APPENDIX 5
Memorandum by the Chartered Society of
Physiotherapy (MS 10)
The Chartered Society of Physiotherapy (the
CSP) is the professional, educational, and trade union body for
the United Kingdom's 40,000 chartered physiotherapists, physiotherapy
students and assistants. The majority of our members work in the
NHS, but a significant proportion is employed in independent hospitals
and higher education. Our members also work for charities, in
residential homes, sports clubs and in private practice. Around
98% of qualified practising physiotherapists are members of the
CSP. Physiotherapy is the largest allied healthcare profession
in the UK.
The CSP welcomes the Health Select Committee
Maternity Services Sub-Committee inquiry into the provision of
maternity services. This submission is primarily concerned with
staffing structures of maternity units and the impact of access
to physiotherapy on the health of the mother and child. Obstetric
physiotherapists are key members of the maternity team and we
are pleased to have the opportunity to respond to the inquiry.
In addition, there are an increasing number of physiotherapists
who specialise in neonatal care.
Physiotherapists support the mother and baby
from early pregnancy through to postnatal and neonatal interventions
and assessments. It is important that women receive advice from
early on in their pregnancy to ensure that preventable discomfort
or even disability is minimised.
The CSP has a network groups of physiotherapists
working in specialised areas, including women's health, paediatrics,
and neonatal care. These groups play a major role in promoting
continuing professional development, undertaking research, sharing
of best practice and contributing publications in their specialised
area.
OBSTETRIC PHYSIOTHERAPISTS
The role of the obstetric physiotherapist is
to promote health throughout the childbearing period and to help
the woman adjust advantageously to the physical and physiological
changes of pregnancy and the postnatal period.
Physiotherapy input varies across the UK. In
some hospitals, all women who have given birth are seen routinely
by a women's health physiotherapist, whilst in others none are
seen unless referred for a given complication. In many maternity
units, physiotherapists are a core part of the team, providing
a service both antenatally and postnatally. They will accept referrals
from all members of the multidisciplinary team.
An obstetric physiotherapist provides antenatal
education classes and an in- and out-patient service. In addition,
they are skilled teachers of effective relaxation, breathing awareness
and positioning and is therefore able to help the woman prepare
for labour.
Other members of the multi-disciplinary team
can also refer patients who need individual musculo-skeletal assessment
and treatment for problems such as back ache, symphysis pubis
dysfunction, carpal tunnel syndrome. Obstetric physiotherapists
can advise on physical activity, such as advice on include pelvic
floor education, reduction of any perineal discomfort, the management
of continence problems and abdominal re-education. If there is
an obstetric high-dependency unit, physiotherapists will be able
to provide assessment and treatment of any chest problems.
There is evidence to suggest that having access
to a physiotherapist before, during and after birth can reduce
the incidence of complications and discomfort. For example, a
recent pilot at Ipswich Hospital NHS Trust has introduced a seven-day
inpatient service for women with obstetric and gynaecological
problems. Women now have access to physiotherapy throughout the
weekend following the peak of those having elective caesarians
on Fridays. This has reduced discomfort for women and their dependence
on services following the birth. Nurses have also reported that
it has reduced their workload, as previously they had felt obliged
to cover the physiotherapist service over the weekend period,
such as giving exercise advice.
This service has been developed by the staff
and is covered by volunteering physiotherapists. Staff will work
four hours on either Saturday or Sunday and have a full day off
in lieu later in the week. Spreading staff attendance has also
led to the workload being more balanced as there were always a
large number of women wanting access to the service on a Monday
morning. These women would also tend to need more help because
of the delay in getting treatment.
COMPLICATIONS DURING
PREGNANCY AND
LABOUR
One complication which can occur during the
child bearing year is symphysis pubis dysfunction (SPD). Pelvic
pain and resulting instability such as this is a relatively common
complication for the pregnant woman. Under the influence of the
pregnancy hormone relaxin, connective tissue and ligaments soften
and stretch to allow the baby to pass easily through the birth
canal, which can make the pelvis unstable.
Signs and symptoms of SPD can vary from woman
to woman, but can result in mild to severe pain. Well over 50%
of women suffer from peripartum pelvic pain, with 5 to 10% becoming
severe. Usually felt low down in the symphysis pubis joint, pain
may also be present in the hips, groin, lower abdomen and inner
thighs. It is worsened by walking and weight-bearing activities,
particularly those which include lifting one leg, such as climbing
the stairs or getting in and out of a car, thus severely compromising
the independence of the woman.
Physiotherapists have a crucial role to play
in limiting or eliminating the cause of SPD. At Queen Charlotte
and Chelsea Hospital (QCCH), physiotherapists have been highlighting
awareness of all staff, including advice on posture, stability
exercises, transfers and relaxation. Management may include careful
explanation of the condition, advice about lifestyles and activities
of daily living, manual therapy, muscle energy techniques, stability
exercises, support belts, walking aids, hydrotherapy, deep water
running and advice about preparing for labour.
In addition, physiotherapists at QCCH have altered
the way that other professions have tackled the birthing process.
Currently, the lithotomy position is widely used—legs supported
in an abducted position. Sometimes the legs can be over-abducted
or the mother is encouraged to push against the attendant's hip
or even shoulder. This can cause trauma to the pelvis and this
position is not recommended practice. Physiotherapists at QCCh
introduced laminated signs for the delivery suite warning staff
"no feet on hips or shoulders". Since then, there have
been no further incidences of mothers developing SPD as a result
of their delivery.
NEONATAL CARE
Developmental care of neonates involves a large
number of different healthcare professions and there is a degree
of overlap between physiotherapists, occupational therapists,
developmental psychologists and specialist nursing staff. There
are areas which are unique to physiotherapy including respiratory
care, the assessment and analysis of movement patterns and postural
dysfunction, orthopedic issues as well as assessment and identification
of gross motor dysfunction.
Neonatal physiotherapy is an advanced practice
sub-speciality area within paediatric physiotherapy. Therapists
who provide services to neonates need advanced clinical skills
and clinical training in neonatal intensive care and intermediate
care settings to manage the rapidly changing physiological and
behavioural stability in neonates, support and education of stressed,
grieving families and collaborate with other professional team
members in development of care plans.
Physiotherapist input into maternity units in
the acute setting is a minority service which can be very important
especially in the field of orthopaedic care, for babies with congenital
talipes or developmental hip dypsplasia for example. These specialist
services can make an important contribution to the development
of newborn babies, but they tend to be provided only in the larger
tertiary hospitals.
Early developmental intervention beginning in
the Neonatal Intensive Care Unit has been shown to improve the
developmental outcome of premature infants and those at risk as
well as being cost-effective.
CONCLUSION
Physiotherapy is an integral part of the maternity
team and can have a demonstrable effect on the health of the mother
and baby. The CSP recommends that all units provide access to
physiotherapy during pregnancy, in preparation for labour and
birth, and postnatally.
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