Antenatal Care & Physiological Changes During Pregnancy PDF

Antenatal care & physiological changes during pregnancy Presented by Dr. Eman Jamal  OBJECTIVES At the end of this lecture the student should 1- be able to summarize the physiological changes during pregnancy. 2- explain the reasons for these changes. 3- be able to...

Antenatal care & physiological changes during pregnancy Presented by Dr. Eman Jamal  OBJECTIVES At the end of this lecture the student should 1- be able to summarize the physiological changes during pregnancy. 2- explain the reasons for these changes. 3- be able to define antenatal period. 4- be able to recognize PT role during this period.  PHYSIOLOGICAL CHANGES DURING PREGNANCY. There are two main reasons for these changes. To provide a suitable environment for the nutrition, growth and development of the fetus. To prepare the mother for the process of parturition and subsequent support of the new born infant. REPRODUCTIVE ORGANS 1- Uterus Uterus-enlargement due to increase estrogen and progesterone Increase vascularity Hyperplasia Hypertrophy  ENLARGEMENT OF THE UTERUS as pregnancy progression, the uterus leaves the pelvis and ascends to the abdominal cavity.  Length: increases from 6.5 cm to 32cm  Width: increases from 4 cm to 24cm  Weight: increases from 50 gm to 1000 gm at 40 weeks..  ENLARGEMENT OF THE UTERUS Fundal height is increased with progressive enlargement of the uterus. ENLARGEMENT OF THE UTERUS  PRODROMAL (PRE- LABOR) STAGE May occur in the last weeks of pregnancy: Uterine Shelfing: It is falling forwards of the uterine fundus making the upper abdomen looks like a shelf during standing position. This is due to engagement of the head the fetus which brings the fetus perpendicular to the pelvic inlet in the direction of pelvic axis. Lightening: it’s the relief of the upper abdominal pressure symptoms as dyspnoea and palpitation due to descent of the fundal level after engagement of the head and shelfing of the uterus.  REPRODUCTIVE ORGANS 2- Cervix * The mucus gland becomes enlarged and secrete mucus which forms a mucus plug called (operculum) that is expelled in labor as the show. * The cervix become more vascular and softer in response to estrogen and progesterone.  REPRODUCTIVE ORGANS 2- Cervix *during labour and delivery: the cervix shortens (effaces) and winding (dilates). It opens 10 cm to allow for the passage of the fetus into the birth canal. REPRODUCTIVE ORGANS 3- Vagina *The muscle layer of the vagina thickens and become more elastic to facilitate its dilation during the 2 nd stage of labor. * the length of the anterior vaginal wall increase. * Increase vascularization due to estrogen and softening due to progesterone * Vaginal discharge tends to be thick and white= leukorrhea * PH at the lower vagina is acidic from 4- 6.5. (Non-pregnant woman 3.5-4.5)  CARDIOVASCULAR SYSTEM. *Increase cardiac out put 30-50% peak at 28-32week. *Blo od p ressu re decreases a little th rough th e second tri me ster so p regn an t wo man may feel faint. *Maternal position has an effect on blood pressure by th e second tri mester lyin g on th e b ack th e u terus an d d ev elop ing bab y pu t pressure on the spine, back muscles, intestin e and inferio r vena cava (IVC). As IVC carrie s b lo od f ro m lower b od y to th e h eart th e in creased p ressu re will decrease card iac ou tpu t and decreases b lood p ressu re to th e h eart and th en decreased blood flow to the uterus and developing baby. Sudden rise in venous pressu re wh ich can lead to p lacental separation , and a decrease in kidney function Lying on the sides take this pressure off. Th is p rob le m known sup in e h ypo ten sion (preg nancy hypo tensive syndro me) which affects 3% to 11 % of pregnant women. PREGNANCY HYPOTENSIVE SYNDROME  RESPIRATORY SYSTEM * Chest increases in size. Diaphragm moves upward toward the chest. * During pregnancy, the body is in a state of hyperventilation, - Hyperventilation syndrome: is a pattern of breathing as the pregnant women breathe more quickly and deeply than normal. Breathing becomes more costal than abdominal Additionally, most women are mouth breathers during pregnancy. - Oxygen consumption increases by 14% to 20%. - Tidal volume increases 30-40 % and this is necessary to meet the increased oxygen requirement for the pregnant woman.  Urinary system *The length of the kidneys increases by 1 to 1.5 cm during pregnancy and decreases in size over a period of 6 months postpartum. *Over all volume of kidneys during pregnancy increases up to 30 %.  Urinary system *As the size of the uterus increase the frequency of micturition increases ( at the 1 st and 3ed trimester ), but at the second trimester the uterus rises up out of the pelvis and pressure on bladder relieved. * Increase the incidence of Urinary tract infection (bladder infection) due to urinary stasis.  GASTRO-INTESTINAL TRACT GIT *Morning sickness and vomiting in early months. *indigestion. *Constipation: due to pressure on the intestines by the enlarged uterus, relaxation of the smooth muscle fibers by relaxin hormone and sedentary habits during pregnancy. *Piles.  NERVOUS SYSTEM * Mood liability, some women are sleepy, depressed but others become excited and suffer from insomnia. * Water retention causes pressure on nerves which resulting neuropraxia (e.g., carpal tunnel syndrome) * Pregnancy cravings.  CUTANEOUS SYSTEM Pigmentations: it usually begins at the 4 th month, the most common sites - Linea nigra: its dark line develops on a stomach usually between the umbilicus and the symphysis pubis.  CUTANEOUS SYSTEM - Darkening areolas: at second trimester of pregnancy results from hormonal changes the primary areola become darker and appearance of the secondary areola, the areola may return to its prepregnancy color after breast feeding or still remains two darker than it was originally.  CUTANEOUS SYSTEM - Cloasma gravidarum (mask face of pregnancy): its butter fly pigmentation Of the forehead, nose, upper lip and cheeks.  CUTANEOUS SYSTEM Due to overstretching of the skin, the elastic-fiber may rupture with small blood vessels and so red streaks appear; known as striae gravidarum and striae rubra. After labour, the red stria become pale white due to fibrosis and they known as stria albicantes.  METABOLIC AND ENDOCRINE CHANGES Relaxin is a hormone secreted by the corpus luteum, the endocrine body located in the ovary at the site of the ruptured ovarian follicle. Other major hormones effecting a woman during pregnancy include estrogen, progesterone, and human placental lactogen.  MUSCULOSKELETAL SYSTEM By the end of pregnancy abdominal muscles are stretched to the point of their elastic limit.  MUSCULOSKELETAL SYSTEM -Hormones affect of producing systemic decrease in ligamentous tensile strength and increase in mobility of structures supported by ligaments lead to injury of patient of joints especially in the weight bearing joints of the back, pelvis and lower extremities. -The pelvic floor muscles withstand the weight of the uterus, the floor drops as much as 2.5 cm  MUSCULOSKELETAL SYSTEM Postural changes: N.B: During pregnancy, postural changes occur to accommodate for abdominal growth. 1- Changes include forward head, rounded shoulder, increase lumbar lordosis, hyperextended knees, and pronated feet. 2- The center of gravity changes lead to change in balance. 3- Muscular changes include shortened hip flexors, muscles of lower back and pectorals. Abdominal muscles, neck, and upper back muscles elongate. This may promote stretch weakness or adaptive shortening. 4- Extra weight is placed on the pelvic floor. 5- Sublaxaion of sacroiliac joint and symphysis pubis due to softening of ligaments by relaxin hormone lead to waddling gait.  MUSCULOSKELETAL SYSTEM During pregnancy, postural changes occur to accommodate for abdominal growth.  Antenatal period: Is the period during pregnancy. Antenatal care is the systemic medical supervision of women during pregnancy. Its aim is to preserve the physiological aspect of pregnancy and labour and to prevent or detect, as early as possible, any pathological conditions. ANTENATAL CARE TEAM obstetrician Obstetrical dietitian PT. psychologist pediatrician  Component of ante-natal care Medical care Psychological Physical care care MEDICAL ANTENATAL CARE: The first visit: includes history taken, general abdominal and vaginal examination, urine analysis for albumin and sugar, blood examination for hemoglobin ,blood group, human immunodeficiency virus (HIV), hepatitis B surface antigen and hepatitis C. Awareness about the benefits and necessity of institutional deliveries and risk involved in home deliveries. Awareness about the dangers and emergency signs. Return visits: Ask about warning symptoms, weight the mother, look for edema and measure blood pressure, do abdominal examination and urine analysis for albumin and sugar. MEDICAL ANTENATAL CARE: Frequency of examinations: Every month until the 7th month Every 2 weeks in 7th and 8th month Every 1 week in the 9th month  OBSTETRIC EXAMINATION Lie Presentation Position Attitude Engagement  -LIE: The relation of the long axis of the fetus and that of the mother or the uterus ( longitudinal- transverse -oblique) - PRESENTATION: It’s the part of the fetus related to pelvic brim and its 1st felt by vaginal examination Cephalic presentation Breech presentation Shoulder presentation - PRESENTATION: Cephalic presentation (96%) which include: Vertix presentation ( fetus head flexed) Brow presentation (fetus head is in mid way Face ( fetus head is extended)  -POSITION : The relation of the back of the fetus (occipts) to the right or the left side of the mother and weather its directed anteriorly or posteriorly -POSITION: There are 4 common classical positions in vertix presentation: ✓ Left Occipito Anterior (60%). ✓ Right Occipito Anterior (20%). ✓ Right Occipito Posterior (25%). ✓ Left Occipito Posterior (5%). -POSITION: -Attitude: - ENGAGEMENT : Engagement is said to have occurred when the widest part of the presenting part has passed successfully through the pelvic inlet  PSYCHOLOGICAL CARE Most pregnant woman experience increase in anxiety during pregnancy and have fears about childbirth process or baby abnormality, pain and mother baby relationship. So psychological support is very important during that period  PHYSICAL PREPARATION FOR PREGNANT WOMEN: - Starting PT program according to the woman condition usually not before 4th month Physical therapy program : - The method of choice for education is the small classes: Time Saving Allow Meeting between pregnant women Psychological Support.  PHYSICAL PREPARATION FOR PREGNANT WOMEN: Antenatal classes 1) Assess physical health and identify any musculoskeletal or neuromuscular problems: Muscle weakness: Abdominal ms. - pelvic floor ms Postural changes 2) Advise on back care and lifting: back strain  is minimized when the spine is held in its  normal curves. So postural correction Ex are  very important to adapt positions which  minimize stress. Applied from standing, sitting,  Lying position, crock lying position. 3) Advise on lifting objects:  lifting from height and carrying from the ground level. Principles to follow when lifting are:  Foot should be apart to increase the base of support.  Any object to be lifted must be held close to the body.  When lifting from ground, it is important to ensure that weight is light enough to be lifted comfortably.  When lifting from height, it is important to hold the object close to the body and to make sure that height is easy reached. 4) TREAT ANY PROBLEM WITH APPROPRIATE PH.TH. SKILLS: Pubic pain: due to diastasis of rectus abdominis in multi gravida women, treated by pelvic support (elastic corset fit under the bulb of the baby. Lumbar pain: may be eased by soft tissue kneading and mobilization. cramp : common in calf muscles, relived by slow sustained stretch and foot ex’s.  5) Teach methods for controlling tension and pain: by teaching the woman how to recognize and deal with neuromuscular tension through:  Relaxation technique: to reduce stress in all life situation. During labour → to reduce the severity of pain.  Breathing awareness → to relax during painful contraction of labour. 6) Teaching positions that may be used for labour. Also, the different stages of labour must be explained for her.  1- First stage:(stage of cervical dilatation): instruction to help woman  >> Walking and to leaning forward on a support during contraction. Sitting comfortably, using a back chair or a rocking chair.   >> As labour progress, fatigue sets in and rest is essential in side lying position.  >> Relaxation techniques can be to preserve energy between contractions.  2- Second stage (expulsive effort of giving birth):  The physiotherapist teach the women how TENS → to relief pain during the birth → to bear down during uterine contraction → to assist expulsion of the fetus.  3- Third stage: (expulsion of the placenta, cord and membranes):  Relaxation and breathing awareness useful in this stage.  General role, No Electrotherapy Should Be Used Over The Pregnant Abdomen. I -Law back pain: a) Ice:- (25 min) (ice backs)  swelling  Decrease nerve conduction velocity  increase Endorphins and enkephalin  I- LOW BACK PAIN: Ice can be applied in tw o forms:  Ice cube massage: in which ice cube is wrapped with a towel leaving one surface free. It is impo rtan t that the ice cube must contact the tissue directly and there is no water around the edges. As tis will upset the temp eratu r e differen ce needed for the required physiological effects. The massag e is continued while the patient feels a burning sensation , followed by aching and then numbn ess, for 10 min. Ice packs or cryo-gel pack technique. This is for 25 min. under the painful region while mother lying in crock position. 1. Ice used safely during pregnancy for pain relief on local lesion because cooling of skin stimu lates cold recepto rs , which send feed back impu ls e that pass into the spinal cord via the posterio r root, through relativ ely large diameter nerve fiber , so block effectiv ely any other pain to reach the cord, in addition, it decreases conduction rate of nerve fiber. 2. Cold stimu lation itself considered as noxious stimu li, so cause stimu lation of areas in mid brain which in turn releas e B- endorphins and enkephalin into posterio r horn cell. 3. Ice cause vasoconstriction which decreas e the rate of swelling and production of irritan t and so alleviate pain.  I- LOW BACK PAIN: b) TENS : Frequency: 80-120 Hz Width: 150 microsec Minimal intensity for 1H, several times/ day. Position: side lying- sitting comfortable.  I- LOW BACK PAIN: c) IF: Coplanar technique. Frequency: 80-100 Hz, for 20 min. Micro-massage effect. Increase circulation remove waste products so decrease pain. Position: side lying  II- MORNING SICKNESS: The causes of Hyperemesis Gravidarum are complex and likely to be multifactorial. It is well recognized that, during pregnancy, there is an increase in fluid secretions from the upper gastrointestinal tract. It is also likely that the incidence of Helicobacter pylori is higher among HG suf ferers. Furthermore, because human chorionic gonadotrophin (hCG) is of similar structure to thyroid-stimulating hormone, the normal physiology of thyroid function may be altered — resulting in transient hyperthyroidism. Other psychological and social factors have also been  II- MORNING SICKNESS:  Pharmacological management:  Fluids  Antiemetic  Vitamins  Physical therapy management:  Ice: on 4th to 8th thoracic vertebra for 10 min to inhibit vomiting reflex.  TENS: one electrode on the tip of the right acromioclavicular joint and the other at right hoku point (dorsal aspect of 1 st dorsal space) (acupuncture points). Rate: 80-120 Hz, width:150 microsec. For 30 min several time/ day.  II- MORNING SICKNESS:  Wearable wrist band( hospital sheet)  Diet modification (hospital sheet)  Acupuncture Acupuncture: - Is defined as the stimulation of an acupoint with a needle on P6 or Nei-Guan point. - Thin sterilized needle ( 0.2-0.3mm) inserted on point. - Patient bilaterally needled at P 6 or Nei-Guan point, needled deep, perpendicular. - The needle were left in for 15- 20 min. - Approximately 5 min before removal of needles, P 6 point was manually tonified (twirled clockwise).  II- MORNING SICKNESS:  Acupressure: Finger pressure: deep pressure on P 6 point or NeiGuan point with circular motion for 10 min as patient feels nausea. - Repeat the process for the other wrist with total treatment period 60 min of acupressure per day for 7 consecutive days. III- CARPAL TUNNEL SYNDROME Ice back:15 min Contrast bath: for 15 min -Hot: 40-45˚C for 3 min. -Cold: 15 ˚C for 1 min. Start and end with hot water  Us: low intensity (0.5-2) W/cm2 , for 10 min. -Micro massage effect : - Heat effect: -Gate control theory: Tens: High frequency 80- 120 HZ, 150 micro sec. Application: one electrode above and below the wrist joint on the palmar surface Night splint : To keep wrist joint in mid position. MODEL OF PHYSICAL THERAPY PROGRAM FOR NORMAL PREGNANT WOMEN: From 4 th to the 6 month of pregnancy: Instructions: about physiology of pregnancy, anatomical background about pelvic joints and muscles. Breathing ex’s Relaxation training Postural correction ex’s. NB: antepartum ex forbid den in cases of habitual abortion. MODEL OF PHYSICAL THERAPY PROGRAM FOR NORMAL PREGNANT WOMEN: FROM THE END OF 6TH MONTH TILL THE END OF 8TH MONTH OF PREGNANCY: Previous ex’s and add Breathing ex’s Relaxation training Pelvic rocking ex’s Leg ex’s Pelvic floor ex’s Abdominal ex’s Arm ex’s MODEL OF PHYSICAL THERAPY PROGRAM FOR NORMAL PREGNANT WOMEN: DURING LAST MONTH OF PREGNANCY: Previous ex’s and add  Instruction about onset of labour  Stages of labour  Pelvic floor relaxation  Walking in fresh air  Teaching mother panting breathing  Explanation for TENS and its use for relieving labour pain. CONTRAINDICATIONS TO EXERCISE IN PREGNANCY  Absolute A histor y of recurrent spontaneous abortion (miscarriage) Vaginal bleeding or ruptured membranes Incompetent cer vix.  Relative Women unused to high levels of exertion. Extreme obesity Breech presentation in third trimester Some blood disorders (sickle cell anemia) Thyroid disorders  REASSURANCE AND ADVICES Exercise and travelling Sleep and rest Warning signs Hygiene teeth Bath Breast Clothes Bowel habit Diet and pregnancy: Caloric intake increase in late preg. to 2500 calories. Protein : 1.5 gm/kg/day Vit A and D Vit C and K Ca+ and iron supplementation Fluids Folic acid  REFERANCES - Beers K and Patel N 2020: Kidney physiology in pregnancy, Advances in Choronic Kidney Disease. 27(6): 449-454 - Gupta S, Mittal p and Garg R 2022: Antenatal care; Handbook. JAYPEE. 4-70.