Antenatal Care PDF

ANTENATAL CARE Prepared by Prof. Dr. Asmaa Mahmoud Aly P.T for Women’s Health Learning Objective: By the end of the lecture," students will be able to: 1.Understand the role of physical therapy in promoting the health and well-being of pregnant indiv...

ANTENATAL CARE Prepared by Prof. Dr. Asmaa Mahmoud Aly P.T for Women’s Health Learning Objective: By the end of the lecture," students will be able to: 1.Understand the role of physical therapy in promoting the health and well-being of pregnant individuals during the antenatal period. 2.Identify common musculoskeletal changes and discomforts experienced during pregnancy and the implications for physical therapy intervention. 3.Demonstrate knowledge of evidence-based exercise programs and therapeutic modalities suitable for antenatal care, including prenatal exercises, stretches, and relaxation techniques. 4.Discuss the importance of postural awareness, body mechanics, and ergonomic adjustments to alleviate discomfort and prevent musculoskeletal complications during pregnancy. 5.Recognize the interdisciplinary approach required for comprehensive antenatal care, including collaboration with obstetricians, midwives, and other healthcare professionals. Definition: 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 education Antenatal educators include obstetricians, pediatricians, obstetric physiotherapist, psychologist and dietitians who all work together as a team. Each team member reinforces the role of the others and this requires good communication with regular contact to operate an effective referral system. Antenatal care team obstetrician Obstetrical dietitian Ph.Th. psychologist pediatrician  Component of ante-natal care Medical care Psychological Physical care care Psychological care ❑Fears about the childbirth process. ❑Baby abnormality. ❑Mother baby relationship. Objectives of Medical antenatal care 1) Regular observation for early detection and if possible, prevention of complications of pregnancy. e.g. preeclampsia or hemorrhage. 2) Detection and management of any complicating general diseases.e.g. anemia and diabetes. 3) Detection of complications which affect labour such as mal-presentation. 4) Instruct the patient about hygiene and diet. 5) Laboratory studies as blood group, Rh typing, etc….. 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: Describes the relationship of the long axis of the fetus to that of the mother (longitudinal, transverse). Presentation The 1st part of the fetus come in contact with the pelvic brim. It describes the part of the fetus at the cervical opening (e.g, breech, vertex, shoulder). Position Known as the relation of the back of the fetus (occiputs) to the right or to the left sides of the mother and whether it is directed anteriorly or posteriorly. There are 4 common classical positions in vertex presentation: ▪ Left occipito-anterior (60%) ▪ Right occipito anterior (20%) ▪ Right occipito posterior (15%) ▪ Left occipito posterior (5%) Attitude: The relation of fetal parts to each other usually complete flexion. Engagement The passage of the widest transverse diameter of the presenting part through the pelvic inlet. Physical Preparation For Pregnant Women: -Date of starting ph.Th. Program for the pregnant women: -Physical therapy program : - the method of choice for education is the small classes: Time Saving Allow Meeting Psychological Support.  Date of starting physical therapy program, after the end of the 1st trimester depends on the medical advisor and should be before the woman increases her weight Role of Physical therapy in antenatal care Prevention / treatment of musculoskeletal problems Promoting healthy lifestyle Postural and ergonomic advice Preparing for labour Teaching relaxation techniques Optimal physical fitness 1. Prevention/Treatment of musculoskeletal problems: Back, Sacroiliac pain and pelvic girdle pain prevention Pregnancy related low back pain is a common complaint that occurs in 20–90% of pregnancies and can be defined as pain between the 12th rib and /pubic symphysis during the course of pregnancy, possibly radiating to the posterolateral thigh, the knee, and the calf. This pain is not the result of a known pathology such as disc herniation and can begin at any point during pregnancy. Although most cases are mild, approximately one-third of women experience severe pain. Pregnancy-related low back pain has been coined multiple times and can be referred to as: Pregnancy- related low back pain (PLBP) or pregnancy-related pelvic girdle pain (PPGP).  The cause of pregnancy related LBP can be due to a combination of mechanical, hormonal, circulatory and psychosocial factors. I- Mechanical There are several possible mechanisms of injury which could be causing pregnancy related LBP. During pregnancy, changes occur in the back muscles, and in ligaments. This is mainly caused by the increased release of the hormone relaxin, which causes ligament laxity, and therefore can affect the stability of the spine and lead to back pain. The enlarging gravid uterus changes the load and body mechanics. It’s shifts the centre of gravity forwards, increasing the stress on the lower back. Postural changes can be used to balance the anterior shift possibly causing an extra lordosis. This increases the natural inward curvature of the spine, which increases the mechanical strain on the lower back. It also puts an extra stress on the intervertebral disc, possibly causing a decreased height an overall compression of the spine. Continue Mechanical causes of LBP during pregnancy Another contributor is the increase in weight that comes with pregnancy. On average, about 11-15 kilograms are gained during pregnancy. The weight gain increases the amount of force placed across joints, changes the center of gravity, and forces the patient into an anterior pelvic tilt. The anterior displacement of the center of gravity will cause women to shift their heads and upper body posteriorly over the pelvis, causing hyperlordosis of the lumbar spine. This in turn, places additional stress on the intervertebral discs, ligaments, and facet joints and can lead to joint inflammation. In addition, abdominal muscles are stretched and weakened.  Continue Mechanical causes of LBP during pregnancy The abdominal muscles also stretch to accommodate the expanding uterus. As they stretch, the muscles become tired and lose their ability to maintain normal body posture, causing the lower back to support the majority of the increased weight of the torso  II-Hormonal causes of LBP during pregnancy A significant portion of women first experience pain during the first trimester of pregnancy. At that moment mechanical changes do not yet play a significant role in the onset of pain. This suggests that hormonal changes during pregnancy can cause inflammation and pain in the back. It has been suggested that the hormone relaxin increases 10-fold in concentration during pregnancy, softening the collagen and causes ligamentous laxity and discomfort. The sacroiliac ligaments, but also other ligaments who surround the pelvic girdle become loose. This causes a decrease in the stability and brings on a potential strain in the pelvic girdle and low back area. III-Circulatory causes of LBP during pregnancy The expanding uterus can press on the vena cava, particularly at night when the mother is lying down. This combined with the increased fluid volume from fluid retention during pregnancy leads to venous congestion and hypoxia in the pelvic and lumbar spine.  IV-Psychosocial causes of LBP during pregnancy Psychosocial factors can also increase low back pain. Pain-related, depression, pain intensity and time result in an increases in pain interference. The findings support the potential utility of the biopsychosocial model. Pain catastrophizing can be considered as a risk factor in the third trimester of pregnancy. Risk Factors for LBP during pregnancy LBP history Multiple abortions Smoking Sedentary lifestyle Number of pregnancies History of hypermobility Periods of amenorrhea Increased physical workload High body mass index Lack of exercise  Clinical Presentation of LBP during pregnancy Onset The onset of pain occurs around the 18th week and reaches peak intensity between the 24th and 36th week of pregnancy and the pain is usually worse in the evening. However it may start as early as the first trimester or be delayed as late s 3 weeks after delivery..  Outcome Measures Several validated instruments to assess back pain exist for general population who can be used in the diagnosis to estimate the complaints more objectively: Visual Analogue Scale (VAS) Oswestry Disability Index N.B During an examination of a pregnant patient, positioning is a key consideration. Excessive time in supine is not recommended due to the weight of the uterus on the vena cava and vital structures. Based on the level of pain and disability of the patient, and potentially the size of the pregnant abdomen, certain tests and measures may need to be modified for this population. Excessive time in supine is not recommended due to the weight of the uterus on the vena cava and vital structures  Symptoms of PGP in pregnancy “shooting” pain in the symphysis pubis; radiating pain into the lower abdomen, back, groin, perineum, thigh, and/or leg; pain on movement, especially walking, unilateral weight bearing or hip abduction; pain with activities of daily living, including bending forward, standing on one leg, rising from a chair, go up or down stairs, turning in bed; the pain was progressively getting worse over time and greatly interfered with the activities of her daily life, such as walking, sitting, rolling over in bed and getting in and out of the car pain relieved by rest; clicking, snapping or grinding heard or felt within the symphysis pubis; occasional difficulty voiding;  Signs of PGP tenderness over the pubic symphysis and/or sacroiliac joints; palpable gap in the pubic symphysis; suprapubic oedema and swelling; positive Trendelenberg’s sign waddling gait with short steps;  Sacroiliac Involvement - Pain is usually unilateral and does not midline, can refer to lower extremities, turning while in supine provokes pain, getting out of the car provokes pain, pain is referred to the groin or genitals, pain is related to menstruation prior to pregnancy because of the effects of cyclic hormones on pre-pregnant SIJ ligaments.”  Treatments for pelvic pain in pregnancy Physiotherapy aims to relieve or ease pain, improve muscle function and improve pelvic joint position and stability, and may include: exercises to strengthen your pelvic floor, abdominal, back and hip muscles. exercises in water. advice and suggestions including positions for labour and birth. Mobilizations to the sacroiliac joints. icing the pubic symphysis equipment if necessary, such as crutches or pelvic support belts Acupuncture may also help to relieve pelvic pain in pregnancy.  Advice for pelvic pain in pregnancy Be as active as possible within your pain limits, and avoid activities that make the pain worse. Rest when you can. Get help with household chores from your partner, family and friends. Home instructions included wearing a pregnancy support belt Wear flat, supportive shoes. Sit down to get dressed — for example don’t stand on one leg when putting on jeans. Keep your knees together when getting in and out of the car — a plastic bag on the seat can help you swivel. Sleep in a comfortable position, for example on your side with a pillow between your legs.  Red Flags The Vaginal bleeding following Dizziness/feeling faint are crucial Shortness of breath to identify Chest pain during treatments: Headache Muscles weakness Calf pain or swelling Uterine contractions Decreased fetal movement Vaginal fluid leakage  To protect pelvic joints during labour –Try not to open your legs wider than this during labour and birth. Sometimes, it might be necessary to open your legs wider than your pain-free range to deliver your baby safely, particularly if you have an assisted delivery (for example with the vacuum). If this happens, your physiotherapist should assess you after the birth. Take extra care until they have assessed and advised you. Absolute contraindications to exercise during pregnancy ❖ Haemo-dynamically significant heart disease like Chronic Hart Failure CHF. ❖ Placenta praevia ❖ Preterm rupture of membranes ❖ Pregnancy-induced sever hypertension ❖ History of preterm labour ❖ Incompetent cervix ❖ Acute infection ❖ Thromboembolism or pulmonary embolism ❖ Persistent second or third –trimester bleeding  Relative Contraindications to exercise during pregnancy ❖ Chronic hypertension ❖ Mild to moderate cardiac disease ❖ Mild and moderate anaemia ❖ Twin pregnancy after 28th week General Guidelines for Exercise in Pregnancy Physical examination is a must. Jerky, bouncing movements/ activities should be avoided. Warm up should precede ex. Session followed by a cool down or gradual decline in activity. Maternal HR should not exceed 140 bpm. Do not overextend, overstretch joint or rapidly change direction. Avoid valsava maneuver and avoid contact sports No prone position after 1st trimester.  General Guidelines for Exercise in Pregnancy Avoid exercise in supine after 4th month. Fluid must be taken before , during and after exercise to avoid dehydration. Empty bladder before exercise and avoid GI discomfort by eating at least 1h prior to exercise. Strenous exercise must be avoided in hot, humid weather or when pregnant woman is pyrexial. Horseback ridingand cycling during pregnancy are not allowed.  Date of starting physical therapy program, after the end of the 1st trimester depends on the medical advisor and should be before the woman increases her weight Role of Physical therapy in antenatal care Prevention / treatment of musculoskeletal problems Promoting healthy lifestyle Postural and ergonomic advice Preparing for labour Teaching relaxation techniques Optimal physical fitness  2. Promoting healthy life style #1 - Eat right Eating a healthy diet is especially important for pregnant women. Your baby needs healthy food, not sugar and fat. Eat plenty of colorful fruits and vegetables, whole grains, calcium-rich foods, and foods low in saturated fat. #2 - Get your vitamins Make sure to get plenty of folic acid and calcium. You can get these and other necessary vitamins and minerals from food and a standard multivitamin. Spinach, oranges, broccoli are rich in folic acid. Milk, yogurt, and spinach are packed with calcium. #3 - Stay hydrated A pregnant woman’s body needs more water than normal. Aim for eight or more cups each day. #4 - Don’t drink alcohol Women should not drink alcohol before and during their pregnancy and while breastfeeding. Drinking alcohol increases the risk of having a baby with fetal alcohol spectrum disorder (FASD). FASD can cause abnormal facial features, severe learning disabilities, and behavioral issues  2. Promoting healthy life style Smoking is unhealthy for you and your unborn child. Ample sleep (7 to 9 hours) is important for you and your baby. Try to sleep on your left side to improve blood flow to you and your child. Reduce stress Exercise regularly:Regular exercise has many benefits for you, and therefore your baby. Hygine for Breast, teeth. Air travel-can fly safely up to 36 weeks.  3. Postural and ergonomic advice 1.Maintain Good Posture: 1. Stand tall with your shoulders back and relaxed. 2. Keep your feet shoulder-width apart for better balance. 3. Avoid locking your knees and distribute your weight evenly on both feet. 2.Sitting Comfortably: 1. Choose a chair that provides good back support. 2. Use a small cushion or lumbar roll to support the natural curve of your lower back. 3. Keep your feet flat on the floor or on a footrest.  3. Postural and ergonomic advice 3. Lifting Techniques: Bend at the knees, not the waist, when picking up objects. Keep the object close to your body and use your legs to lift. 4. Sleeping Position: Sleep on your left side to improve blood flow to the baby and reduce pressure on major blood vessels. Use a pregnancy pillow to support your back and belly. 5. Desk Ergonomics: Adjust the height of your desk and chair to maintain a neutral wrist position. Position your computer monitor at eye level to avoid straining your neck.  Date of starting physical therapy program, after the end of the 1st trimester depends on the medical advisor and should be before the woman increases her weight Role of Physical therapy in antenatal care Prevention / treatment of problems musculoskeletal Promoting healthy lifestyle Postural and ergonomic advice Preparing for labour Teaching relaxation techniques Optimal physical fitness 4.Preparing for labour Birthing options that are available to the woman: water births, home based or hospital based delivery. Pain relief in labour Relaxation and body awareness Breathing exercises Massage TENS 5. Teaching Relaxation techniques ❑ Deep Breathing ❑ Progressive Muscle Relaxation (PMR): PMR involves tensing and then relaxing different muscle groups throughout the body. Start by tensing a muscle group (such as your fists or shoulders) for a few seconds, then release and relax the muscles completely. Move through each muscle group, working your way from head to toe. 5. Teaching Relaxation techniques Guided Imagery: Guided imagery involves imagining peaceful and calming scenes or scenarios. Close your eyes and visualize a place that brings you a sense of tranquility, such as a serene beach, a peaceful forest, or a tranquil garden.  6. Optimal physical fitness by exercising 1. Exercise is safe for the mother and fetus. 2. Reduces common complaints of pregnancy such as fatigue, varicosities and swelling of extremities. 3. Reduces insomnia, stress, anxiety and depression. 4. Weight-bearing exercises reduce the length of labour and prepares the woman for physical demands of labour. 5. Improves core stability and pelvic floor muscle strength. 6. Improve glycemic control  Date of starting physical therapy program, after the end of the 1st trimester depends on the medical advisor and should be before the woman increases her weight Role of Physical therapy in antenatal care Prevention / treatment of musculoskeletal problems Promoting healthy lifestyle Postural and ergonomic advice Preparing for labour Teaching relaxation techniques Optimal physical fitness 6. Optimal physical fitness by exercising  The Borg Rating of Perceived Exertion (RPE) is a way of measuring physical activity intensity level. Perceived exertion is how hard you feel like your body is working.  The Borg Rating of Perceived Exertion Although this is a subjective measure, your exertion rating based on a 6 to 20 rating scale, may provide a fairly good estimate of your actual heart rate during physical activity  The Borg Rating of Perceived Exertion It is based on the physical sensations a person experiences during physical activity, including increased heart rate, increased respiration or breathing rate, increased sweating, and muscle fatigue. Duration of exercise session Staring from 15mins and progressing to 30 mins Proper warm up and cool down periods of 5-10 mins each Frequency Minimum of 3 times a week, Progressing to 4-5 times a week.  Model of physical therapy program for normal pregnant women From 4th to the 6 month of pregnancy: Instructions Breathing ex’s Relaxation training Postural correction ex’s 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  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 TENS and its use