Presentor:- SAMEEKSHA SIDHPURIA

Moderator:- Mrs. ANUPAMA

 Antenatal period is the period during pregnancy

 Antenatal care of the woman during pregnancy

 Primary aim is to achieve at the end of the pregnancy,

a healthy mother and a healthy baby

 Starts immediately from the time of conception

 During pregnancy, the pregnant mother undergoes significant
anatomical and physiological changes in order to nurture and
accommodate the developing foetus.

 Plasma volume increases progressively throughout normal

pregnancy.

 Most of this 50% increase occurs by 34 weeks’ gestation and is

proportional to the birth weight of the baby.

 The platelet count tends to fall progressively during normal

pregnancy, but it remains within normal limits. In a proportion
of women (5–10%), the count will reach levels of 100–150 ×
109 cells/l by term.
 Pregnancy causes a two- to three-fold increase in the
requirement for iron.

 There is a 10- to 20-fold increase in folate requirements and

a two-fold increase in the requirement for vitamin B12.

 The concentrations of certain clotting factors, particularly

VIII, IX and X, are increased. Fibrinogen levels rise
significantly by up to 50% and fibrinolytic activity is
decreased.

 Venous stasis in the lower limbs is associated with

venodilation and decreased flow.
CARDIAC CHANGES:-
 By eight weeks’ gestation, the cardiac output has already increased
by 20%.

 The maximum cardiac output is found at about 20–28 weeks’

gestation. There is a minimal fall at term

 An increase in stroke volume is seen in pregnancy, although stroke

volume declines towards term

 The heart is physiologically dilated and myocardial contractility is

increased.

 The increase in maternal heart rate (10–20 bpm) is maintained.

 Blood pressure decreases in the first and second trimesters but

increases to non-pregnant levels in the third trimester
CHANGES IN RENAL VASCULATURE:-
 The primary adaptive mechanism in pregnancy is a marked fall in
systemic vascular resistance (SVR) occurring by week six of
gestation.

 The 40% fall in SVR also affects the renal vasculature.

 Despite a major increase in plasma volume during pregnancy, the

massive decrease in SVR creates a state of arterial under-filling
because 85% of the volume resides in the venous circulation.

 This arterial under-filling state is unique to pregnancy.

 Relaxinan important role in the regulation of haemodynamic and

water metabolism during pregnancy. It rise to a peak at the end of
the first trimester and fall to an intermediate value throughout the
second and third trimester.
RESPIRATORY CHANGES:-
 There is a significant increase in oxygen demand during
normal pregnancy.

 A mild fully compensated respiratory alkalosis is therefore

normal in pregnancy.

 Diaphragmatic elevation in late pregnancy results in

decreased functional residual capacity.

 Inspiratory reserve volume is reduced early in pregnancy but

increases in the third trimester.

 Pregnancy may also be accompanied by breathlessness

without hypoxia and is most common in the third trimester
but may start at any time during gestation.
ENDOCRINE CHANGES:-
 There is an increase in the production of thyroxine-
binding globulin (TBG) by the liver.

 Levels of free T3 and T4 decrease slightly in the second and

third trimesters of pregnancy and the normal ranges are
reduced.

 Serum concentrations of TSH are decreased slightly in the

first trimester in response to the thyrotropic effects of
increased levels of human chorionic gonadotropin.

 During pregnancy there is also an increase in serum levels

of deoxycorticosterone, corticosteroid-binding globulin
(CBG), adrenocorticotropic hormone (ACTH), cortisol and
free cortisol.
 The pituitary gland enlarges in pregnancy. Serum prolactin
levels increase in the first trimester and are 10 times higher
at term.

 Maternal insulin resistance begins in the second trimester

and peaks in the third trimester.

 This is the result of increasing secretion of diabetogenic

hormones such as human placental lactogen, growth
hormone, progesterone, cortisol and prolactin.

 There is an increase in total serum cholesterol and

triglyceride levels in pregnancy.

 During pregnancy, protein catabolism is decreased as fat

stores are used to provide for energy metabolism.
 There is a decrease in total serum calcium concentration during
pregnancy.

 Increased calcium absorption is associated with an increase in

calcium excretion in the urine and these changes begin from 12
weeks.

SKELETAL AND BONE DENSITY CHANGES:-

 Bone turnover is low in the first trimester and increases in the
third trimester when foetal calcium needs are increased.

 There is exaggerated lordosis of the lower back, forward flexion of

the neck and downward movement of the shoulders.

 Joint laxity in the anterior and longitudinal ligaments of the

lumbar spine.

 Widening and increased mobility of the sacroiliac joints and

pubic symphysis.
DEEP VEIN THROMBOSIS:-
 Pregnancy and the puerperium are well-established risk factors
for venous thromboembolism (VTE), a disease that includes
pulmonary embolism (PE) and deep venous thrombosis (DVT).

 Pregnancy is a prothrombotic state; it has all components of

Virchow’s triad: venous stasis, endothelial damage and
hypercoagulability.

 During normal pregnancy, a hypercoagulable state is initiated.

This is the most important risk factor contributing to
thrombosis during pregnancy.

 Mechanical prophylaxis with pneumatic compression stockings

is effective post-cesarean thromboprophylaxis.
AMNIOTIC FLUID EMBOLISM:-
 Amniotic fluid embolism (AFE) is one of the most catastrophic
complications of pregnancy in which it is postulated that amniotic
fluid, fetal cells, hair, or other debris enters the maternal pulmonary
circulation, causing cardiovascular collapse.

 Amniotic fluid enters the circulatory system of the mother via tears in
the placental membrane or uterine vein rupture.

 Fetal cells are found in the maternal circulation, when the fetal cells
and amniotic fluid enters the bloodstream, reactions occur that cause
severe changes in the mechanisms that affect blood clotting.

 Disseminated intravascular coagulation occurs and results in serious

bleeding.

 Positive end expiratory pressure (PEEP) is often needed to improve

oxygenation.
GESTATIONAL DIABETES:-
 Gestational diabetes mellitus (GDM) occurs in about 5% of
pregnancies.

 In normal pregnancy, maternal tissues become progressively

insensitive to insulin.

 In normal pregnancy, insulin-mediated whole-body glucose

disposal decreases by 50% and in order to maintain a
euglycemic state, the woman must increase her insulin
secretion by 200%-250%.

 GDM develops when the pregnant woman is not able to

produce an adequate insulin response to compensate for this
normal insulin resistance.
 A program of either aerobic exercise or resistance training
appears equally effective, as long as it is performed at least at
a moderate intensity or greater, for 20 to 30 minutes, three to
four times a week.

 The exercise program should suit an individual's preference

for the adherence to exercise.
 Brisk walking, yoga, resistance exercise with bands are
appeared to be associated with higher levels of adherence.

 Exercises given should include large muscle group and less

pressure on joints like walking, static cycling, swimming.
DIASTASIS RECTI ABDOMINIS:-
 Muscles in your abdomen separate during pregnancy,
leaving a gap that allows your belly to pooch .

 The diastasis may simply extend a few centimetres above

and below the umbilicus and only be 2–3 cm wide, it may
only appear below the umbilicus, or it may involve the
major part of the linea alba, extending from just below the
xiphisternum to just above the symphysis pubis and can be
as much as 20 cm in width.

 Abdominal retraction – transversus abdominis; repeat

frequently and integrate into all the activities of daily
living.
 Pelvic tilting – a dynamic progression, must be performed with
full engagement of the abdominal muscles

 Ck.ly. abdominal retraction – pelvic tilt then head and shoulder

raise; progress from pillow support to no support as muscle
strength improves; if ‘doming’ occurs on the head raise the
mother can apply external counter pressure, and pulling
medially, using crossed arms; at the point of doming ‘hold’,
raise no further, and lower slowly.

PREECLAMPSIA:-
 Pre-eclampsia is a multisystemic disease characterized by the
development of hypertension after 20 weeks of gestation, with
the presence of proteinuria or, in its absence.

 Alpha-methyldopa is an α-adrenergic receptor agonist which is

also an effective and safe drug in pregnancy.
CARPAL TUNNEL SYNDROME:-
 Carpal tunnel syndrome (CTS) is a frequent complication
of pregnancy.

 CTS commonly presents during the third trimester, but

can occur during the first trimester.

 In pregnancy, the likely causes are hormonal changes and

edema. Gestational diabetes can also play a role due to
generalized slowing of nerve conduction.

 Exercises, massage, splints, activity modification, steroid

injections are effective in carpal tunnel syndrome.
 To improve the physical and mental health of mother and
children.

 To ensure that the mother and her baby are in the best
possible health.

 To detect early and treat properly complications .

 Offering education for parenthood

 To prepare the woman for labor, lactation and care of her

infant
 To develop awareness and control of posture during after
pregnancy.

 To develop strength for demands of infant care , as well as

increase weight bearing and circulatory compromises.

 To prepare for labour, delivery and post partum activities.

 Prevention/Treatment of musculoskeletal problems

 Promoting healthy lifestyles

 Postural and Ergonomic advice

 Preparing for labour

 Teaching relaxation techniques

 BACK PAIN CARE:-
 Postural, hormonal and weight changes, ergonomic
education.

 Sittingand working positions, bending, lifting and

household activities should all be considered.

 Activities that reproduce the symptoms should be avoided

 Proper postural education

 For relief of pain: Gentle massage, Hot pack

 SYMPHYSIS PUBIS DYSFUNCTION (SPD):-
 It is a common occurrence usually beginning in the
antenatal period.

 Many women may experience the signs and symptoms of

SPD but are unaware of its management.

 Rest and reduction of non essential chores

 Keeping the leg adducted

 Avoiding single-leg stance.

 Avoid long strides when walking, walking on uneven
surfaces and excessive use of step

 Gentle isometrics of hip adductors, pelvic support

belts, ice packs.

 PELVIC FLOOR AND PELVIC TILTING

EXERCISES:-
 Pelvic floor muscle (PFM) contractions practice during
pregnancy experienced less urinary incontinence
postpartum.
 Pelvic tilting can be demonstrated while sitting on the
edge of a chair.

 It is helpful for maintaining abdominal muscle strength

correcting posture and easing backache

 It can be done in a standing position as well as crook lying,

side lying and prone kneeling.
 EXERCISE FOR CIRCULATION AND CRAMP:-
 Pregnancy can affect leg circulation.

 Ankle dorsiflexion and plantar flexion, and foot

circling carried out for 30 seconds regularly.

 The technique of stretching in bed with the foot

dorsiflexed and not plantar flexed for preventing and
easing calf cramp.

 Avoiding long periods of sitting, a pre-bedtime walk,

calf stretches, a warm bath, and foot and ankle
exercises in bed before going to sleep.
 VARICOSE VEINS :-
 Avoid standing or sitting for long periods, with the
legs dependent

 Frequent and vigorous ankle dorsiflexion and plantar

flexion may be performed

 Brisk walking

 Elevate feet when sitting or lying.

 Elastic stockings may be worn

 Work, adaptations and alterations in lifestyle.

 Sport and exercise should all be discussed.

 Education regarding diet and personal hygiene.

 Advice on coping strategies and relaxation techniques.

 Air travel- can fly safely up to 36 weeks.

 LYING SUPINE- place a towel roll under the waist and a
pillow under the knees.

 SIDE LYING- place a pillow underthe top thigh and knee

 SITTING – sit with hip and knee with at right angle, back
should be support, a pillow can be placed ,a low stool can
be used for foot support.

 STANDING / WALKING – walking is more preferred than

standing still and while standing try to distribute weight
equally to avoid pelvic rotations.
 Birthing options that are available to the woman:

1. Water births:- The facilities for water birth can be hired for
use at home or in hospital. Potential benefits of immersion
in warm water include relaxation, pain relief and less
perineal trauma, with adverse consequences including
infection, water inhalation by the baby and decreased
mobility.

2. Home based:-Its a mainstream maternity care and offered

as a realistic and positive option. This can be promoted by
selecting low-risk women and providing adequate
infrastructure and support.
 Hospital based delivery:- Hospital birth is still
perceived as a safer option than home delivery even
though there is no evidence that this so.

Labour positions can be divided into two stages:

 Ist stage
 IInd stage
Ist stage:-
 IInd stage:-
 The Mitchell Method of physiological relaxation:-
 This method utilises knowledge of the typical
stress/tension posture and the reciprocal relaxation of
muscle – whereby one group relaxes as the opposing
group contracts.

 Thus, stress-induced tension in the muscles that work to

create the typical posture may be released by voluntary
contraction of the opposing muscle groups.
 Contrast method:-
 Alternately contracting and relaxing muscle groups
progressively round the body to develop recognition of
the difference between tension and relaxation.

 Visualisation and imagery:-

 This method encourages a person to think in pictures as
opposed to words, using all of the senses, this can be used
to induce a feeling of calm and enhance the relaxation.

 Touch and massage:-

 Soothing stroking, effleurage or kneading to appropriate
areas may be used for good effect.
 Breathing:-
 Expiration frequently accompanies the spontaneous
release of tension.

 The outward breath is the relaxation phase of the

respiratory cycle.

 The very rhythm of slow, easy breathing and its

predictability is reassuring and calming.
 Reduces common complaints of pregnancy such as
fatigue, varicosities and swelling of extremities.

 Reduces insomnia, stress, anxiety and depression.

 Weight-bearing exercises reduce the length of labour and

prepares the woman for physical demands of labour.

 Improves core stability and pelvic floor muscle strength.

 Improves glycaemic control.

 Protective effect on coronary heart disease, osteoporosis
and hypertension.

 Improves posture, strengthens muscles, and maintains

muscle length and flexibility.

 Decreased birth weight and less maternal weight gain.

 Improves the feeling of wellbeing.

 Helps in achieving the pre-pregnancy fitness levels

Maternal risks Foetal risks
 Musculoskeletal trauma  Foetal distress
 Supine hypotension  Foetal growth and
syndrome development
 Abnormal rise in the
 Foetal malformation
temperature
 Preterm labour
 Hypoglycaemia
 Fall
 Increased minute
ventilation
 Absolute contraindications:-
1. Cardiovascular disease
2. Acute infection
3. A history of recurrent spontaneous abortion
4. Preterm labour in current or previous pregnancy
5. Multiple pregnancy
6. Vaginal bleeding or ruptured membranes
7. Incompentent cervix
8. Pregnancy-induced hypertension
9. Suspected IUGR or foetal distress
10. Thrombophlebitis or pulmonary embolism
11. Chronic hypertension, active thyroid, cardiac, vascular
or pulmonary disease
12. Diabetes type 1 uncontrolled

 Relative contraindications:-
1. Women unused to high levels of exertion
2. Blood disorders such as sickle cell disease and anaemia
3. Thyroid disease
4. Diabetes – however, a carefully supervised programme
of gentle exercising may actually benefit some patients
5. Extreme obesity or underweight
6. Breech presentation in third trimester
 Physical examination is a must.

 Jerky, bouncing, ballistic movements and activities should

be avoided.

 Regular mild to moderate exercise sessions, at least three

times a week, are safer than intermittent bursts of activity.

 A careful ‘warm-up’ should precede vigorous exercise,

which must always be followed by a ‘cool-down’ or gradual
decline in activity.
 Flexibility and mobility follow the warm-up section,
avoiding ballistic stretching.

 Strenuous exercise must be avoided in hot, humid

weather, or when the pregnant woman is pyrexial.

 The maternal heart rate should not exceed 140 b.p.m. and
vigorous exercise should not continue for longer than 15
minutes.

 Fluid must be taken before, during and after exertion to

avoid dehydration.
 An aerobic component should be in the mode best suited
to the individual, using large muscle groups and being
rhythmical in nature, i.e. brisk walking, cycling, aerobic
dance – all avoiding high impact.

 Avoid supine positions after the first trimester.

 Avoid standing motionless for long periods of time.

 Exercise should be decided by the limitations imposed by

pregnancy.
 Excessive shortness of breath.
 Chest pain or palpitations.
 Painful uterine contraction.
 Presyncope or dizziness.
 Leakage of amniotic fluid.
 Vaginal bleeding.
 Excessive fatigue.
 Abdominal pain.
 Reduced fetal movement
 Swimming is possibly the perfect pregnancy exercise.

 Even non-swimmers can benefit from a programme of

exercise and relaxation in a pool.

 Exercise in water offers several physiological advantages to

the pregnant woman.

 Women should ‘warm up’ prior to their main swim, and

‘cool down’ following it.
 Asession of relaxation aided by the buoyancy of the
water can be most therapeutic, particularly in the final
trimester.

 For non-swimmers a programme of suitable exercises

can be suggested, including activities for the legs, arms
and trunk, as well as ‘water walking’ and relaxation
 Pilates is currently enjoying vast popularity.

 The Pilates method encompasses an holistic approach to

exercise, developing body awareness and general fitness.

 It starts from a central core of stability concentrating on

abdominal and pelvic floor muscles.

 Hence, this gentle form of exercise can be employed by the

pregnant and postnatal exercising woman to help maintain
and retrain these muscles in both stages.

 Help focusing on posture and coordination.

 It is a breathing technique based on the idea that controlled
breathing can enhance relaxation and decrease the perception of
pain.

 Lamaze teach expectant mothers many ways to work with the

labor process to
1. Reduce the pain associated with childbirth
2. Promote normal birth including the first moments after birth.

 Techniques include allowing labour to begin on its own,

movement and positions, massage, aromatherapy, hot and cold
packs, breathing techniques, the use of a "birth ball" (yoga or
exercise ball), spontaneous pushing, upright positions for labour
and birth, breastfeeding techniques, and keeping mother and
baby together after childbirth.
 The core beliefs of Lamaze is summarized with their Six
Healthy Birth Practices. These six practices are as follows:
1. Healthy Birth Practice 1: Let labor begin on its own
2. Healthy Birth Practice 2: Walk, move around and change
positions throughout labor
3. Healthy Birth Practice 3: Bring a loved one for
continuous support
4. Healthy Birth Practice 4: Avoid interventions that are
not medically necessary
5. Healthy Birth Practice 5: Avoid giving birth on your back
and follow your body's urges to push
6. Healthy Birth Practice 6: Keep mother and baby together
- It's best for mother, baby and breastfeeding
From 4th to 6 the month of pregnancy:
This includes:
 Instruction about the anatomy and physiology of female pelvis,
pelvic joints and muscles especially pelvic floor.

 Instruction and training for:

 Breathing exercises (deep breathing).

 Postural correction to avoid postural problems.

 Relaxation in any comfortable position, room must be calm,

quite, warm, light music assist physical and mental relaxation.
 From the end of 6th month till the end of 8th month of
pregnancy:
 Deep breathing exercise.

 Relaxation training.

 Pelvic rocking (upward ,backward).

 Leg exercises to improve circulation and maintain tone of the

muscles which support foot arches, also to prevent edema and
varicose veins.

 Pelvic floor contraction and relaxation to get pelvic floor muscles

strong and elastic.

 Abdominal exercises.

 Arm exercise for preparation of lactation and to allow free flow of

milk
During the last month of pregnancy:
 Instruction about onset of labour.

 Stages of labour.

 Training for pelvic floor, relaxation (diversion drill) and

walking in open fresh air.

 Teaching mother panting breathing.

 Explanation for the TENS and its effect in relieving labour

pain.
 Effects of a stability ball exercise programme on low
back pain and daily life interference during
pregnancy.

 Writer: Yan CF, Hung YC, Gau ML, Lin KC

 RESULTS:This study shows that the women who

participated in the antenatal stability ball exercise
proramme showed reduced low back pain and interference
in daily life at 36 weeks of gestation.
Effects of exercise on diastasis of the rectus abdominis
muscle in the antenatal and postnatal periods: a
systematic review.

 Writer: Benjamin DR, van de Water AT, Peiris CL.

 RESULTS: This study included total 8 studies which

included total 336 women of antenatal and postnatal
period. All these studies included intervention exercise
targeting abdominal/ core strengthening. The evidences
showed that exercise during antenatal and postnatal
period reduces DRAM width.
 The efficacy of moderate-to-vigorous
resistance exercise during pregnancy: a randomized
controlled trial.
 Writers: Petrov Fieril K, Glantz A, Fagevik Olsen M.

 RESULTS: In this study there was a significant difference

between the groups. Women who underwent
resistance exercise during pregnancy delivered significantly
heavier newborn compared to control group. Both groups
showed normal health-related quality of life, blood pressure,
and perinatal data.
 Developing strategies to be added to the protocol for
antenatal care: An exercise and birth preparation
program

 Writers: Maria Amélia Miquelutti, José Guilherme

Cecatti, and Maria Yolanda Makuch

 RESULTS: The program was an innovative type of

intervention that systematized birth preparation activities
that were organized to encompass aspects related both to
pregnancy and to labor and that included physical,
educational and home-based activities.
 Combination of a structured aerobic and resistance
exercise improves glycaemic control in pregnant
women diagnosed with gestational diabetes
mellitus. A randomised controlled trial.

 Writers: Sklempe Kokic I, Ivanisevic M, Biolo G, Simunic

B, Kokic T, Pisot R.

 FINDINGS: This study showed that the group who

received structured aerobic and resistance exercise
showed lower post prandial glucose level at the end of
pregnancy but there was no difference in between the
groups in the level of fasting glucose at the end of
pregnancy.
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