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ANTENATAL CARE

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Systemic supervision (examination and advice) of a woman during pregnancy is called antenatal care.[1] 

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Aims of modern antenatal care[2]  - 

  1. To promote and maintain optimal physical  and emotional maternal health throughout pregnancy.

  2. To recognise and treat correctly medical or obstetric complications occurring during pregnancy.

  3. To detect foetal abnormalities as early as possible.

  4. To prepare for and inform both parents about pregnancy, labour, the puerperium and the subsequent care of their baby.

  5. To motivate the couple about the need of family planning and appropriate  advice seeking medical termination of pregnancy

  6. The overriding goal is that pregnancy will result in a healthy mother and a healthy infant.

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Impairments 

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BODY STRUCTURES  

  • Stria Gravidum

  • Linea nigra

  • Diastesis recti

  • Increased lumbar lordosis and thoracic kyphosis

  • Protracted shoulders

  • Stretching, lengthening and consequent thinning of the pelvic floor and perineum

  • Enlargement of breasts and they become nodular and lumpy

  • Increased joint laxity

  • Bipedal edema in 3rd trimester

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BODY FUNCTIONS

  • Reduced strength

  • Reduced endurance 

  • Reduced ROM

  • Back pain

  • Pelvic girdle pain

  • Fatigue

  • Waddling gait

  • Weakness of pelvic floor muscles

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Goals 

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Short term

  • Patient education

  • Reduce pain

  • Reduce bipedal oedema

  • Ergonomics

  • Relaxation

  • Increase muscle performance

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Long term 

  • Correction of posture

  • Correction of diastesis recti

  • Strenghening of core muscles 

  • Strenghening of pelvic floor muscles

  • Proper breastfeeding techniques

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Management/Physical Therapy

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Patient education and Ergonomics 

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Guidelines

  • Jerky, Bouncing, Ballistic movements and activities should be avoided.

  • Regular mild to moderate exercises sessions, at least 3 times a week, are safer than intermittent bursts of activity.

  • A careful warm up should precede vigorous exercise, followed by a cool down.

  • Flexibility and mobility follow the warm up section, avoiding ballistic stretching. All main ms groups should be included and positions stretching at the extreme range should be avoided

  • Strenuous exercises must be avoided in hot, humid weather or when the pregnant women is pyrexial.

  • The maternal heart rate should not exceed 140 b.p.m. and vigorous exs should not continue for longer than 15 mins.

  • Fluid must be taken before, during and after exertion to avoid dehydration

  • An aerobic component should be in the mode i.e. brisk walking, cycling, aerobic dance  (all avoiding high impact) 

  • Avoid supine position after 3rd trimester

  • Not to cross the knees while sitting

  • Avoid long periods of standing or sitting , pre bedtime walk, calf stretches, warm bath and foot exercises in bed before sleep

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Back care

  • Advice on sitting position, working position, bending, lifting, and household activities.

  • Instructions on using seatbelt

  • Instructions on changing position from supine to sitting

  • Instructions on Proper technique of lifting , bending, carrying things

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Reduce back pain and pelvic girdle pain 

  • Rolling with adduction of hip and flexion of knees, folding the arms across the chest.

  • Gentle heat and massage

  • Cat and camel exercises in quadruped position

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Reduce Bipedal oedema

  • Elevation, Compression with less pressure, walking, active stretching.

 

Pelvic floor Strenghening (To avoid urge and stress incontinence)  

  • Pelvic floor exercises and pelvic tilting while sitting on the edge of the chair or standing – contract the muscles as if stopping the flow of urine.

  • Pillow squeeze exercise – Keep a pillow between the knees in crook lying position and squeeze the pillow while also contracting PFM muscles.

  • Elevator exercise – Contracting the PFM muscles slowly and relaxing slowly.

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Relaxation

  • The Mitchell method of physiological relaxation

  • Edmund Jacobson method i.e. alternately contracting and relaxing muscle groups progressively round the body.

  • Visualisation and Imagery of a pleasant warm environment can induce feeling of calm and relaxation

  • Massage to induce relaxation and relieve pain. (Soothing stroking, effleurage or kneading )

  • Expiration is the relaxation phase of respiratory cycle, rhythm of slow, easy breathing is calming  

  • Swimming 

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Maintain circulation and avoid cramp

  • Foot and ankle exercises i.e. Plantarflexion , dorsiflexion and foot circling carried out for 30 secs regularly 

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Relieve morning sickness

  • TENS -120 Hz 150 m/s to the web space between thumb and forefinger on the right arm

 

Relieve Muscle cramps  

  • Calf stretches to relieve ms spasm

  • Knee extension with dorsiflexion

  • Massage – deep kneading 

  • Foot exercises

  • Pre bedtime brisk walk, warm bath maybe prophylactic 

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Contraindications to vigourous exercises during pregnancy [2] –

 

ABSOLUTE

  • Cardiovascular disease    

  • Acute infection    

  • A history of recurrent spontaneous abortion (miscarriage)    

  • Preterm labour in current or previous pregnancy    

  • Multiple pregnancy    

  • Vaginal bleeding or ruptured membranes    

  • Incompetent cervix    

  • Pregnancy induced hypertension    

  • Suspected IUGR or foetal distress    

  • Thrombophlebitis or pulmonary embolism    

  • Chronic hypertension, active thyroid, cardiac ,vascular or pulmonary disease    

  • Diabetes type 1 uncontrolled    

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RELATIVE

  • Women unused to high levels of exertion

  • Blood disorders such as sickle cell anaemia

  • Thyroid disease

  • Diabetes – however a careful supervised program of gentle exercising may benefit some patients

  • Extreme obesity or underweight

  • Breech presentation in third trimester

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REFERENCES 

  1. D.C. Dutta, Hiralal Konar , Textbook of Obstetrics including Perinatology and Contraception , 7th Edition , Page no. – 94

  2. Jill Mantle, et. al. , Physiotherapy in Obstetrics and Gynaecology, 2nd Edition, Page no. -94-162

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