ANTENATAL CARE

-BINAL DOSHI
Programme Aims
1. Prepare the prospective parents for the birth and care of
the baby and for parenthood.
2. Give confidence to the woman in her own abilities
through an understanding of how her body functions and
the various changes occurring during pregnancy and birth.
3. Introduce each member of the team and ensure that the
woman knows who to go to for advice.
4. Provide a forum for the prospective parents to meet each
other and discuss aspects of hopes , fears, problems and
expectations.
PLAN:
 If possible, two or three classes should be attended by the
woman at around 6-8 weeks pregnancy for early
physiotherapy advice and instruction .
 Then there is usually a course of six classes of 2 hours
each, once per week during the third trimester. The
physiotherapist takes 1 hour of each class and the other
hour is taken by various members of the team, e.g.
Health visitor or dental hygienist.
Role of the Physiotherapist:
 1. Complement instructions from other members of the team, relating
to policies of the hospital and community care.
 2. Assess physical health and identify any musculoskeletal or
neuromuscular problems that could be aggravated by pregnancy.
Teach leg, abdominal pelvic floor muscle exercises
 3. Advise on continued sport or work, and how to recognize fatigue as
an important sign over activity
 4. Advise on back care and lifting.
 5. Treat any problems with appropriate physiotherapy skill .
 6. Teach methods for controlling neuromuscular tension.
 7. Teach positions that may be used for labour.
 8. Teach postnatal exercises.
Back care and lifting
 Back strain is minimized when the spine is held in its normal curves
but spinal posture has to change with pregnancy .
 The COG moves forwards and there is tendency to an increased
lumbar curve with consequent stress on the posterior muscles and
ligaments .
 There are also compensating changes in the thoracic and cervical
spine which cause discomfort in these areas.
 It is important to teach a woman how to adopt a positions which
minimize stress and to change position regular.
 Standing-
 stretch head up out of shoulders .
 Feel baby sit in the pelvis , pull in the abdominal muscles , tighten
buttocks.
 Feel poised,
 release tension without sagging.
 Avoid transferring the weight through one leg for long periods of time
.
 Lean back against a wall or chair back for support if standing is
essential and try to go up and down on the toes several times to keep
the circulation moving and ease muscle tension .
 Sitting - Practise sitting back into the chair so that it feels as if the
weight of the baby is taken on the seat, and try to have the feet well
supported on a little stool if necessary.
 If sitting for a long time pelvic tilting should be practised regularly.
 A small cushion should be placed in the back to preserves light
lumbar curve and reduce the stretch on the posterior spinal
structures.
 It is also important when resting in sitting to have the legs supported
in slight elevation or at least horizontal.
 Whether sitting or standing , it is important to remember
that if the arms are in use in front of the body the spinal
extensors are working hard and need to be eased by
placing the hands on the pelvis along the iliac crest and
extending backwards.
 It is important to avoid twisting with the knees or feet
apart because this causes stress on the sacroiliac joints, as
does stepping on to high stools or going up two stairs at a
time .
 Sleeping positions :
 In pregnancy, sleeping positions may have to be altered because of the
body’s weight gain and altered shape (lying prone is not possible).
 For most women, quarter-turn from prone (recovery position) is
acceptable as the weight of the baby is taken on the bed. With a pillow
under the abdomen and another under the top knee the position can be
very comfortable.
 Sleeping supine should be avoided but, if necessary, a pillow under the
thighs and another under the head and shoulders(perhaps two under
the head) will ensure flattening and support of the lumbar spine.
 When changing position in bed, e.g. turning, keeping the flexed knees
together reduces the strain in the sacroiliac joints.
 Getting in and out of bed, the woman should go into side-lying and
avoid abdominal strain from sitting up or lying straight down
 Lifting advice This involves lifting from a height and carrying as well as lifting
from the ground level
 The principles to follow are: never stoop, feet should be apart to increase the
base and any object to be lifted must be held close to the body (if held at
arm's length the leverage on the spine causes high loading of the spinal
extensors).
 When lifting from the floor, it is important to ensure that the weight is light
enough to be lifted comfortably.
 It may be advisable to lift in stages such as floor to chair and then chair to
upright.
 When lifting from a height, it is important to hold the object close to the
body and to make sure that the height is within easy reach.
 Later in the pregnancy, it is inadvisable to stand on high stools or to climb
step-ladders because balance secure with the centre of gravity moved
forward.
 Activities and back care Low-down activity should be
performed from kneeling positions, for example cleaning
the bath, making beds or playing with small children.
 Standing at work surfaces is more comfortable for the
back with one foot forward and possibly on a low stool.
 When hoovering, hanging out washing or ironing it is
important to ensure that the body weight is over a base
with the feet apart and one in front of the other.
 At intervals during these activities and others involving
flexion it is important to ease the spinal extensor muscle
tension by placing the hands on the iliac crests and easing
the spine into extension
Treatment of neuromuscular and
musculoskeletal problems
 Sacroiliac pain, due to immobility, is treated with low-grade
mobilizations.
 For example, with the patient lying, the knee of the affected side is
flexed towards the opposite shoulder and then an oscillatory force is
applied along the long axis of the femur .
 At home, it helps if the woman lies on her back and pulls the knee
and foot of the affected side up to her chest, holds and rests a few
times to ease the pain (ankle towards groin and knee towards
shoulder)
 Pubic pain is often related to diastasis of the rectus abdominis
muscles, especially following many pregnancies.
 This pain is treated by pelvic support for example from a Fembrace a
firm elasticated corset, modified in design to fit under the main bulk
of the baby. Abdominal contractions must continue as a daily routine.
 Lumbar pain may be cure by soft-tissue kneading and
mobilizations such as transverse vertebral pressure to the
spinous processes with the patient inside-lying or lumbar
rotation .
 All these treatments are followed by reinforcing
education on posture, back care and lifting plus any
exercise specific to the patient's requirements.
 Rib-cage pressure : If the patient supports the arms
above the shoulder height this feeling of pressure can be
reduced .
 Pelvic pressure : Some patients find kneeling , with knees
shoulder width apart and leaning forward on to the
forearms is helpful.
 It is important to instruct the woman to keep her feet
together .
 This occurs most commonly in the calf muscles often at
night or after a period of rest.
 It can be relieved by slow sustained stretch on the
muscles pushing the foot and ankle into dorsiflexion.
 Some people find that it is possible to prevent cramp by
performing foot exercises just after getting into bed and
when turning in bed to keep the feet in dorsiflexion
 Stitch This is a sharp pain in the side brought onby fast
activity, particularly fast walking. Thereforeadypace and
become slower as the pregnancy proceeds
Bladder control:
 Strong pelvic floor muscles are needed to support the ever increasing
weight.
 these muscles are weak a slight dribble of urine can occur when the
abdominal pressure is increased, for example in coughing, sneezing,
laughing or lifting
 Previous pregnancies make the woman more likely to have this
problem.
 The treatment is pelvic floor exercises. The woman is instructed to
tighten and pull up muscles between the legs plus tightening the
abdominal muscles, hold for a count of 4 and rest repeat six times.
 This should be practised during pregnancy so that the woman
understands how to do the exercise during the difficult postnatal time
when the area is numb.
 Since these muscles fatigue easily with voluntary exercise
only 4-6 isometric contractions should be performed at
any one time, but frequent practice throughout the day is
essential
 Once mastered, the exercise can be performed with the
woman in any position; but to start with sitting on a hard
chair with knees apart, leaning forward so that the
perineum is in contact with the chair seat , assists
learning through awareness and proprioception.
Neuromuscular tension control:

 Relaxation techniques :

 Relaxation techniques are taught as 'coping strategies’ measuring pain tolerance in

labour and also as a means of reducing stress in all life situations.
 The method used is physiological relaxation based on the Laura Mitchell method.
 The principle underlying this approach is to make a group of muscles contract
isometrically so that there is relaxation and lengthening effect of the antagonists.
 The general position of tension is flexion with hunched shoulders, arms held in,
elbows flexed and clenched, legs flexed, chin held downward, and teeth gritted.
 Other signs of tension are a dry mouth, sweating, tachycardia and breath holding.
 The physiotherapist must teach the woman to recognize tension and
how to deal with it.
 At first it is helpful to practise relaxation in lying.
 The woman is taught to tighten the muscles opposing the tension po
 1. Push the legs into the supporting surface, feel the support, now stop
pushing and register the comfort the floor, feel the support and then stop
pushing .
 2. Stretch the hands and elbows, push the arms into.
 3.Push the shoulders down, feel that they are comfortable and stop
pushing.
 4. Push the head down into the pillow, stretch the head out of the neck
(feel that this is comfortable) and then stop pushing and stretching
 5. Face and jaw: Feel smoothness over the face and up over the head.
Open mouth like a yawn and rest, to release clenching of the teeth.
BREATHING AWARENESS:

 The respiratory centre in the medulla is sensitive to carbon dioxide

excess so that breathing rate and depth change to meet the oxygen
debt.
 Care is therefore necessary in explaining the use of conscious
breathing so that hyperventilation does not occur.
 Keeping to the natural breathing rhythm, the woman is taught to sigh
out slowly during the expiratory phase of respiration and fill up
comfort-ably.
 This can help with relaxation during the painful contractions of
labour.
TOUCH AND MASSAGE:

 Touch is known to release the body's own opiates that help

to block sensory pain; it is a natural reaction to rub an
intact area that hurts.
 Firm holding of the lower back or deep, slow massage by
the partner or midwife can reduce the pain of labour.
 Also self-stroking, or holding of the abdomen or pubis can
help to reduce pain and release tension.
ROCKING MOVEMENTS:

 Rocking in a rocking-chair can induce comfort , again it is

thought- by releasing the body's own opiates.
 This principle can therefore be incorporated into gaining
relaxation during labour, e.g. rocking the pelvis
backwards, forwards and sideways in different positions.
TEACHING POSITIONS FOR LABOUR:

 First stage (waiting for cervical dilatation) Remaining upright and

mobile with gravity assisting fetal descent can make contractions more
effective and possibly less painful .

 The following may be helpful:

 1.Walking about, changing to leaning forwards on a support during
contractions when necessary
 2. Sitting comfortably, leaning on a table or using the chair back and
sitting astride the chair seat or use a rocking-chair
 3. Kneeling leaning forward with the forearms and trunk on a bank of
pillows, big bean pillow or bed backrest.
SECOND STAGE (EXPULSIVE EFFORT OF
GIVING BIRTH)
 Midwife and physiotherapist together describe the sensations of the expulsive
effort and of giving birth .
 Most women sit supported in bed in a modified squat position, but some use
side-lying and a few use kneeling or a childbirth chair.
 The midwife explains the various types of obstetric assistance
available(episiotomy, caesarean section, forceps delivery) as well as the
forms of pain relief (pethidine injection , nitrous oxide plus oxygen
inhalation, spinal epidural).
 This enables the woman to understand the effects and implications of these
procedures and to participate in the choice when the time comes.
 The physiotherapist may teach the woman how transcutaneous electrical
nerve stimulation (TENS) may be used to relieve pain during the birth.
Third stage (expulsion of the placenta, cord and
membranes)

 The midwife explains this stage.

 Relaxation and breathing awareness are again useful.