delivery remains small, from 2001 to 2003 the rate of elective C-sections in first-time mothers grew 36%.

Pregnant women need to be informed as to the risks and benefits of each choice in order to make informed decisions. These statistics are the focus of much discussion within obstetrics, and because of this high incidence and new trends, physical therapists must be prepared to address these issues with all pregnant patients.

Women who have had Cesarean delivery may still require pelvic floor rehabilitation. Many women experience a lengthy labor, including prolonged second stage (pushing), before a C-section is deemed necessary. Therefore, the pelvic floor musculature and the pudendal nerves are not always spared the stress of labor. Also, pregnancy itself creates significant strain on the pelvic floor musculature and tissues.

Postpartum intervention for the woman who has had cesarean delivery is similar to that of the woman who has had a vaginal delivery. However, a C-section is major abdominal surgery with all the risks and complications of such surgeries, and therefore the woman may also require general postsurgical rehabilitation.

All childbirth preparation classes do not adequately educate and prepare couples for the experience of a cesarean delivery. As a result, the woman with an unplanned C-section frequently feels as if her body has failed her, causing her to have more conflicting emotions than a woman who has experienced a vaginal delivery.

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Childbirth is obviously the most significant risk factor for pelvic floor impairments. The process of labor, particularly with vaginal delivery and current medical management, can produce significant trauma to the structures of the pelvic floor.

• A longitudinal cohort study with follow-up 15 years after delivery (N = 55) showed that stress incontinence during the first pregnancy doubled the risk of re-occurrence 15 years later.

• Other potential obstetric risk factors include multiple deliveries, prolonged second stage of labor, use of forceps or oxytocin, third-degree perineal tears, and birth weight greater than 8 lb.

Other Causes
Women who have never been pregnant may also present with pelvic floor dysfunction. Excessive straining because of chronic constipation, smoking, chronic cough, obesity, and hysterectomy can contribute to these impairments in any woman . The role of estrogen in the development of incontinence is still unclear, with some studies citing estrogen depletion as a risk factor and others that found a connection between incontinence and estrogen replacement therapy.High caffeine intake (more than 400 mg/day) is a specific risk factor for urge incontinence.

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Early Intervention
It is a progressive disorder unless vigorous intervention is used during the acute stage. The best intervention is prevention when it is recognized that development of CRPS type I (RSD) is a possibility, such as when there has been trauma to the extremity or when the extremity is immobilized. It requires that the therapist motivate the patient to move the entire extremity safely, minimize edema and vascular stasis with elevation and activity of the distal segments (squeeze and open hand with upper extremity lesions, or ankle pumping and toe curls with lower extremity lesions), and be alert to the development of adverse symptomatology.

Summary of Guidelines for Management of Complex Regional Pain Syndrome Type I (RSD)

Stage I (early intervention)
Relieve pain and control edema
• Modalities
• Retrograde massage
• Elevate, elastic compression

Increase mobility (specific to involved tissues)
• Tendon gliding in the hand
• Nerve mobilization

Improve muscle performance
• Stress loading in quadruped position
• Distraction
Improve total body circulation
• Low impact aerobic exercise

Desensitize the area
• Desensitization techniques for brief periods 5x/day

Educate the patient

• Teach interventions that deal with variable vasomotor responses; when to use heat, cold, gentle exercises
Medical intervention is a necessity to manage this syndrome. The physician may choose to utilize analgesics, sympatholytic drugs, local anesthetic blocks, stellate ganglion blocks, spinal cord stimulation, or upper thoracic sympathectomy or may use oral steroids or intramuscular medication. Because there is often an emotional or psychological component, medical intervention includes therapies to manage this area (antidepressants). This is done in conjunction with active exercise (including exercise in warm water) to manage physical impairments and functional limitations.

• Pain and edema control. Use modalities such as ultrasound, vibration, transcutaneous electrical nerve stimulation (TENS), or ice. Utilize retrograde massage. Elevate and use elastic compression when not undergoing pneumatic compression treatment.

• Mobility. In the early stages, use gentle, active exercises to manage the increasing stiffness. Have the patient actively contract the musculature while the part is held near the end of the pain-free range. It is important to avoid increasing painful reactions that would decrease mobility. Support and have the patient actively move each joint for a short period of time. They should follow this program of brief motion frequently throughout the day.
  • In the hand, include tendon glide exercises

  • Butler suggested that there may be adverse tension in the sympathetic trunk influencing sympathetic activity and therefore suggested mobilization of the nervous system.

• Muscle performance. Facilitate active muscle contractions. Include joints proximal to the symptoms (shoulder/hip); they often develop restrictions due to pain or lack of use. Use both dynamic and isometric exercise and alternating controlled stress loading (compressive loading) with distraction activities for neuromuscular control as well as afferent fiber stimulation. The objective is to provide tissue stress with minimal joint motion. Suggested exercises include:

  • Stress load the upper extremity by scrubbing with a brush in the quadruped position, beginning at 3 minutes and incrementally increasing to 10 minutes three times a day. For the lower extremity, utilize progressive weight-bearing activities.

  • Distraction by carrying 1 to 5 pounds up to 10 minutes at a time frequently throughout the day

• Total body circulation and cardiac output. Initiate a program of low-impact aerobic exercises.

• Desensitization. Utilize desensitization techniques for brief periods five times per day, such as having the patient work with various textures and tap or vibrate over the sensitive area. The patient is instructed to wear a protective glove during activities of daily living.

• Patient education. Emphasize the importance of following the program of increased activity. Teach the patient interventions that deal with the variable vasomotor responses with the use of gentle heat when at home, gentle exercises for short periods throughout the day, and use of associated parts of the extremity.

Intervention-Stages II and III

• Pain management. Modalities are often used as palliative interventions prior to or in conjunction with exercise to minimize pain.

• Desensitization. Progress the desensitization techniques to increase the patient’s tolerance to various textures.

• Mobility. Use joint mobilization, neuromobilization, and stretching techniques to address tissues limiting mobility. Because of the pain and significant limitations, little progress is sometimes seen with the stretching maneuvers, so surgical intervention may be required to gain motion.

• Muscle performance. Develop an exercise program to improve strength, endurance, and overall functional performance that meets the specific needs of the patient.

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Pelvic floor strengthening. Exercises should be resumed as soon after the birth as possible. These exercises may increase circulation and aid healing of lacerations or episiotomy. Combining pelvic floor contractions with feeding or changing the baby may help them become integrated into the daily routine.

Diastasis recti correction. The testing procedure for diastasis recti was described earlier in this chapter. The mother should be taught this test and encouraged to perform it on the third postpartum day. Corrective exercises should continue until the separation is two fingerwidths or less. At that time, more vigorous abdominal exercise can be resumed.

Aerobic and strengthening exercises. As soon as the woman feels able, cardiopulmonary exercise can be resumed with gradual increasing intensity. A physical examination is suggested before the onset of vigorous exercise or sport-specific training.

• If bleeding increases or turns bright red, exercise should be postponed. Tell her to rest more and allow a longer recovery time.

• Joint laxity may be present for some time after delivery, especially if breastfeeding. Precautions should be taken to protect the joints as described previously. Adequate warm-up and cool-down time is important.

• Avoid the prone knee-chest position for at least 6 weeks postpartum because of the risk of air embolism.

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• Limitation of motion develops. Typically, the shoulder develops limitation in a capsular pattern with most restriction in lateral rotation and abduction. In the wrist and hand, the most common restrictions are limited wrist extension and metacarpophalangeal and proximal interphalangeal flexion.

• Edema of the hand and wrist secondary to circulatory impairment of the venous and lymphatic systems, which in turn precipitates stiffness in the hand.

• Vasomotor instability.

• Trophic changes in the skin.

As the condition progresses, the pain subsides but limitation of motion persists. The skin becomes cyanotic and shiny, the intrinsic muscles of the hand atrophy, subcutaneous tissue in the fingers and palmar fascia thicken, nail changes occur, and osteoporosis develops.

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• A recent cross-sectional study found stage I prolapse in 33% of the subjects, and stage II descent in 62.9%. The sample included 270 women with a mean age of 68.3 years and median parity of three vaginal births. This is critically important information for all clinicians prescribing trunk stabilization programs for female patients, regardless of diagnosis.

• From a biomechanical aspect, activation of the pelvic floor is necessary in coordination with core muscle activation and trunk strengthening activities to prevent excessive downward forces. Otherwise, trunk strengthening will likely increase a previously undetected prolapse, or aggravate an existing condition.

• As prolapse progresses, functional changes occur as a result of perineal pressure and heaviness, low back pain, abdominal pressure or pain, and voiding difficulties. Currently, there is very limited evidence regarding prevention or treatment of pelvic organ prolapse.

Urinary or Fecal Incontinence
Involuntary loss of bladder or bowel contents, often a result of both neuromuscular and musculoskeletal impairments, often occurs in combination with prolapse. A conservative estimate of persons affected with urinary incontinence is 15 million in the United States alone (approximately 1 in 20 persons); women are twice as likely to have these symptoms as men. These patients often have significant social discomfort and anxiety regarding leakage and hygiene concerns.

Pain and Hypertonus
The broad category that encompases pain and hypertonus includes a variety of causes. Pain and hypertonus may be related to delayed healing of perineal lacerations, trauma to the soft tissues or the sacro-coccygeal joint during delivery, pelvic obliquity, multiple gynecologic/visceral diagnoses, cauda equina involvement, scar tissue adhesions, or muscle spasm/guarding throughout the pelvis.

• Accurate statistics are lacking; however, in one study with a total sample of 581 women (age 18 to 45), the following prevalence was found: pelvic pain, 39%; dyspareunia, 46%; and dysmenorrhea, 90%.
• Functional limitations may include pain with ADLs, decreased sitting tolerance, dyspareunia (pain with intercourse), and difficulty with elimination of bladder and bowel contents. In patients with pelvic pain impairments, often referred to as chronic pelvic pain (CPP), persistent tightness of the lumbar paraspinals and hip flexors is typically present.

• Because of the breadth of this topic, treatment recommendations are conflicting. Recent guidelines stress the importance of multidisciplinary assessment and consideration of myofascial dysfunction for successful outcomes.

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Bilateral straight-leg raising. This exercise typically places more stress on the abdominal muscles and low back than they can tolerate. It can cause back injury or diastasis recti, and therefore should not be attempted.

“Fire hydrant” exercise. This exercise is performed on hands and knees, and one hip is abducted and externally rotated at a time (the “image” of a dog at a fire hydrant). If the leg is elevated too high, the sacroiliac joint and lumbar vertebrae can be stressed. The exercise can be performed safely if hip abduction remains within the physiologic range. It should be avoided by any woman who has pre-existing sacroiliac joint symptoms or if these symptoms develop.

All-fours (quadruped) hip extension. It becomes unsafe and can cause low back pain when the leg is elevated beyond the physiologic range of hip extension, causing the pelvis to tilt anteriorly and the lumbar spine to hyperextend.

Unilateral weight-bearing activities. Weight bearing on one leg (which includes slouched standing with the majority of weight shifted to one leg and the pelvis tilted down on the opposite side) during pregnancy can cause sacroiliac joint irritation and should be avoided by women with pre-existing sacroiliac joint symptoms. Unilateral weight bearing also can cause balance problems because of the increasing body weight and shifting of the center of gravity. This posture becomes a significant problem postpartum when the woman carries her growing child on one hip. Any asymmetries become accentuated, and painful symptoms may develop.

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Visual Imagery
Use instrumental music and verbal guidance. Instruct the woman to concentrate on a relaxing image such as the beach, mountains, or a favorite vacation spot. Suggest that she focus on the same image throughout the pregnancy so that the image can be called up to the conscious level when recognizing the need to relax during labor.

Muscle Setting
• Have the woman lie in a comfortable position.

• Have her begin with the lower body. Instruct her to gently contract and then relax first the muscles in the feet, then legs, thighs, pelvic floor, and buttocks.

• Next progress to the upper extremities and trunk, then to the neck and facial muscles.

• Reinforce the importance of remaining awake and aware of the contrasting sensations of the muscles. Emphasize “softening” of the muscles as the session continues.’

• Add deep, slow, relaxed breathing to the routine.

Selective Tension
Progress the training by emphasizing awareness of muscles contracting in one part of the body while remaining relaxed in other parts. For example, while she is tensing the fist and upper extremity, the feet and legs should be limp. Reinforce the comparison between the two sensations and the ability to control both tension and relaxation.

Breathing
• Slow, deep diaphragmatic breathing is the most efficient method for exchange of air to use with relaxation techniques and for controlled breathing during labor.

• Teach the woman to relax the abdomen during inspiration so that it feels as though the abdominal cavity is “filling up.” During exhalation, the abdominal cavity becomes smaller; active contraction of the abdominal muscles is not necessary with relaxed breathing.

• To prevent hyperventilation, emphasize a slow rate of breathing. Caution the woman to decrease the intensity of the breathing if she experiences dizziness or feels tingling in the lips and fingers.

Relaxation and Breathing During Labor

First Stage
As labor progresses, the contractions of the uterus become stronger, longer, and closer together. Relaxation during the contractions becomes more difficult. Provide the woman with suggested techniques to assist in relaxation.

• Ensure the woman has emotional support from the father, family member, or special friend to provide encouragement and assist with overall comfort.

• Seek comfortable positions including walking, hands and knees, lying on pillows, or sitting on a Swiss ball; include gentle repeated motions such as pelvic rocking.

• Breathe slowly with each contraction; use the visual imagery and relax with each contraction. Some women find it helpful to focus their attention on a specific visual object. Other suggestions include singing, talking, or moaning during each contraction to prevent breath-holding and encourage slow breathing.

 • During transition (near the end of the first stage) there is often an urge to push. Teach the woman to use quick blowing techniques, using the cheeks, not the abdominal muscles, to overcome the desire to push until the appropriate time.

• Massage or apply pressure to any areas that hurt such as the low back. Using the hands may help distract the focus from the contractions.

• Apply heat or cold for local symptoms; wipe the face with a wet wash cloth.

Second Stage
Once dilation of the cervix has occurred, the woman may become active in the birth process by assisting the uterus during a contraction in pushing the baby down the birth canal. Teach her the following techniques:

• While bearing down, take in a breath, contract the abdominal wall, and slowly breathe out. This will cause increased pressure within the abdomen along with relaxation of the pelvic floor.

• For maximum efficiency, maintain relaxation in the extremities, especially the legs and perineum. Keeping the face and jaw relaxed assists with this.

• Between contractions, perform total body relaxation.
• As the baby is delivered, just “let go” and breathe with light pants or groans to relax the pelvic floor as it stretches.

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