Antenatal Care

SHS.509 LEC-07
DR.TAMKNAT
Aims of Antenatal Care

 To promote and maintain optimal physical and emotional maternal health

throughout pregnancy
 To recognise and treat correctly medical or obstetric complications occurring
during pregnancy
 To detect foetal abnormalities as early as possible
 To prepare for and inform both parents about pregnancy, labour, the
puerperium and the subsequent care of their baby
 The overriding goal is that pregnancy will result in a healthy mother and a
healthy infant
Antenatal Care Options
 Water births
 Home birth
 Gp/midwifery shared care
 Midwifery-led units
 General practitioner units
 Consultant care
 Consultant obstetric units
 Private obstetric care/independent midwives
Routine Antenatal Care
 Occurs between 12 and 14 weeks’ gestation, but realistically ranges from 9 to
16 weeks
 Booking visit
 Woman’s social history
 Family history
 Medical history
 Psychological history
 Past obstetric history
 Body mass index (BMI)
 Subsequent visits
 Anomaly scan’ at 20 weeks
 Monthly visits from 24–26 weeks
 Fortnightly visits from 32–34 weeks to 40 weeks
 Routine Antenatal Care
 Weekly visits until delivery
 Blood pressure
 Urine
 Weight
 Oedema
 Fundal height and the ‘lie’ of the foetus:
 Intrauterine growth restriction (IUGR) may be suspected if the fundal height is lower than
expected.Multiple pregnancy or polyhydramnios could cause an increase in fundal height.
By 36 weeks more than 95% will be in a cephalic presentation
 Foetal movements
 Although foetal movements are usually noticed by the mother, at some time between 16 and
22 weeks’ gestation, the foetus has in fact been moving from 8 weeks, the woman is
unaware of movements because the uterus is insensitive to touch.
 Kick’ charts are an easily used monitoring device. If a foetus moves less than
10 times in an average day, the pregnancy is likely to be assessed more
carefully.
 FOETAL HEART RATE:
 Although the foetal heart can be seen to be functioning as early as 8–10
weeks using ultrasound scanning, The normal rate will vary between 110 and
150 b.p.m.
 Other tests
 Blood tests
 Haemoglobin levels
 Sexually transmitted infection
 Blood group
 Haemoglobinopathiese (sickle cell disease and thalassaemia),
 Antenatal Screening

A) Maternal serum screening

(i) Alpha fetoprotein (AFP) level

 High levels may indicate neural tube defects (NTDs) such as spina bifida

(ii) Hormone levels

It is usually performed between 15 and 18 weeks of pregnancy, and if women have a
screen positive result (i.e. above the cut-off value) then they will be referred for
further invasive diagnostic procedures such as chorionic villus sampling (CVS) or
amniocentesis.
 Antenatal Screening
B) Nuchal translucency (NT) measurement
(i) Ultrasound Scanning:
Measure the nuchal translucency, an area of subcutaneous fluid at the nape of the foetal
neck
 Increase thickness may indicate Down’s syndrome
 At least one anomaly scan at around 20 weeks’ gestation,for detection of certain
abnormalities
 Spina bifida
 Cardiac abnormalities

C) Chorionic Villus Sampling:

D) Amniocentesis
Preconceptual Care

 Every organ system within the mother’s body will alter and
adjust according to the demands made upon it by the growing
foetus
 Exercising weekly pre-pregnancy reduces risk of back pain
during pregnancy
 Genetic counselling should be available to parents with a family
history of hereditary disease
 Disorders, as well as identified risk factors for maternal
morbidity and mortality should be treated and stabilised before
conception
 Preconceptual Care
 Infertility/ Subfertility:
 The causes of infertility can be divided into:
 Male factors
 Female factors
 Combination of the two
 Hormonal treatment may be advocated for a woman failing to ovulate as with
polycystic ovaries (PCO). Clomifene is commonly used, either alone or with
gonadotrophins; however, there is an increased risk of multiple pregnancies and
ovarian hyperstimulation syndrome (OHSS). If a woman has tubal disease, then
in vitro fertilisation (IVF) is one of the first options, with success affected by
duration of infertility, woman’s age and previous pregnancies.
Preconceptual Care
 Early Pregnancy:
 An early introduction is essential to patient regarding:
 Ergonomic back-care education
 Understanding of stress and its control
 Importance of physical health
 Strength
 Endurance
 Activities can be included for:
 The pelvic floor
 Abdominal muscles
 Legs
 Arms
Antenatal Classes
 Concerned with women to prepare for and cope with labor pain
 Couples should be helped to check and increase their knowledge of the
physiological changes of pregnancy, labor and the puerperium.
 Couples should be shown ways that may be useful for coping with the physical
changes of pregnancy and their associated discomforts.
 Couples should be encouraged to consider the profound change in lifestyle that
parenthood brings, and the emotional maturity necessary to manage successfully
their additional responsibilities.
 Couples should be encouraged to talk and air any fears, ask questions, and be
helped to obtain satisfactory answers in an open environment
 Antenatal Classes
‘Early Bird’ Classes:
 Some centres are offering sessions directly after the initial
booking visit when interest and motivation are often at its
highest. Women are encouraged to bring their partners or
some other person of their choice
The classes will probably be shared by physiotherapists
with:
Dieticians
Health visitors
Dentists
Doctors
Antenatal Classes
Following essential subjects be included in the physiotherapist’s
part of the sessions:
 Pregnancy back care
 Postural, hormonal and weight changes, ergonomic education involving sitting
and working positions, bending, lifting and household activities should all be
considered. Ideally, no woman should go home without an individual posture
check, instruction in using seatbelts in pregnancy.
 Symphysis pubis dysfunction (SPD)
 Although the true incidence of this pregnancy-related condition has not yet
been identified, it is a common occurrence usually beginning in the antenatal
period. Many women may experience the signs and symptoms of SPD but are
unaware of its management.
Back Care
Back Care
Pelvic
 floor and pelvic-tilting
exercises
Women who had learnt and practised PFM contractions during
pregnancy experienced less urinary incontinence postpartum
than those who had not learnt the skill antenatally.
Women understand that this exercise can be helpful for
maintaining abdominal muscle strength (particularly the
transversus abdominis muscle), correcting posture and easing
backache, and that it can be done in a standing position as well
as crook lying, side lying and prone kneeling
 Exercises for circulation and cramp
 pregnancy can affect leg circulation and women who travel long
distances and have sedentary jobs should especially be
encouraged to carry out frequent foot and ankle exercises.
 Ankle dorsiflexion and plantar flexion, and foot circling carried
out for 30 seconds regularly, should be suggested; women should
be advised not to cross the knees when sitting.
 The technique of stretching in bed with the foot dorsiflexed and
not plantar flexed for preventing and easing calf cramp should
also be shown. Additional suggestions for cramp relief include
avoiding long periods of sitting, a pre-bedtime walk, calf
stretches , a warm bath, and foot and ankle exercises in bed
before going to sleep.
 Fatigue
 Many women who are pregnant for the first time (and their partners) are
completely overwhelmed by the intense tiredness that they experience in the
first trimester. Sometimes this is so severe that they feel totally unable to
function when evening comes.
 This fatigue is sometimes aggravated by ‘evening sickness’.
 The effects of stress on body and mind
 The Mitchell method of physiological relaxation is ideally suited for
teaching informally and can be reinforced by a handout. Other stress-coping
strategies, such as music, a warm bath or shower, a walk or exercise,
dancing and massage,
 Emotional reactions
 Advice on lifestyle
 Stress and relaxation
Relaxation
Posture
 Teaching neuromuscular control
 Contrast method
 The contrast method stems from the work of Edmund Jacobson and
involves alternately contracting and relaxing muscle groups
progressively round the body to develop recognition of the difference
between tension and relaxation
 Visualisation and imagery
 Touch and massage
 Breathing
 Exercise and Pregnancy
 The physiological changes that occur when a woman exercises,
particularly in aerobic exercise, are primarily to maintain the woman’s
internal homeostasis during the exercise period
 Maternal Risks:
 Greater risk of musculoskeletal trauma
 Joint laxity
 Postural changes
 Impair balance and coordination as the centre of gravity alters
 Cardiovascular system
 Increase in blood volume
 Cardiac output and resting pulse
 Decrease in the systemic vascular resistance
 After the first trimester the supine position should be avoided as it
may cause supine hypotension
 Supine hypotensive syndrome is characterized by pallor,
bradycardia, sweating, nausea, hypotension and dizziness and occurs
when a pregnant woman lies on her back and resolves when she is
turned on her side. The aorta and inferior vena cava are central
vessels, the largest artery and vein.
 Calories
 smallincrease in the number of calories per day needed during
pregnancy and this is mostly significant in the last trimester.
 Hypoglycaemia is more likely to happen during a resting and
fasting state
  Thermoregulation
 Increase in basal metabolic rate and heat production during pregnancy with the foetal
temperature approximately 1°C higher than the maternal temperature.
 Hyperthermia can cause teratogenic effects to the foetus, a maternal temperature of
39.2°C being the possible threshold for neural defects within the first trimester of
pregnancy and IUGR during later pregnancy.
 Respiratory changes
 Increase in ventilation by almost 50%
 Increase in oxygen uptake with an increase in oxygen consumption of 10–20%
 Increase in resting oxygen requirement
 The increase in resting oxygen requirement is due to the mechanical effect of
the uterus upon the diaphragm, which will reduce the availability of oxygen
available for aerobic-type exercise
 Foetal Risks:
 Foetal distress
Redistribution of blood flow away from the splanchnic
organs
 Foetal growth and development
 Foetal malformations
Teratogenic effects of a raised maternal core
temperature during the first trimester.
 Preterm labour
Exercise may trigger uterine contractions
Contraindications to Exercise
Guidelines for Exercise

 Jerky, bouncing, ballistic movements and activities should be

avoided.
 Regular mild to moderate exercise sessions, at least three times
a week, are safer than intermittent bursts of activity.
 A careful ‘warm-up’ should precede vigorous exercise, which
must always be followed by a ‘cool-down’ or gradual decline in
activity.
 Flexibility and mobility follow the warm-up section, avoiding
ballistic stretching. All main muscle groups should be included
and positions stretching at the extreme range of movement
avoided.
 Strenuous exercise must be avoided in hot, humid weather, or
when the pregnant woman is pyrexial.
 The maternal heart rate should not exceed 140 b.p.m. and
vigorous exercise should not continue for longer than 15
minutes.
 Fluid must be taken before, during and after exertion to avoid
dehydration, and energy intake must be sufficient for the
needs of pregnancy as well as the exercise.
 It is essential that those accustomed to a sedentary lifestyle
should start with low intensity physical activity.
 Walking, swimming, stationary bicycling or yoga are
probably ideal, with gradual increases in activity levels
according to a woman’s own individual tolerance
capacity.
 An aerobic component should be in the mode best suited
to the individual, using large muscle groups and being
rhythmical in nature, i.e. brisk walking, cycling, aerobic
dance
 Avoid supine positions after the first trimester.
 Avoid standing motionless for long periods of time.
 Exercise should be decided by the limitations imposed by
pregnancy
 Use the BORG rating of perceived exertion (RPE) aiming
between 12 and 14 or the ‘talk test’
 List of signs and symptoms from the ACSM (1995)
are considered significant and, if apparent, would
need medical review:
 Any signs of bloody discharge from the vagina
 Any‘gush’ of fluid from the vagina (premature rupture of
membranes)
 Sudden swelling of ankles, hands or face
 Persistent,
severe headaches or visual disturbance, or both;
unexplained spell of faintness or dizziness
 Swelling, pain and redness in the calf of one leg
 Elevation of pulse rate or blood pressure that
persists after exercise, excessive fatigue, palpitations
and chest pain
 Persistent contractions (6–8 hours) that may suggest
onset of premature labour
 Unexpected abdominal pain
 Insufficient weight gain (1.0 kg/month during the
last two trimesters)
 Absence of or reduced foetal movements
Swimming & Water Exercise in
Pregnancy
 Buoyancy of the water supports the mother’s increasing body weight

 Toning and strengthening activity which increases her physical fitness

and endurance

 Women should ‘warm up’ prior to their main swim, and ‘cool down’
following it
 A session of relaxation aided by the buoyancy of the water can be most
therapeutic, particularly in the final trimester
 For non-swimmers a programme of suitable exercises can be suggested,
including activities for the legs, arms and trunk, as well as ‘water
walking’ and relaxation
Pilates
 Central core of stability concentrating on abdominal and pelvic floor
muscles

 Help maintain and retrain:

 Posture

 Coordination

 Abdominal muscles

 Pelvic floor muscles

 Hence, this gentle form of exercise can be employed by the pregnant
and postnatal exercising woman
Diet & Weight Gain in Pregnancy

 During pregnancy, the body works more efficiently, saving energy

by adjustments in physical activity and adapting its metabolic rate

 An extra need of 300 calories per day in the second and third
trimester

 A normal weight gain of 11–15 kg (25–35 lb) is expected

 Breastfeeding is often advocated to help lose weight retained

postpartum
Nutrients
 Folic Acid
 Prevent of neural tube defects
 Found in:
 Vegetables (cauliflower, peas, tomatoes)
 Oranges
 Breakfast cereals
 Yeast extract
 A daily supplement of folic acid 0.4mg/day
 Calcium
 Needed for bone, teeth and gum formation
 Found in:
 Dairy products
 Sardines
 Dried fruit
 Omega-3 Fatty Acids
 For development of brain and neural development
 Found in:
 Mackerel
 Salmon
 Sardines and other oily fish
 Iron
 To combat anaemia
 Found in:
 Red meat
 Beans
 Nuts
 Green vegetables
 With vitamin C for good absorption
Dietary Fibre
 Prevent the constipation
 Found in
Fruit
Vegetables
Nuts and pulses
Bread and cereals
 Foods to Avoid
 Liver
 Excessive vitamin A associated with congenital malformations

 Dark Fish
 Contain high levels of mercury
 Affect the development of the foetal nervous system

 Peanuts
 Children with allergies, including peanut allergy, with unknown reason
 It is thought that they may develop during pregnancy
 Avoid peanuts both during pregnancy and whilst breastfeeding
 Caffeine
 Suggest to limit it to 300mg/day
 Found in:
 Tea
 Coffee
 Cola drinks
 Chocolate
 Associated with low birth weight babies and miscarriage
 Smoking
Medication in Pregnancy
 The most sensitive time for embryonic damage is in the first trimester
 antiemetic drug given in early pregnancy to women suffering from nausea
and vomiting was found to be the cause of severe limb and organ
deformities in their babies, it has become obvious that the placenta does
not act as a barrier to harmful chemicals
 retinoic acid (used to treat severe acne), some cytotoxic drugs and
radiochemicals can cause grave damage. Pregnant women whose foetuses
have been exposed to these substances are offered terminations.
 Tetracycline taken in pregnancy is known to cause subsequent
discoloration of children’s teeth
Planning to Leading Labour & Parent-
craft Classes

 Class Arrangements

 Explore the perceived needs of the prospective to client

 Adapting the classes according to the needs of the group

 A 6- Week Course
 Week 1: Introductions
 Tackle immediate problems and worries

 A suitable, short general programme of exercises to promote comfort,

mobility and strength

 When to come into hospital (early signs of labour) and what to bring into
hospital
 Week 2:
 Stage of labour, And Length Of Labour, Birth Plans/Choices

 Labour

 First stage of labour

 Relaxation

A discussion on the causes and effects of stress, and coping

strategies
 Week 3: Coping With The First Stage Of Labor
 Coping strategies for early stage of labor
 TENS
 The first stage progresses: positions, breathing awareness, massage and
visualisation techniques.

 Week 4: Pain Relief and other Possibilities

 Medical pain relief, including the use of Entonox, and epidurals
 Discussion of the end of the first stage, transition and the second stage of labor
 Positions for the second stage
 Foetal monitoring, episiotomies, assisted deliveries, vacuum extraction and
forceps.
 Week 5: Further Possibilities In Labour, And Feeding Baby
 Third stage of delivery, the use of syntometrine

 Induction of labour, caesarean delivery

 The first feed and the postnatal care of woman and baby in
hospital

 Breastfeeding, benefits of breastfeeding for babies and

mothers
 Week 6: Parenthood & Getting Back into Shape!
 Care of the new baby, a 24-hour job

 Transition to parenthood, adjustment to relationships

 Postnatal depression

 Postnatal exercises
ROLE OF THE WOMEN’S HEALTH
PHYSIOTHERAPIST

 The topic of breast or artificial feeding is one of the

main priorities to cover within parentcraft education
by the doctor
 Thewomen’s health physiotherapist can provide
valuable additional advice and ergonomic education
regarding best feeding positions to ensure proper
support of the sore perineum and spine
 Because the shape of the breast when the nipple is
offered is all important, women must appreciate that
it will be more difficult for their baby to be positioned
correctly if they are leaning back, as their breasts will
be flatter than if leaning forward, in which the breast
assumes a more pointed shape making it easier for
their baby to ‘latch on’.
 Side lying, as well as leaning forward
initially when sitting, can achieve the
desired effect, with the former also being
comfortable for backache. Whilst the
promotion of breastfeeding for both
mother and baby is to be recommended, it
is necessary to remember that some
women will choose not to do so or
discontinue at an early stage.
pelvic tilt activity URL
      
https://www.google.com/search?
q=pelvic+tilting+exercise&rlz=1C1GCEB_enPK858PK858&o
q=pelvic+tilting+&aqs=chrome.0.0i457j69i57j0l4j0i22i30l2.68
84j0j15&sourceid=chrome&ie=UTF-
8#kpvalbx=_fzS_X6HJN5yAhbIPpY602AE16
 PELVIC FLOOR ACTIVITIESURL
 Students can manually mark this item complete: PELVIC
FLOOR ACTIVITIES
 https://www.youtube.com/watch?v=NKl8ImI3OVE
 LINK FOR KEGEL EXSURL
 Students can manually mark this item complete: LINK FOR
KEGEL EXS
 https://www.webmd.com/urinary-incontinence-oab/video/
corio-kegels
 LINK FOR KEGEL ACTIVITIESURL
 Students can manually mark this item complete: LINK FOR
KEGEL ACTIVITIES
 https://www.youtube.com/watch?v=Wjb20SXIvA4
 LINK FOR ANKLE PUMPSURL
 Students can manually mark this item complete: LINK FOR
ANKLE PUMPS
 https://www.youtube.com/watch?v=KxfFzSOAT7g
 JAZAKALLAH