1. Antenatal Care (ANC)
presented By:
Dr. Radwa M. Yehia
lecturer of PT ACU
Department of PT for Pediatrics & women’s health
2. Objectives
Define antenatal period.
• Describe benefits & aims of ANC.
• Emphasize role of physiotherapy during pregnancy
• List interventions for common problems during pregnancy.
• List recommended exercise approaches meeting the physical
condition of each pregnant women.
• Describe general health advices and nutritional
recommendations for best pregnancy outcome.
3. Antenatal Period
• Definition:
It is the period during pregnancy.
Aims of adequate antenatal care:
1. To detect and treat any physical or psychological defect.
2. Prepare the parents for the birth and care of the baby.
3. 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.
4. Who provide antenatal care?
• Antenatal care team:
1. Obstetrician,
2. Pediatrician,
3. Physiotherapist specialized in woman’s health &
4. Dietitian
5. Date of starting physical therapy program
• Depends on the medical advisor and should be
before the woman increases her weight.
• After end of 1st trimester.
6. Psychological preparation for pregnant women
• Most primigravidae women experience an increase in anxiety
during pregnancy and have fears about childbirth due to:
• Baby will die in uterus.
• Baby will not be born normally.
• Baby will not be healthy.
• Childbirth will be traumatic and pain relief will not be
provided.
• Drugs taken during pregnancy may cause birth defects .
7. Psychological preparation for pregnant women
• The greater the anxiety, the greater the chance that labour
will be more difficult.
• So the pregnant women should talk about their anxieties.
The team members must describe to them, the changes
which are occurring in their bodies and explain the
purpose of investigation they make.
8. Physical preparation for pregnant women
• Physical plane should include certain anatomical
structure of :
• The bony pelvis, its size and shape.
• Its position in the body in relation to posture.
• The attachment of pelvic inlet and outlet.
• The attachment of the muscle of the pelvic floor.
• The development of muscles, ligaments, joints.
• The role of pelvic floor muscles and abdominal muscles
during labour.
• A selected number of illustration will greatly helpful.
9. Ante natal classes applied in small groups
Advantages:
1. Time saving.
2. Allow meeting between pregnant
woman with another at the same
state so, give psychological support.
3. Helps to emphasize the view that
pregnancy is physiological process.
10. Role of physiotherapist during pregnancy
1. Assess physical health & identify any musculoskeletal or neuro-muscular
problems that could be aggravated by pregnancy. The physiotherapist should
identify and try to prevent any problem. e.g. pregnant woman should
perform:
a) leg exercises to prevent varicose veins.
b) Abdominal contractions are taught to be practiced in sitting, lying and
standing positions.
c) Pelvic tilting and postural correction exercise from various positions.
d) Pelvic floor contractions are taught in stride sitting with elbows resting on
the knees.
11. Role of physiotherapist during pregnancy
2. Advices on back care, standing, sitting & lying: back strain
is minimized when the spine is held in its normal curves. So it is
important to teach the woman how to adapt positions which
minimize stress. So, Postural correction exercises are practiced
from different positions:
• Standing.
• Sitting.
• Lying position.
• Crock lying position.
12. Role of physiotherapist during pregnancy
3. Lifting advices: It involves lifting from
a height and carrying as well as lifting
from the ground level.
• The principles to follow when lifting
are:
a) Foot should be apart to increase the base of support.
b) Any object to be lifted must be held close to the body.
c) When lifting from the ground, it is important to ensure that the weight is
light enough to be lifted comfortably.
d) When lifting from a height, it is important to hold the object close to the
body and to make sure that the height is easy reached
13. Role of physiotherapist during pregnancy
4. Treat any problem with appropriate physio-therapy skills.
• Pubic pain: related to diastasis of the rectus abdominis muscles
due to repeated pregnancies. This pain is treated by pelvic support
as a firm elastic corset which modified to fit under the main bulb
of the baby.
• Lumbar pain: may be eased by soft tissue kneading and
mobilization.
• Cramps: occurs most commonly in the calf muscles. It can be
relieved by slow, sustained stretch on the muscles, and by foot
exercises.
14.
15. Role of physiotherapist during pregnancy
5. Teach methods for controlling tension and pain:
• Neuromuscular tension: The physiotherapist must teach the
pregnant woman how to recognize tension and how to deal with
it though:
a) Relaxation techniques: that taught as a mean by reducing
stress in all life situation. During labour, relaxation principles
can reduce the severity of pain.
b) Breathing awareness: can help with relaxation during painful
contraction of labour.
16. Role of physiotherapist during pregnancy
6. Teaching positions that may be used at First stage labour
a) Walking and leaning forward on a support during
contractions.
b) Sitting comfortably, using a back chair or a rocking chair.
c) As labour progress, fatigue sets in and rest is essential in a side
lying position.
d) Relaxation techniques can be used to preserve energy
between contractions.
18. Exercises during pregnancy
• Regular moderate aerobic exercise, at least three times a
week is recommended for all pregnant women with no
contraindications
• Best time to initiate program in the second trimester
when nausea & vomiting of first trimester have passed &
before the physical limitations of third trimester
19. Structured aerobic exercise program based on FITT
principle (frequency, intensity, time, type of activity)
• Frequency: 3 increasing to 4 times/week
• Intensity: previous sedentary mild increasing to moderate intensity
• Time (duration): 15 minutes increasing to 30 minutes with 5-10
minutes of warm up & cool down
• Type of activity: aerobic exercise should involve large muscles
groups as walking , swimming, bicycle, each woman must find the
modality to which she can adhere for long term, the best modalities
of exercise are swimming & walking (safe has no negative effect on
mother & foetus).
20. Model of P.T program for normal
pregnant women
• Not before 4th month to avoid abortion.
• If the is history of abortion, no ante partum
exercise.
21. From 4th to 6th month
• Instruction about anatomy & physiology of female pelvic
structures.
• Training for:
1) Deep breathing ex.
2) Relaxation training: in any comfortable position chosen
by mother, room must be calm, quite, warm, no air
draft, no direct light, light music assist physical and
mental relaxation.
3) Postural correction: to avoid postural problems.
22. From the end of 6th month till the end of 8th
month
All previous in addition to:
1. Pelvic rocking ex.
2. Leg & foot ex.
3. Pelvic floor ex.
4. Abdominal ex.
5. Core stability ex.
6. Arm strengthen ex.
23. During the last month ( woman & her partner)
All previous in addition to:
1. Instruction about onset of labour.
2. Stages of labour.
3. Walking in fresh air.
4. Teaching panting breathing.
5. Relaxation training (diversion drill)
6. Explanation about effect of TENS on pain.
7. Avoid supine hypotension syndrome.
25. Obstetric examination
• Lie:
The relation between the long axis of the fetus & that of
the uterus (feto-pelvic relationship). Longitudinal,
transverse or oblique.
26. Obstetric examination
• Presentation:
The part of the fetus that is closest to the birth canal.
1. Cephalic (95%) =by occiput (vertex, sinciput, brow or
face).
2. Breech (4%).
3. Shoulder (1%).
28. Obstetric examination
Position
The relation of the back of the fetus
(occiput) to the Rt. or Lt. side of
the mother directed anteriorly or
posteriorly.
Common positions in cephalic
presentation:
Lt. occiput anterior (60%).
Rt. occiput anterior (20%).
Rt. occiput posterior (15%).
Lt. occiput posterior (5%).
30. Obstetric examination
Fetal Station
It is the relationship of the presenting
part to the ischial spines (assessed
vaginally). It is measured in
centimeters above (-) or below (+) the
ischial spines.
Floating The presenting part is moving
toward the pelvic inlet (not engaged)
31. Obstetric examination
Engagement
• The passage of a widest
transverse diameter of the
presenting part through the
pelvic inlet (at level of ischial
spines).
• In the majority the engagement
occurs between 38-42 weeks or
even during the first stage of
labour.
32. Obstetric examination
Crowning
The passage of a widest transverse diameter of the
presenting part through the pelvic outlet (at level of
coccyx).
• Occur at end of 2nd stage
of labour.
33. Advices
1. Exercises: The pregnant woman must avoid vigorous
exercises as swimming, tennis and cycling especially in the
first part of pregnancy, the best exercise is walking in open
fresh air, at least one hour daily.
2. Travelling: should be avoided, particularly during the
last month especially on hard roads and for a long
distances. If there is a history of habitual abortion or
premature labours, travelling should be completely
prevented.
34. Advices
3. Sleep and Rest: Sleep for at leas8 hours every night
Rest in a quiet room for 2 or 3 hours every afternoon.
Avoid prone position to avoid intrauterine fetal death.
4. Breasts: massage the nipple with a mixture of glycerin
and alcohol to reduce the incidence of cracking
5. Daily washes, Baths: The bath should be tepid and
given by a shower, vaginal douching should be avoided
because it leads to ascending infection.
35. The best sleep position during pregnancy
• It is “SOS” (sleep on side) because it
1. provides the best circulation for you and your baby.
2. It also places the least pressure on your veins and
internal organs.
3. Sleeping on your left side will increase the amount of
blood and nutrients that reach the placenta.
36. Advices
6. bowel-habit: Avoid constipation because it leads to
straining down, so, piles and genital prolapse may occur.
This could be avoided by eating fresh vegetables, milk,
performing pelvic floor exercise and taking mild
laxatives
7. Clothes: Should be loose, comfortable, avoid tight breast
support. The shoes should be easily fitting, with low heels.
37. Advices
8. Teeth: Regular cleaning at least in the morning and
night.
9. Warning signs: As vaginal bleeding, abdominal pain,
severe persistent headache, swelling in lower limbs
which demand immediate physician calling.
38. Advices
10. Nutrition during pregnancy
• Caloric requirements of pregnant woman: 2300-2500 Kcal/day
• Protein requirement is increased (120gm of red meat, fish, liver)
• 400ml milk or its derivatives
• Iron: 30-60mg/day
• Folic acid: 400 µg/day important for cell division and replication so reduce risk of
neural tube defects
• Fresh fruits and vegetables (dark green)
• Vitamin A and B are essential for growth of fetus and formation of fetal skeleton.
• Vitamin C and K reduce the incidence of abortion and either ante or post
partum hemorrhage.
• Salt restrictions (in cases with marked edema and tendency to hypertension)
• Avoid excess carbohydrates and fats
• Sufficient fluids
39. Sources of vitamins and minerals
calcium Milk and its derivatives, dark green vegetables
iron Lean red meat, poultry, fish
iodine Dairy products, sea food, eggs, cereals, iodized
table salt
Vitamin A dark green vegetables
Vitamin C Citrus fruits
Vitamin D Sun light, milk, sea food
B6 Whole grain cereals
B12 Meat ,poultry, fish, milk
41. Common complains during pregnancy
A- Pubic pain: related to diastasis of rectus abdominis
muscles due to repeated pregnancies.
• TTT: firm elastic corset and abdominal exercises.
42. Common complains during pregnancy
B- Low back pain (LBP) pain and sacroiliac joint
pain(SIJP): TTT OF LBP & SIJP:
1- Gentle soft tissue massage
2- Abdominal exercises, core stability ex. & posture
correction ex.
3- Ice packs under painful region from crock lying position
or ice cube massage for 25 minutes
43. Common complains during pregnancy
B- Low back pain (LBP) pain and sacroiliac joint
pain(SIJP): TTT OF LBP & SIJP:
4-TENS
• Frequency: 80-120 Hz
• Width:150 microsecs
• Minimal intensity
• 1hour, 3-4 times daily
44. TENS (Electrode placement):
• From modified side lying position sticky electrodes
placed:
• LBP: paravertebral
• SIJP: over each SIJ on both sides
• TENS can be used for Sciatic radiculopathy.
• (Channel 1): L5 nerve root & Gluteus maximus,
• (Channel 2): Popliteal space & Post to lateral
malleolus
• Electrodes are placed close to the vertebral column, so
that, there is no risk of current spread to the abdomen.
45. Common complains during pregnancy
TTT OF LBP & SIJP:
5-Interferential (IF)
• Frequency: 80-100HZ, 20minutes, co-planner
application, 4 electrodes on both sides of the painful area
46. Common complains during pregnancy
C- Carpal Tunnel Syndrome (CTS):
It is associated with:
-Oedema
-Parasthesia and pain, which is commonly experienced at
night
-Difficulty holding objects and performing fine movements
47. Management of CTs
• Avoid sleeping on the affected side & elevate the hand
• Wrist and hand exercises to increase circulation &
reduce edema
• Night splint with hand in neutral position
• Ice packs: on the wrist, while support arm over pillow for
15 minutes (Mechanism of pain relieve)
48. Management of CTs
• Contrast bath:
2 baths of cold 15º C & hot 40-45º C water
Each cycle: Begin & end with hot one, place hand 2 min
in hot water immediately afterwards place for 1min in
cold water, repeat cycle 3 times with total time should not
take more than 15 min
49. Management of CTs
• TENS:
Frequency: 80-120HZ
Pulse width: 150micrsecs
1hour, daily
Electrode placement: one above & other below wrist
joint on palmar surface of hand
• Ultrasound (US):
Low intensity : 0.5-2W/Cm2 for 15 min
50. Common complains during pregnancy
D- Morning sickness (Nausea & vomiting):
Caused by the raised level of Human chorionic
gonadotropin (HCG) at this stage, decreased intestine
mobility & lower esophageal sphincter pressure by
elevated levels of estrogen, progesterone & relaxin
hormones.
51. Common complains during pregnancy
D- Morning sickness (Nausea & vomiting):
It is often more severe in multiple gestation (if severe
nausea & vomiting leading to dehydration & nutrition
disorders called hyperemesis gravidarum rare affect 0.5-
2%).
52. TTT of morning sickness:
Deep breathing & relaxation exercises
Regular walking facilitate movement of the intestine
Vitamin B6 supplement
Nutritional instructions: eating small frequent meals,
avoiding spicy & high fat food, drink herbals like ginger
can help digestion
53. TTT of morning sickness: TENS
Frequency: 80-120 Hz, pulse width: 150 µs, minimal
intensity 30 min each morning can control all through
the day
Electrode placement: one electrode: at the right
acromioclavicular tip
Other electrode: at the right dorsal web space between
thumb and forefinger
