PRENATAL PHYSIOTHERAPY / antenatal pt management

physiology is explained system & organ wise references are provided of the particular books

1. PRENATAL PHYSIOTHERAPY Manashvi D makwana

2. Agenda A Introduction Maternal physiology Antenatal care -aims -role of physiotherapy -references Presentation title 2

3. Introduction Antenatal care is the care of the woman during pregnancy. The primary aim of antenatal care is to achieve at the end of a pregnancy as a healthy mother and a healthy baby. Ideally this comprise the series of events occurring from conception through first second & 3 rd trimester of the pregnancy to the delivery of child Presentation title 3

4. First trimester- (0-12 weeks)- in this trimester both mother & fetus are changing rapidly includes – Morning sickness – due to increase in level of hormones to sustain pregnancy Mood swings irritability & other physical symptoms – due to surges in hormones Increase frequency of urination Reduced peristalsis of alimentary tract Second trimester (13-27 weeks)- the symptoms of the 1 st trimester may improve, baby grows larger & women begins to show larger belly appetite & weight Mother experiencing the movement of fetus (starts- 20 weeks) Skin pigmentation on face & belly due to pregnancy hormones Reduction in need to urinate often as uterus grows out of pelvic cavity, reliveing pressure on the bladder 4

5. Third trimester-(28-40 weeks)- physical & emotional challeges increases as the fetus grows more in size & weight. Baby is considered full term at the end of 37 weeks Edema on ankle, hand& face due to retained fluid Skin pigmentation becomes more apparent Backache Fourth trimester (first 12 weeks of postpartum) Presentation title 5

6. PHYSIOLOGICAL CHANGES IN ANTENATAL CARE Presentation title 6

7. CHANGES IN GENITAL ORGAN VULVA- becomes oedematous & hyperaemic Superficial varicosities may appear specially in multiparae Labia minora are pigmented & hypertrophied VAGINA- vaginal walls become hypertrophied oedemantous & more vascular Increase blood supply of venous plexus surrounding the walls The length of the anterior vaginal walls is increased Secretion- copious, thin, & curdy white PH- acidic 3.5-6

8. UTERUS - non pregnant state weighs about 60gm with the cavity of 5-10ml & measures about 7.5 cm in length At terms it weighs about 900-1000gm & measures 35 cm in length Changes occurs in part of uterus body , cervix, isthmus There is an increase in growth a& enlargement of uterus Changes in muscle-1) hypertrophy & hyperplasia- occurs under the influence of hormones estrogen & progesterone- limited to first half of pregnancy & pronounced up to 12 weeks 2)stretching- the muscle fibers further elongate beyond 20 weeks due to distension by the growing fetus the Wall becomes thinner At term- measures about 1.5cm or less 8

9. ARRANGEMENT OF MUSCLE FIBERS- 1 ) outer longitudinal- hood like arrangement over the fundus; some fibres are continuous with round ligament 2) Inner circular- scanty & have sphincter like arrangement around the tubal orifices 3) Intermediate- thickest & strongest layer arranged in criss-cross fashion through which the blood vessels run. 9

10. VASCULAR SYSTEM- uterine artery diameter becomes double Blood flow increases by 8 folds at 20 weeks of pregnancy Vasodilatation is mainly due to estradiol & progesterone Veins become dilated & are valveless , numerous lymphatic channels opens up the vascular changes are most pronounced at the placental site WEIGHT- the increase in weight is due to increased growth of uterine muscles, connective tissue & vascular channels SHAPE- Nonpregnant pyriform shape is maintained in early months Changes to globular at 12 weeks As the uterus enlarges, the shape once more becomes pyriform or ovoid by 28 weeks changes to spherical beyond 36th week

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12. POSITION - Normal anteverted position is exaggerated up to 8 weeks the enlarged uterus may lie on the bladder Afterwards, it becomes erect, the long axis of the uterus conforms more or less to the axis of the inlet, there is a tendency of anteversion In primigravidae with good tone of abd muscle it is held firmly against the maternal spine Contractions (Braxton-Hicks): - The contractions are irregular, infrequent, spasmodic and painless without any effect on dilatation of the cervix ISTHMUS- During the first trimester, isthmus hypertrophies and elongates to about 3 times its original length. It becomes softer 12

13. CERVIX- hypertrophy and hyperplasia of the elastic and connective tissues. Vascularity is increased softening of the cervix (Goodell’s sign) Epithelium: the squamous cells become hyperactive Secretion: The secretion is copious and tenacious Anatomical: The length of the cervix remains unaltered but becomes bulky. The cervix is directed posteriorly but after the engagement of the head, directed in line of vagina. FALLOPIAN TUBE- The total length is somewhat increased. The tube becomes congested. Muscles undergo hypertrophy. Epithelium becomes flattened, and patches of decidual reaction are observed 13

14. 14 OVARY- The growth and function of the corpus luteum reaches its maximum at 8th week it measures about 2.5 cm and becomes cystic Hormones estrogen and progesterone—secreted by the corpus luteum maintain the environment for the growing ovum before the action is taken over by the placenta These hormones not only control the formation and maintenance of decidua of pregnancy but also inhibit ripening of the follicles

15. Breast- 2-4 weeks unusual tenderness and tingling may be experienced in the breasts and enlargement begins soon- nodular & lumpy There is an increase in blood supply (veins may become visible on the chest) There maybe evidence of striation due to stretching of cutis 8 weeks -sebaceous glands in the pigmented area around the nipples become enlarged and more active, appearing as nodules s (Montgomery’s tubercles) 12 weeks -the nipples and an area around them (the primary and secondary areolae), become more pigmented and remain so for as much as 12 months after parturition. a little serous fluid may be expressed from the nipple 16 week- colostrum can be expressed. Human milk ‘comes in’ about the 3rd or 4th postpartum day. 15

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17. CUTANEOUS CHANGES- Face (chloasma gravidarum or pregnancy mask)- an extreme form of pigmentation around the cheeks forehead & around the eyes – patchy or diffuse; disappears spontaneously after delivery Breast Abdomen- linea nigra- brownish black pigmented area In midline stretching from xiphisternum to symphysis Pubis Striae gravidarum- slightly depressed marks with varying length & breadth found in pregnancy Vascular spider & palmar erythema 17

18. HAEMATOLOGICAL CHANGES BLOOD VOLUME- due to increased in vascularity of enlarging uterus, blood volume is markedly raised during pregnancy The blood volume starts to increase from about 6 th week expands rapidly thereafter to max 40-50% above nonpregnant level at 30-32 weeks PLASMA VOLUME- starts to in 6 weeks Rate of increase almost parallels to blood volume Reached to the extent of 50% Total plasma volume increase to the extent of 1.25 liter 18

19. RBC & HAEMOGLOBIN- RBC mass has increased to the extent of 20-30% Increase in demand of o2 transport during pregnancy Disproportionate increase in plasma & RBC volume produces state of hemodilution(fall in hematocrit) Hb fall is about 2gm% from the non pregnant value 19

20. METABOLIC CHANGES GENERAL METABOLIC CHANGES- total metabolic is increased due to the needs of growing fetus & the uterus Basal metabolic rate is increased to the extent of 30% higher than that of avrg non pregnant women PROTIEN METABOLISM- positive nitrogenous balance throughout pregnancy At term, the fetus & placenta contains about 500gm of protein & maternal gain is also about 500gm CARBOHYDRATE METABOLISM- insulin secretion is in response to glucose & Amino acid Hyperplasia & hypertrophy of beta cells of pancreas Increase insulin level favors lipogenesis (fat storage) this mechanism ensures continuous supply of glucose to the fetus 20

21. FAT METABOLISM- an avrg of 3-4 kg of fat is stored during pregnancy mostly in the abdominal wall, breast, hips & thighs IRON METABOLISM- : Iron is absorbed in ferrous form from duodenum and jejunum and is released into the circulation as transferrin About 10% of ingested iron is absorbed Total iron requirement during pregnancy is estimated approximately 1,000 mg In the absence of iron supplementation, there is drop in hemoglobin, serum iron and serum ferritin concentration at term pregnancy Thus, pregnancy is an inevitable iron deficiency state 21

22. WEIGHT GAIN In early weeks, the patient may lose weight because of nausea or vomiting. During subsequent months, the weight gain is progressive until the last 1 or 2 weeks, when the weight remains static. The total weight gain during the course of a singleton pregnancy for a healthy woman averages 11 kg This has been distributed to 1 kg in first trimester and 5 kg each in second and third trimester. Importance of weight checking : Rapid gain in weight of more than 0.5 kg a week or more than 2 kg a month ,in later months of pregnancy may be the early manifestation of preeclampsia and need for careful supervision. Stationary or falling weight may suggest intrauterine growth retardation or intrauterine death of fetus. Obese women are in increased risk of complications in pregnancy, labor and puerperium 22

23. The total weight gain at term is distributed approximately as:- Presentation title 23

24. 24 RESPIRATORY

25. ENDOCRINE SYSTEM The changes of pregnancy are orchestrated by hormones progesterone, estrogens and relaxin seem to be the most important for the physiotherapist. Increased joint laxity has been demonstrated in pregnancy 25

26. MUSCULOSKELETAL CHANGES Increase in joint laxity and joint ranges There is increased mobility of the pelvic joints due to softening of the ligaments caused mainly by hormone Increase in water retention- oedema & nerve compression The distance between the two rectus abdominis muscles can be seen to widen throughout a pregnancy and the linea alba may even split under the strain (diastasis recti), and this may lead to poorer mechanical function. (elongation of muscle) the lumbar and thoracic curves are increased during later months of pregnancy due to enlarged uterus produces backache and waddling gait. 26

27. RESPIRATORY SYSTEM With the enlargement of the uterus there is elevation of diaphragm 4cm & breathing becomes diaphragmatic Subcostal angle (68-103)* Transverse diameter of chest expands -2cm ;chest circumference 5-7cm The mucosa of the nasopharynx becomes hyperemic and edematous. This may cause nasal stuffiness and rarely epistaxis. A state of hyperventilation occurs during pregnancy leading to increase in tidal volume and therefore respiratory volume by 40% Due to progesterone acting on repi Centre in sensitivity centre of co2 the Women feels shortness of breath 27

28. NERVOUS SYSTEM Some sorts of temperamental changes are found during pregnancy and in the puerperium. Nausea, vomiting, mental irritability and sleep disorders are probably due to some psychological background Postpartum blues, depression or psychosis may develop in a susceptible individual Water retention quite frequently causes unusual pressure on nerves, particularly those passing through canals formed of inelastic material like bone and fibrous tissue (e.g. the carpal tunnel), with resulting neuropraxia. This can be relieved by the use of lightweight splint There is an increase in threshold to pain at full term and in labor probably due to increased levels of plasma endorphins and progesterone CSF pressure remains unchanged during pregnancy but is increased during uterine contractions and bearing down. There is more dependence on sympathetic nervous system for maintenance of hemodynamics . 28

29. CARDIOVASCULAR SYSTEM 29 ANATOMICAL CHANGES: Due to elevation of the diaphragm consequent to the enlarged uterus, the heart is pushed upward and outward with slight rotation to left Muscle particularly, the left ventricles hypertrophies leading to enlargement of the heart During pregnancy the heart rate & stroke vol(amount of blood pumped by a heart with each beat) due to the increase blood volume & o2 requirement of maternal tissue and growing foetus

30. Cardiac output The cardiac output (CO) starts to increase from 5th week of pregnancy and reaches its peak 40–50% at about 30–34 weeks CO is lowest in the sitting or supine position and highest in the right or left lateral or knee chest position Cardiac output increases further during labor (+50%) and immediately following delivery (+70%) BLOOD PRESSURE- during mid-trimester, changes in blood pressure may occur causing fainting In later pregnancy hypotension may occur in 10% of women in unsupported supine position termed as SUPINE HYPOTENSION SYNDROME (POSTURAL HYPOTENSION) The pressure of gravid uterus compresses the vena cava, reduces the venous return due to which the cardiac output is by 25-30% & blood pressure may fall by 10-15% Presentation title 30

31. REGIONAL DISTRIBUTION OF BLOOD FLOW Uterine blood flow - increased from 50 mL/min in nonpregnant state to about 750 mL near term. Pulmonary blood flow (normal 6,000 mL/min) is increased by 2,500 mL/min Renal blood flow (normal 800 mL) increases by 400 mL/min at 16th week and remains at this level till term The blood flow through the skin and mucous membranes reaches a maximum of 500 mL/min by 36th week. Heat sensation, sweating or stuffy nose complained by the pregnant women can be explained by the increased blood flow Presentation title 31

32. URINARY SYSTEM / RENAL Kidney - enlarge in length 1cm Renal plasma flow 50-75% max Glomerular filtration rate (GFR) 50% throughout pregnancy Ureter –become atonic due to high progesterone & so that they are a little dilated Hypertrophy of muscle & sheath of ureter specially pelvic due to estrogen There is an increased urinary output, and small changes in tubular resorption Bladder- hypertrophy of muscle & elastic tissue of the wall Late pregnancy- bladder mucosa becomes edematous & stress incontinence due to urethral sphincter weakness, frequency of micturition reappears 6-8 weeks- frequency of micturition (subsides 12 weeks) 32 b

33. ALIMENTARY SYSTEM 33 Nausea ,vomiting -if inappropriately managed in severe cases (hyperemesis gravidarum) can lead to maternal dehydration, malnutrition and weight loss The gut musculature becomes slightly hypotonic and the motility of GIT is decreased due to high progesterone level Increased salivation (ptyalism) Taste is often altered very early in pregnancy Increased appetite & thirst – frequent small snacks Heart burn- (reflux esophagitis) relaxation of cardiac sphincter due to progesterone & relaxin Emesis gravidarum- morning sickness 50% Constipation- reduced gut motility due to progesterone Increased water & salt absorption

34. LIVER AND GALLBLADDER Although there is no histological change in the liver cells, but the functions are depressed. With the exception of raised alkaline phosphatase levels, other liver function tests are unchanged There is mild cholestasis (estrogen effect). There is marked atonicity of the gallbladder (progesterone effect) This, together with high blood cholesterol level during pregnancy, favors stone formation 34

35. Physiotherapy management in antenatal care Presentation title 35

36. Aims to promote and maintain optimal physical and emotional maternal health throughout pregnancy to recognize and treat correctly medical or obstetric complications occurring during pregnancy to detect fetal abnormalities as early as possible to prepare for and inform both parents about pregnancy, labor, the puerperium and the subsequent care of their baby the overriding goal is that pregnancy will result in a healthy mother and a healthy infant Presentation title 36

37. Offering education for parenthood To prepare women for labor, lactation & care for infants To develop awareness and control of posture during and after pregnancy To prepare for labor, delivery and post partum activities To teach the mother elements of child care, nutrition, personal hygiene, and environmental sanitation Presentation title 37

38. ROLE OF PHYSIOTHERAPY IN ANTENATAL CARE Prevention/treatment of musculoskeletal problems Promoting healthy lifestyle Postural & ergonomic advice Preparing for labor Teaching relaxation technique Optimal physical fitness Presentation title 38

39. Biomechanics on child bearing year During pregnancy a number of biomechanical & hormonal changes occur that can alter spinal curvature, balance & gait patterns The significant physical & physiological changes occur during child bearing year require musculoskeletal adaptations Lumbopelvic instability Postural deviations Modified lower extremity weight bearing & challenges with balance & gait 39

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41. FUNCTIONS OF LOCAL MUSCLE SYSTEM- local muscle play an imp role in stabilizing joints of pelvic girdle & vertebral column Transverse abdominis with multifidus including their fascia creates a corset of support for the lumbopelvic region According to Richardson & coworkers co-contractions of transverse abdominis & multifidus increases the stiffness of SI joint POSTURAL DEVIATIONS- 41

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43. MODIFIED LOWER EXTREMITY WEIGHT BEARING- static & dynamic changes of lower limb Increased weight & anterior displacement of COG compensated by biomechanical changes that results in posterior displacement of trunk center of mass The biomechanical changes related to realignment of spinal curvature include increase in sagittal pelvic tilt CHALLENGES WITH BALANCE- balance & control of movement starts affected mainly during 3 rd trimester Static postural control decreases in situation of reduced base of support Decrease in postural stability of pregnant women increases the risk of fall when compared to normal women 43

44. 44 GAIT

45. 45 Antenatal care team

46. Goals & treatment during antenatal period To educate the mother regarding changes of pregnancy To increase & maintain CVS fitness To maintain abdominal function & prevent to diastasis recti or correct if it exist To train the mother for improving control strength of pelvic floor muscle by educating awareness regarding it To prevent msk injury by teaching specific exercises & preventive measures To encourage resistance training to muscle strength & endurance To educate correct body mechanics & diff positions To improve the postural deviation & maintain it by increasing the awareness of posture control To prepare the mother for labor & postnatal exercise & it imps 46

47. Prevention/treatment of musculoskeletal problems posture Pregnancy back care- Postural, hormonal and weight changes, ergonomic education involving sitting and working positions, bending, lifting and householdactivities should all be considered Nerve compression syndrome- carpal tunnel syndrome the following may all give relief: • ice packs (a small bag of frozen peas wrapped in a wet handkerchief could be used at home) • resting with the hands in elevation • wrist and hand exercises • ultrasound • splinting limiting wrist flexion 47

48. SI joint Pregnancy could have many possible effects on the sacroiliac joint; for example joint laxity may allow repetitive new movement at one, or both, joints causing pain, if combined with sufficient activity This usually disappears in a few months, but indicates transient stress. A support belt may provide comfort for some women various self help maneuver can be taught to relive SPD 48

49. SCIATICA- h reduced activity levels, within pain-free range. Advice from the physiotherapist on positioning, back care, posture correction, activities of daily living and pain relief COCCYDYNIA - this condition is rare antenatally unless caused by a fall. cushion when sitting, taking pressure through ischial tuberosities and thighs • ice packs, heat, and TENS. 49

50. SYMPHYSIS PUBIS DYSFUNCTION (SPD) Difficult activities will include: • getting in or out of the car or bath • changing position in bed, particularly ‘turning over’ • dressing • walking, which is severely restricted or impossible. The possible link with sacroiliac dysfunction Rest and reduction of non-essential ‘chores’ keeping the legs adducted and avoiding single leg standing Pelvic support may reduce pain levels Gentle isometric contraction of hip adductors, in sitting – small cushion between the knees (whilst maintaining pelvic stability), may relieve adductor tension. 50

51. MUSCLE CRAMP- • calf stretches to relieve muscle spasm • knee extension with dorsiflexion will release calf cramp • massage – deep kneading • vigorous foot exercises, to prevent the bruise-like pain which often follows a cramp ‘event’ • a pre-bedtime brisk walk, vigorous foot exercises, and a warm bath may be prophylactic Ankle dorsiflexion and plantar flexion, and foot circling carried out for 30 seconds regularly, should be suggested; women should be advised not to cross the knees when sitting 51

52. General Guidelines for Exercise Instruction Physical examination is must prior to engaging a pt. in an Exercise Programmed. Each person should be individually evaluated for preexisting Musculo -skeletal problems, posture & fitness level Exercise regularly, at least thrice a week Avoid ballistic movements & rapid change in directions. include warm-up & cool down session avoid an anaerobic pace. strenuous activities should be avoided. avoid prolong period of standing specially in third trimester. adequate caloric intake, increase to 300 kcal./day for ex. during preg . & 500 kcal./day for ex. during lactation. low resistance & high repetitions ex. is recommended, avoid valsalva maneuvers. stop ex. if any unusual symptoms occur. 52

53. contraindications 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 • Chronic hypertension, active thyroid, cardiac, vascular or pulmonary disease • Diabetes type 1 uncontrolled Relative- • Women unused to high levels of exertion • Blood disorders such as sickle cell disease and anemia • Thyroid disease • Diabetes – however, a carefully supervised programme of gentle exercising may actually benefit some patients • Extreme obesity or underweight • Breech presentation in third trimester

54. Sequence of exercise General rhythmic activities to warm-up. Gentle selective stretching Aerobic activities for CVS conditioning UL &LL strengthening ex. Abdominal ex Pelvic floor ex. Relaxation /cool down activities Educational information [if any] & postpartum ex. Education. Presentation title 54

55. Exercise technique Postural exercise. Abdominal exercise Stabilization exercise Pelvic motion training & strengthening. Modified UL & LL strengthening. Perineum &adductor flexibility. Relaxation &breathing exercise Presentation title 55

56. Postural exercise Includes: Strengthening exercise Stretching exercise STRETCHING EXERCISES – Upper neck extensors & scalenes Scapular protractors, shoulder internal rotators & levetor scapulae Low back extensors Hip adductors [caution do not over stretch in women with pelvic instability] Ankle planter flexor Presentation title 56

57. Presentation title 57 Scalene self stretching Scalene stretch by therapist

58. Low back extensors stretching Presentation title 58

59. Antenatal adaptation & exercises Hip adductor stretching/ exercise – 59

60. Strengthening Exercise Upper neck flexors lower neck &upper thoracic extensors Scapular retractors &depressor Shoulder external rotators Hip & knee extensors Ankle dorsi flexors 60

61. Presentation title 61

62. Pelvic tilting exercise/ pelvic floor streghening 62

63. Exercises Abdominal muscles- plays a crucial role in trunk stability, maintaining good posture & during 2 nd stage of labor for expulsion of baby 1-leg sliding exercises/ B/l leg slide 2-quadruped pelvic tilt exercises 3-trunk curls/ diagonal curls Corrective exercise for diastasis recti- head lift Head lift with pelvic tilt Spinal stability- possible factors affecting spinal stability Hormonal laxity of ligaments Lengthening of abdominal muscle 63

64. Antenatal ergonomics- ergonomic during pregnancy involves educating women regarding body mechanics positioning & energy conservation method Principles of ergo should be applied during Activities of daily living Instrumental activities of daily living Work place Sitting Lying standing 64

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66. Presentation title 66

67. RELAXATION & BREATHING EX Relaxation & Breathing exercise. Are given with the following objectives To obtain rest during preg . To help the mother regain normal health afterwards by preventing unnecessary fatigue Most common method of relaxation is MITCHELLS METHOD Presentation title 67

68. 4. Patient position in kneeling forward on to one’s arm on a cushion placed on a seat of a chair. 5. In this position wt. of the fetus lies on the anterior abdominal wall & pelvic floor relaxes 6. In this position pt. take deep diaphragmatic breathing. 7. Other methods of relaxation are a. mental imagery. b. muscle setting – “ Jacobson’s Method ” Presentation title 68

69. Touch relaxation It is used by involving the partner as the touch of partner seems to provide relaxation Touch relaxation is responding to womens labour partners touch by relaxing or releasing tense muscle This can be done with gentle pressure or stroking Women can start by tensing and releasing to her labour partners touch Presentation title 69

70. Promoting healthy lifestyle Prenatal advice & education regarding Diet Personal hygiene Use of drugs Alcohol & smoking 70

71. references 1) Physiotherapy in Obstetrics and Gynecology - Jill Mantle 2) DC Dutta’s OBSTETRICS including Perinatology and Contraception 3) physiotherapy in general medical & surgical condition- megha seth Presentation title 71

72. Thank you