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  3. 3. •What is child bearing year? - “ time from conception through post partum adjustments” •Nine months of pregnancy + three months after birth of baby •What is fitness? - physical + psycho-emotional well being
  4. 4. • Conception • First trimester • Second trimester
  5. 5. • Third trimester • Labour • Peurperium and post natal period
  6. 6. 1)To promote good health, poise and sense of well being during pregnancy and encourage preventive medicine 2) To give opportunity to discuss fears and expectations 3) To provide instructions in skills to conserve energy, pain tolerance level and strains of pregnancy
  7. 7. 4) To alleviate the stress and strain 5) To rehabilitate women during puerperium and post natal life as same as pre – pregnant state
  8. 8. Physiological changes Biomechanical changes Emotional changes Child bearing year
  9. 9. Physiological changes - Morning sickness ( nausea/ vomiting) - Increased urinary frequency - Mild enlargement of breast - Increased vaginal secretions - Fatigue
  10. 10. Biomechanical changes
  11. 11. Emotional changes - Mixed feelings - acknowledgment
  12. 12. • Goals : 1) To educate the pregnant woman along with her spouse by any means like ante natal classes, pictures, videos, booklets etc.
  13. 13. • Education regarding : - Pregnancy  physiology and psychology - Physical and psycho-emotional changes - Need for partner and family support - Screening examinations
  14. 14. - Coping with changes and minor discomforts - Small frequent meals - Eat before rising - Avid greasy and rich food - Propping up the bed head - If necessary, contact doctor
  15. 15. - Empty bladder often - Take frequent fluid intake - Eat fiber reach diet - If necessary, contact doctor
  16. 16. - Warning signs:
  17. 17. - Fetal development - Nutrition  folic acid  calcium  omega – 3 fatty acid  iron  dietary fibers
  18. 18. - Postural awareness
  19. 19. - Back care - Ergonomics at home and work place
  20. 20. - Relaxation techniques - Breath awareness
  21. 21. • Referral for specific problems
  22. 22. Physiological changes - Uterus palpable above pubic bones - Excess oil produce in skin leads to acne - Increased perspiration - Foetal movements felt by mother - Increased blood volume - Weight gain - Supine hypotention
  23. 23. Physiological changes - Waist thickness - Pigmentation changes - Stretch marks - Heart burn - Indigestion - Chloasma - Varicosities - Braxton Hicks contractions
  24. 24. Biomechanical changes
  25. 25. Emotional changes - Stage of consolidation
  26. 26. • Goals: 1) To educate women to cope up with certain physiological changes 2) To perform brief screening assessment before starting actual exercise programme 3) To give proper exercise guidelines 4) To check contraindications 5) To inform regarding precautions
  27. 27. 6) To introduce proper exercise programme
  28. 28. - Light frequent meals - Sleep in semi recumbent position - Ingest proper milk - Avoid fatty foods, coffee
  29. 29. Constipation & haemorrhoids - Increased soluble fiber and fluid intake - Increase activity level like exercise, walking - Change iron supplements - analgesics, ice , padding
  30. 30. - Support hosiery - Avoid prolonged standing - Walk rather than stand - Elevate feet when lying - Rest frequently
  31. 31. • Exercise guidelines : set by the American College of Obstetricians and Gynecologists 1) Consult with medical caregiver before commencing exercises 2) Gradually increase exercises if previously sedentary 3) Women can continue to exercise during pregnancy and can experience health benefits even from mild to moderate exercise. Regular exercise at least three times per week is recommended.
  32. 32. 4) Maximum heart rate should not exceed 140-150 beats/min or limit set in consultation with doctor. 5) Do not perform exercises that require lying on your back after the first trimester of pregnancy. 6)Prolonged periods of motionless standing should be avoided. 7) Avoid over flexing and overextending joints, quick direction changes, jumping and jarring motions. Be careful during exercises requiring balance and use outside support.
  33. 33. 8) Modify the intensity of cardio exercise according to perceived exertion or the “talk test.” Stop exercising when fatigued and do not exercise to exhaustion. ” listen to your body.” 9) Never exercise when you have a fever or if the climate is hot and humid. Wear loose, cool clothing to stay cool. 10) Drink liquids before, during and after exercise and be particularly careful to ensure an adequate diet due to increased caloric needs.
  34. 34. 11) Your fitness goals during pregnancy should not be exercising for weight loss, increase in flexibility or strength gain. 12) If a regular pattern of contractions, low back pain, pelvic pressure, or any other unusual symptom develops while exercising, stop and communicate with your health care provider. 13) Always include at least a 5-minute warm-up and a 5- minute cool down period. 14) Get up and down from floor carefully and keep legs moving when you first stand up. This prevents blood from pooling in the legs and causing dizziness.
  35. 35. 15) Pain, discomfort, or shortness of breath should be avoided. Valsalva manoeuvers should be avoided. 16) Vary your exercise program. Some excellent alternatives are walking, swimming and stationary cycling.
  36. 36. Absolute contraindications Relative contraindications Severe cardiovascular, respiratory or systemic disease History of repeated (3 or more) miscarriage or premature labor Uncontrolled hypertension, diabetes or thyroid disease Diabetes Ruptured membranes or premature labor History of rapid labor or poor fetal growth Persistent bleeding after 1st trimester Early pregnancy bleeding Incompetent cervix Sedentary lifestyle with very poor fitness Preeclampsia or toxemia Breech presentation after 28 weeks Multiple pregnancy (triplets, etc.) Palpitations or arrhythmias Poor fetal growth Anemia or iron deficiency Extreme over- or underweight
  37. 37. Potential risk to the foetus from maternal exercises Hypothermia Hypoxia Abnormal heart rate Decreased utero placental flow Increased uterine contractions Reduced maternal glucose level Disruption of maternal endocrine haemostasis Poor growth
  38. 38. • Warm up:
  39. 39. • Exercise programme : strengthning exercises
  40. 40. Pelvic tilting ex’s
  41. 41. • Cool down: - Mild stretching - Breathing techniques - Mental imagery techniques - Relaxation - Listening calm music - Touch of spouse
  42. 42. Benefits of exercise • Maintain healthy body weight and avoid excess fat accumulation • Maintain or improve cardiovascular fitness, muscular strength, endurance, and flexibility • Decreased musculoskeletal complaints such as back pain • Decreased minor discomforts of pregnancy • Improved posture and body mechanics, which may improve coordination, balance, and body awareness
  43. 43. • breath awareness and relaxation • Prevention and treatment of problems associated with gestational diabetes, hypertension, and preeclampsia • Stress reduction and enhanced self-image • Possible easing of labour with fewer complications of delivery faster postnatal recovery
  44. 44. Physiological changes - Varicose veins - Haemorrhoids - Lower limb oedema - Frequency of urination - Breathlesness
  45. 45. Physiological changes - indigestion and constipation - “sick of being pregnant” - “show” in the days or hours preceding labour
  46. 46. Biomechanical changes
  47. 47. Emotional changes - Mood swings increased - Preparation for labour
  48. 48. • Goals: 1) To educate the woman to get relax and stress free 2) To educate woman for dressing 3) To continue exercises as much as possible of second trimester but with mild intensity 4) To educate the woman to cope up with changes 5) To educate and practice for different positions helpful in labour
  49. 49. Ex’s for circulation & cramp
  50. 50. • Breathing exercise: - Explain how “ slow “ , “ low ”, “ deep “ , “ calm “ abdominal breathing
  51. 51. • Relaxation exercises/ techniques: - Major aim is to prevent the mother becoming unduly tired - To help the mother in labour - To help the mother to control her thoughts and emotions
  52. 52. Mitchell method Jacobson relaxation technique Dissociation and blocking Imagery technique Relaxation techniques
  53. 53. • Principles of teaching relaxation: - Enablement - Understanding - Beware - The ‘whole’ - Flexibility - Practice - Motivation - Confidence - Safety
  54. 54. • Teaching different positions for labour :
  55. 55. • “ the process in which the foetus, placenta secundines are expelled from the uterus via the birth canal after minimum period of 20 weeks” • Mainly 3 stages of labour
  56. 56. • Stage 1 – from onset of labour untill full dilation of cervix • Changes during this stage – pain and contractions
  57. 57. • Stage 2 – full cervical dilation to expulsion of the foetus from vagina
  58. 58. • Massage to the back:
  59. 59. • Other approaches: - TENS - Acupuncture - Hypnosis - Water bath - Medications or injections
  60. 60. Delivery Caesarian section Normal / episiotomy
  61. 61. Immediate post natal symptoms - Episiotomy pain - Muscles and ligament laxity causing diastasis recti - Oedema - Back pain - Breast engorgment - Psychological state
  62. 62. • Goals : 1) Relief of pain either of episiotomy or caesarian 2) Ergonomic advices for preventing further complications 3) Educate Exercise programme
  63. 63. • Episiotomy pain: - Icing - Water baths - Ultra sound ( 3 MHz, 0.5 W/cm for 2 min) - Pulsed electromagnetic energy(40-50 pulse width, 10-220 repetitions)
  64. 64. - Advice for abdominal binder or tubigrip or supportive under wears - Abdominal retraction exercises - Pelvic tilting exercise - Progression with coming up upto the hands
  65. 65. DRAM management
  66. 66. - Ultrasound to the periphery initially - Warm compresses - Crushed ice - PEME
  67. 67. 1) Jennifer Hollowell et al., did study on The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review • 36 distinct eligible studies covering a wide range of interventions, including group antenatal care, clinic-based augmented care, teenage clinics, prenatal substance abuse programmes, home visiting programmes, maternal care coordination and nutritional programmes.
  68. 68. • Conclusions: There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing infant mortality in disadvantaged/vulnerable women. • BMC Pregnancy and Childbirth 2011, 11:13
  69. 69. • Ana L Vallim et al., did study on Water exercises and quality of life during pregnancy to evaluate the effects of a physical exercise program of water aerobics on the quality of life (QOL) of sedentary pregnant women • 35 women was given routine antenatal care, while another group of 31 women, in addition to receiving the same routine care as the first group, also participated in three classes of water aerobics per week.
  70. 70. • QOL was evaluated by applying the WHOQOL- BREF questionnaire in both groups at the 20th, 28th and 36th weeks of pregnancy. • Conclusion : The great majority of the participants considered that the practice of water aerobics had benefitted them in some way. QOL scores were found to be high in both groups during follow-up. There was no association between the practice of water aerobics and QOL. • Reproductive Health 2011, 8:14
  71. 71. • Po-Chun Ko, Ching-Chung Liang et al. did study on A randomized controlled trial of antenatal pelvic floor exercises to prevent and treat urinary incontinence • to evaluate the effect of antenatal pelvic floor muscle exercise (PFME) in the prevention and treatment of urinary incontinence during pregnancy and postpartum period • Three hundred women were randomly assigned to the PFME group and control group.
  72. 72. • Urogenital Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire-7 (IIQ-7), and question of self-reported urinary incontinence. • Conclusions: PFME applied in pregnancy is effective in the treatment and prevention of urinary incontinence during pregnancy, and this effect may persist to postpartum period. • International Urogynecology Journal January 2011, Volume 22, Issue 1, pp 17-22
  73. 73. • J.T. van der Spank ET AL. did study on Pain relief in labour by transcutaneous electrical nerve stimulation (TENS) by burst – conventional obstetric TENS-apparatus • On 59 women compare to epidural analgesia • Conclusion : During TENS application the pain scores were significantly lower (p<0.0001) • Archives of Gynecology and Obstetrics November 2000, Volume 264, Issue 3, pp 131- 136
  74. 74. • Keep the “WOMAN” fit and happy, always gives “SAFTEY” to “MUMMY AND BABY”
  75. 75. • R Sapsford et all; WOMEN’S HEALTH – a textbook for physiotherapists, part two – child bearing year • Jil mentle, Jeanette Haslam, Sue Barton, Physiotherapy in Obstetrics and Gynaecology, pg no 93 – 244 • Elizabeth Noble, Essential Exercises for the Childbearing Year: A Guide to Health and Comfort Before and After Your Baby Is Born
  76. 76. • Margaret Polden, Jill Mantle , Physiotherapy in Obstetrics and Gynaecology • Exercise guidelines by The American College of Obstetricians and Gynecologists, 2001 • Ann Thomson, Alison Skinner, Joan Piercy, Tidy’s Physiotheray, twelfth edition , pg no :382-400 • Sandie Keane, Pilates for core strength • Roger L. Hammer, PhD ,Jan Perkins, MSc,Richard Parr, EdD, FACSM, Exercise During the Childbearing Year. Journal of Perinatal Education, 9(1), 1-13; pregnancy, postpartum exercise, guidelines.
  77. 77. • Jennifer Hollowell et al., The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high- income countries: a systematic review, BMC Pregnancy and Childbirth 2011, 11:13 • Ana L Vallim et al., Water exercises and quality of life during pregnancy Reproductive Health 2011, 8:14 • Po-Chun Ko, Ching-Chung Liang et al. A randomized controlled trial of antenatal pelvic floor exercises to prevent and treat urinary incontinence. International Urogynecology Journal January 2011, Volume 22, Issue 1, pp 17- 22
  78. 78. • J.T. van der Spank ET AL. Pain relief in labour by transcutaneous electrical nerve stimulation (TENS) Archives of Gynecology and Obstetrics November 2000, Volume 264, Issue 3, pp 131-136