ANTENTAL PERIOD

DR. AMBER TARIQ

MS-NMPT (RIU)
DPT (UOL)
INTRODUCTION

 Team consists of GP, obstetrician, midwives, ultra-sonographers, phlebotomists,

women’s health physiotherapist, dentist, dietitians, health visitors & pediatricians.
 All should be aware of special needs of a pregnant woman
 Every year there are 600,000 maternal deaths due to hemorrhage, sepsis,
hypertensive diseases, prolonged labour and complications of abortion
 Contraction of some diseases such as TB, malaria & HIV may be aggravated by
pregnancy and poor nutrition and also lack of access to clean water may
increase complications
AIMS OF ANTENATAL CARE

 To promote & maintain optimal physical & emotional maternal health throughout
pregnancy
 To recognize & treat correctly medical or obstetric complications
 To detect fetal abnormalities as early as possible
 To prepare for and inform both parents about pregnancy, labour, the
puerperium and the subsequent care of their baby
 Healthy mother and healthy infant
ANTENATAL CARE OPTIONS

 Informed choice
 Choose the place of delivery and type of care
 WATER BIRTHS :
 Increasingly popular choice by women
 Pools can be hired for use in home or hospital
 Benefits of immersion in warm water include relaxation, pain relief, and less
perineal trauma with adverse consequences including infection, water inhalation
by the baby & decreased mobility
 HOME BIRTHS :
 No legal permission required in UK
 Realistic & positive option
 Selecting low risk women
 Hospital birth still perceived as safer option than home delivery
TEAM/ CASELOAD/ MIDWIFERY/ DOMINO (DOMICILIARY
MIDWIFE IN & OUT)

 Midwifery led care should be promoted for women experiencing normal

pregnancy & birth
 Cared for throughout the pregnancy, delivery and postpartum period by same
community based team of midwives (ideally 6 per team) thus providing a
continuity of care lacking in hospital based obstetrics
 Call midwife when she considers labour to have begun
 In domiciliary model midwife accompanies her to hospital, delivers the baby &
brings the mother home again 6-7 hours after birth
GP/MIDWIFERY SHARED CARE

 GPs who have undergone an appropriate training may offer a service with
midwives based at the local surgery
 Delivery may be at the home or in hospital
MIDWIFERY-LED UNITS

 Stand alone units

 Provide maternity services fulfilling individual needs
 Shared care (doctor & midwife)
 Women using both services expressed satisfaction with care but the midwifery
led model scored higher in all aspects from antenatal to postnatal period
GENERAL PRACTITIONER UNITS

 Independent
 In a hospital or may stand alone as a consultant unit
 Uncommon
CONSULTANT CARE

 Women who are at risk of thromboembolism, thrombosis, gestational diabetes,

HTN diseases or with a poor obstetric history based under care of consultant
obstetrician having hospital based visits on a more frequent basis
 Shared with GP or midwives
CONSULTANT OBSTETRIC UNITS

 Larger units based in district or regional centres

 Access for up to date diagnostic procedures and be able to call upon staff if
required
 Pediatric/neonatal intensive care unit attached
PRIVATE OBSTETRIC CARE/INDEPENDENT
MIDWIVES

 Private hospitals
 Independent midwife who provides care at home or in a private unit
THE ANTENATAL CARE

 BOOKING VISIT :
 Reviewed by midwife unless risks are identified
 For developing antenatal care plan to meet her individual needs, details of the
woman’s social, family, medical, psychological and past obstetric history are
taken
 BMI assessed before booking visit
 BMI more than 30 indicates obesity; a risk factor for thromboembolism,
gestational diabetes and pre-eclampsia
 Low BMI indicates an eating disorder
 1st visit provides advice and education regarding lifestyle for example diet,
exercise, alcohol & smoking etc
 Correct use of car seatbelts
 Routine blood tests
 Any history of violence (physical, psychological, sexual & emotional abuse)
 SUBSEQUENT VISITS :
 Anomaly scan at 20th week
 Monthly visits from 24-26 weeks
 Fortnightly visits from 32-34 weeks to 40 weeks
 Weekly visits until delivery are usual
 Blood pressure, urine, presence of edema, weight, fundal height and lie of the
fetus, fetal movements & fetal heart rate should be always recorded
FUNDAL HEIGHT & THE LIE OF THE FETUS

 Level of fundus of uterus is noted & compared with gestational stage

 Intra-uterine growth restriction if fundal height is lower than expected
 Multiple pregnancy or polyhydroamnios can increase fundal height
FETAL MOVEMENTS

 Noticed by mother b/w 16 & 22 weeks gestation

 Woman is unaware of movements because uterus is insensitive to touch
 Mildest expression of maternal anxiety
 Kick charts
 If fetus moves less than 10 times in a day, then pregnancy should be assessed
more carefully
 Fetal heart rate assessed using a CTG, ultrasound scanning at 16th week using a
sonic aid monitor (normal rate vary b/w 110 & 150 bpm)
 OTHER TESTS

 BLOOD TESTS : To detect Hb levels, presence of sexually transmitted infections, blood

group, blood sugars, rubella antibodies and haemoglobinopathies
 HAEMOGLOBIN LEVELS : Decrease in normal Hb because of increased blood plasma
volume. Anemia may occur. Iron supplements prescribed.
 SEXUALLY TRANSMITTED INFECTION : Information on HIV and its transmission from
mother to child. HIV testing should be recommended as part of routine antenatal
care. Transmission to child can be reduced by medications, delivery by C-section or
avoiding breast feeding.
 BLOOD GROUP : If a rhesus negative status is identified, prophylactic anti-D injections
administered at 28-34 weeks of gestation. Anti-D administered to prevent mother
from developing antibodies to the rhesus factor. These antibodies can cause fetal
anemia.
 HAEMOGLOBINOPATHIES : Tests for sickle cell disease & thalassemia carried out if one
of the parent is of northern-European descent
ANTENATAL SCREENING

 MATERNAL SERUM SCREENING : Alpha feto-protein level, Other hormones assessed too.
Depending on how many markers are used, this is termed as double, triple or quadruple
test. High levels of AFP indicate neural tube defects such as spina-bifida or anencephaly.
 ULTRASOUND SCANNING : Measures the nuchal translucency, an area of subcutaneous
fluid at the nape of fetal neck. Increased thickness indicates down’s syndrome or any
other chromosomal and structural abnormality. Between 11 & 14 weeks.
CHRONIC VILLUS SAMPLING

 Trans abdominally carried out

 Fragments of placental chorionic villi removed under U/S and then inspected of
genetic fetal abnormalities such as down’s syndrome
 Between 11 & 13 weeks
AMNIOCENTESIS

 Small amount of amniotic fluid withdrawn trans abdominally

 Assistance through U/S monitoring
 Fetal sex determined
 Important when there is familial history of sex linked disorders such as hemophilia
or DMD
ACCEPTABILITY OF ANTENATAL TESTING

 Most parents enjoy seeing their baby during a scan

 Respect for a woman’s wishes must be considered if she declines screening
 If a woman is not prepared to terminate her pregnancy there is no point in
suggesting CVS, amniocentesis or any other test that shows abnormalities
PRECONCEPTUAL CARE

 Diet, alcohol consumption, smoking habits, exercise routines, occupation & drug
intake
 Woman should be fit & comfortable
 If spina bifida or anencephaly have previously occurred, folic acid
recommended
 Genetic counselling to parents with a family history of hereditary diseases
 Renal disorders should be treated & stabilized before conception
 Preconception advice to women with disabilities
 Teach principles of body care
 Pelvic floor & abdominal muscle education or re-education using exercise and
biofeedback
INFERTILITY/SUBFERTILITY

 Male & female factors or combination of the two

 Hormonal treatment for women who are unable to ovulate such as in polycystic
ovaries (PCO)
 Clomifene commonly used alone or in combination with gonadotrophins
(increased risk of multiple pregnancies and ovarian hyper-stimulation syndrome)
 Woman with tubal disease; in vitro fertilization (egg is fertilized before it transfers to
uterus) with success affected by duration of infertility, woman’s age and previous
pregnancies
 Intra-cytoplasmic sperm injection (sperm is directly injected into cytoplasm of the
egg). Used when sperm count is low.
EARLY PREGNANCY

 Entire female organism adapts to preserve & nourish the fetus growing within the
uterus and with the anabolic metabolism comes a mental tranquility and
somnolent beauty
 Every system changes within 9 months
 Early back care education, understanding of stress & its control, importance of
physical health
 Activities for pelvic floor & abdominal muscles, legs and arms must be taught
 Do not overburden women
ANTENTAL CLASSES

 Held in hospitals but increasingly held in community

 Place which is convenient and accessible to the patients
 Appropriate time should be given
 Preparation of parenthood
 Fulfill parent’s expressed needs
 Self learning approaches
 Couples should be helped to check and increase their knowledge of
physiological changes of pregnancy, labour and puerperium
 How to cope with these physiological changes and their associated discomforts
 Encouraged to consider the change in lifestyle that parenthood brings and
emotional maturity essential to manage successfully their additionally
responsibilities
 Encouraged to talk and air any fears, ask questions to obtain satisfactory answers
EARLY BIRD CLASS

 Women encouraged to bring their partners along or some other person of their
choice
 Physiotherapists, midwives, dietitians, health visitors, dentists and possibly doctors
 Quality of presentation

 Practical participation by all members

PREGNANCY BACK CARE

 Postural, hormonal and weight changes, ergonomic education involving sitting &
working positions, bending, lifting and household activities should all be
considered
 Instructions in using seat belts
SYMPHYSIS PUBIS DYSFUNCTION

 Many woman experience this during pregnancy but are unaware of its
management
 Teach women in antenatal class for help during pregnancy & labour
PELVIC FLOOR & PELVIC TILTING EXERCISES

 Teach PFM contractions

 Decreases UI postpartum
 Pelvic tilting demonstrated while sitting on the edge of chair
 Maintain abdominal muscle strength
 Corrects posture
 Ease back ache
 May be done in a standing position as well as crook lying, side lying & prone
kneeling
EXERCISES FOR CIRCULATION & CRAMP

 Frequent foot & ankle exercises

 Ankle DF & PF
 Foot circling carried out for 30 seconds regularly
 Do not cross knees when sitting
 Stretching of foot in bed while dorsi-flexing foot
 Easing calf cramp
 Warm bath
 Fatigue
 Effects of stress on body & mind (music, warm bath or shower, walk or exercise,
dancing, massage)
 Emotional reactions
 Advice on lifestyle
STRESS & RELAXATION

 PHYSIOLOGICAL EFFECTS OF STRESS :

 Body’s response to threat is fight n flight
 Increased HR, BP, rapid respiration, or breath holding
 Blood delivered to skeletal muscles from GIT & skin
 Mouth dries, pupils dilate, liver releases its glycogen store, blood coagulation time
decreases, spleen discharges additional RBCs into the circulation, bladder
frequency, diarrhea
 Hunched shoulders, flexed elbows, adducted arms, clenched or clutching hands,
and flexed head, trunk, hips, knees & ankles
 In anger, brow furrowed, chin juts forward, but in grief or pain, it is drawn in & out
to the chest
TEACHING NMS CONTROL

1. MITCHELL METHOD OF PHYSIOLOGICAL RELAXATION :

 Utilises typical stress/tension posture & reciprocal relaxation of muscle
 Thus stress induced tension in muscles that works to create typical posture may
be released by voluntary contraction of opposing muscle groups
 Laura Mitchell developed simple & elegant technique; devised a series of very
specific orders given to areas of body affected by stress e.g. for hunched
shoulders pull your shoulder towards feet– stop; feel your shoulders are further
away from your ears– your neck may feel longer.
2. CONTRAST METHOD :
 Involves alternately contracting & relaxing muscle groups progressively round the
body to develop recognition of difference b/w tension & relaxation
3. VISUALISATION & IMAGERY :
 Encourages a pt to think in pictures as opposed to words using all of the senses
 Relaxation, feeling of calmness
 TOUCH & MASSAGE :
 Relaxation & relieving pain
 Simple touch → companionship, caring & sharing
 Soothing, stroking, effleurage or kneading to appropriate areas
 BREATHING :
 Expiration accompanies release of tension
 Appropriate position must be taught. Woman should be comfortable, and fully
supported in lying, side lying or sitting
EXERCISE & PREGNANCY

 Physiological effects on mother and effect on fetal well being

 MATERNAL RISKS :
 Musculoskeletal trauma, increased joint laxity, posture changes due to change in
size & orientation of uterus; impairs balance & coordination. Reduced
coordination
 Increased demands on CVS system already altered by pregnancy which include
↑ in blood volume, cardiac output & ↓ systemic vascular resistance
 Small ↑ in number of calories per day needed; hypoglycemia with maternal
exercising that could lead to fetal hypoglycemia
 Thermoregulation -- ↑ in both basal metabolic rate & heat production during
pregnancy with fetal temperature 1°C higher than maternal temperature;
Hyperthermia; 39.2°C being the threshold for neural defects; moderate exercise
recommended rather than vigorous exercise
 Respiratory changes ---↑ in minute ventilation by almost 50% due to an ↑ in tidal
volume; ↑ in oxygen uptake and consumption of 10-20%; this increase is due to
mechanical effect of uterus upon diaphragm. When moderate activity
advocated the supply for oxygen should not impose difficulties
 FETAL RISKS :
 Fetal distress due to vigorous exercise b/c of selective redistribution of blood flow
away from splanchnic organs including shunting away of utero-placental blood
flow towards the working muscles; ↑ in 5-15 beats per minute
 Fetal growth & development – Studies have shown maternal exercise to increase,
decrease & have no effect on birthweight
 Fetal malformations due to raised maternal core temperature
 Pre-term labour; exercise triggers uterine contractions
CONTRAINDICATIONS
GUIDELINES FOR WOMEN EXERCISING
DURING PREGNANCY

 Jerky, bouncing, ballistic movements avoided

 Regular mild to moderate sessions at least 3 times a week are safer
 Careful ‘warm-up’ followed by a ‘cool-down’
 Strenuous exercise avoided in hot, humid weather or when women is pyrexial
 Maternal HR should not exceed 140 bpm & vigorous exercise should not be
continued for longer than 15 minutes
 Fluid must be taken before & after exercise to avoid dehydration
 Avoid high impact exercises
 Avoid supine positions after first trimester
 Avoid standing motionless for longer periods
SIGNS & SYMPTOMS NEEDING A MEDICAL
REVIEW

 Any signs of bloody discharge from vagina

 Any gush of fluid from vagina (premature rupture of membranes)
 Sudden swelling of ankles, face or hands
 Persistent severe headache or visual disturbance, or both; unexplained faintness or
dizziness
 Swelling, pain & redness in calf of one leg
 Elevation of pulse rate or BP that persists after exercise; excessive fatigue, palpitations
& chest pain
 Persistent contractions (>6-8 hours) suggesting onset of pre-mature labour
 Unexpected abdominal pain
 Insufficient weight gain (<1.0 kg/ month during last two trimesters)
 Absence or reduced fetal movements
SWIMMING & WATER EXERCISE

 Buoyancy supporting mother’s increased body weight

 Increases physical fitness & endurance
 Warned to listen to her body & slow down accordingly
 Warm up prior to main swim & cool down following it
 Activities for arms, legs and trunk as well as water walking and relaxation for non-
swimmers
 Yoga (must be done after proper training)
 Pilates (holistic approach to exercise, developing body awareness & general
fitness, which starts from a central core of stability concentrating on abdominal
and pelvic floor muscles; also focusing on posture & coordination)
DIET & WEIGHT GAIN IN PREGNANCY

 300 extra calories per day needed

 Nutritional intake in 1st trimester is important as the formation of fetus is occurring
& major influences will be uterus, placental structure & mother
 Normal weight gain of 11-15 kg (25-35 lbs) but varies according to weight, height,
age and whether the woman has had a baby previously
 Maternal weight gain or loss is poor indicator of fetal well being
 Women should eat according to apetite, adopt the habits of a healthy diet &
may be advised that pregnancy is not the right time to diet
 Single birth suggests a 2-3 kg increase in body weight
 Breastfeeding advocated to lose weight postpartum
NUTRIENTS

 FOLIC ACID : Prevention of neural tube defects such as spina bifida

 CALCIUM : Needed for bone, teeth & gum formation
 OMEGA 3-FATTY ACIDS (FISH OILS) : Development of baby’s brain & neural
development
 IRON : To combat anemia
 DIETARY FIBRE : Help prevent constipation
FOODS TO AVOID

 LISTERIA : causes flu like symptoms in mothers, miscarriage in early pregnancy,

premature labour & still birth. For preventing this avoidance of soft cheeses,
meat, fish, soft whip ice cream etc
 SALMONELLA : Food poisoning causing sickness & diarrhea in mother. Avoid
mayonnaise, mousses made with raw eggs, always defrost poultry and cook
thoroughly
 TOXOPLASMOSIS : Caused by organism found in raw meat & cat faces & can
have a serious effect on fetus causing hydrocephalus, epilepsy, hearing or visual
problems even blindness. Guidelines such as wash hands after handling raw
meat, wash salads & vegetables, avoid unpasteurized sheep & goat dairy
products etc
 LIVER : Congenital malformations due to excessive amount of vitamin A in retinol.
Avoid liver & liver products
 DARK FISH : Contains high levels of mercury & can affect fetal nervous system
therefore should not be eaten frequently. Limit consumption to 2 portions per week
 PEANUTS : A woman or her partner having peanut allergy, asthma, eczema, hay fever
or other food allergies should avoid peanuts during pregnancy or breastfeeding
 CAFFEINE : Limit to 300 mg/day. Associated with low birthweight babies &
miscarriage.
 ALCOHOL : Excessive or binge drinking causes a condition known as fetal alcohol
syndrome (severe learning difficulties as well as cognitive, hearing & visual
disturbances)
SMOKING IN PREGNANCY & LATER

 Affects health of children after they are born

 Direct link b/w maternal smoking & low birthweight
 Associated with fetal hypoxia, IUGR, placental abruption, premature rupture of
membranes, miscarriage, premature delivery and low APGAR score
 Risk of stillbirths associated with mothers who smoked
 Sudden infant death syndrome (SIDS) postnatally
 Postnatal growth retardation & chronic respiratory illnesses
MEDICATION IN PREGNANCY

 Antiemetic drug cause of severe limb & organ deformities in their babies
 Mother’s health primary consideration
 Safer drugs with least risk
 Drugs with major teratogenic effects are rare, but retinoic acid (used to treat
severe acne), some cytotoxic drugs & radio-chemicals can cause grave
damage. Women with such drug exposures are offered terminations.
 Tetracycline causes discoloration of children’s teeth
 Avoid unnecessary medications during pregnancy
 Paracetamol painkiller commonly used without ill effect
ADDICTIVE DRUGS IN PREGNANCY

 Congenital abnormalities following use of narcotics, cocaine, lysergic acid

diethylamide (LSD) & amphetamines (including Ecstasy)
 Placental insufficiency, IUGR, perinatal mortality caused when women use
heroine
 Prognosis is good if mother cooperates with antenatal care & drug control
MULTIPLE PREGNANCIES

 Due to increased use of assisted conception

 30% of couples using assisted conception will conceive twins or higher order
multiple pregnancies
 Increase in maternal age is also associated with increased probability of twins
 Twins arise from splitting of one fertilized ovum (monozygotic or uniovular) or from
the fertilization of two ova (dizygotic or biovular)
 Family history of twins
 Diagnosis by U/S or sometimes the shape of uterus is much larger than expected
 Discomfort may be intensified due to increased weight
 Higher risk of PIH, antepartum hemorrhage & C-section
 Incidence of preterm delivery is common with low birthweight babies & perinatal
mortality
 Average length for twins is 35 weeks & 33 weeks for triplets
PLANNING & LEADING LABOUR &
PARENTCRAFT CLASSES

 Parent education aim is to empower parents, educating individuals to increase

their knowledge thereby enabling them to make informed decisions
 With more control regarding their choice builds parent’s confidence & self
esteem
 Help pregnant woman to acquire knowledge of childbirth & parenting
CLASS ARRANGEMENTS

 Perceived needs of prospective clientele; vary from area to area & can fluctuate
within a community
 Women’s health physiotherapist flexible in approach i.e. adapting the classes
according to the needs of the group
 Content of classes
 Main antenatal course consists of four to six sessions & usually begins around 32
week
 Group should be of 8-16 people; session of at least 2-21/2 hours
ENVIRONMENT

 Frequently held in very unsuitable places such as ‘nooks & crannies’, basements
& windowless cupboards
 Should be held in places that are purpose built, carpeted, light & airy, clean &
with windows
 Ease of access & transportation such as that for wheelchair uses, & be large
enough to include an area for socializing, drinking tea/coffee & reading
information & booklets
 Space for exercising & relaxation, and toilets, refreshment & washing facilities &
ample storage space close by
 Welcoming atmosphere by attractive curtains, pictures and plants
 Furniture & equipment including mats, wedges, bean bags must be chosen
keeping in mind their safety principles
A 6 WEEK COURSE

 WEEK 1 : INRODUCTIONS :
 Class & class facilitators meet each other
 Tackle immediate problems & worries (any queries)
 Encourage attendees to take responsibility of their own learning
 Short general programme of exercises to promote comfort, mobility & strength
(e.g. foot & ankle exercises, wall press-ups, tailor sitting & posture correction etc)
 When to come in hospital (early signs of labour) & what to bring into hospital
 WEEK 2 : STAGES, SIGNS & LENGTH OF LABOUR, BIRTH PLANS/CHOICES :
 Labour
 1st stage of labour
 Relaxation (discussion on causes & effects of stress & coping strategies)
 WEEK 3 : COPING WITH THE FIRST STAGE OF LABOUR :
 Coping strategies for early stage of labour; distractions including reading, music,
television, showers, light meals etc
 TENS
 Positions, breathing awareness, massage & visualization techniques
 WEEK 4 : PAIN RELIEF & OTHER POSSIBILITIES :
 Include medical pain relief
 Discussion of end of 1st stage, transition & 2nd stage of labour
 Positions for 2nd stage
 Fetal monitoring, episiotomies, assisted deliveries, vacuum extraction & forceps
 WEEK 5 : FURTHER POSSIBILITIES IN LABOUR & FEEDING BABY :
 Third stage of delivery
 Induction of labour, caesarean delivery
 1st feed & postnatal care of woman & baby in hospital
 Breastfeeding, benefits of breastfeeding for babies & mothers, practical information
regarding positioning, latching on & possible hurdles
 WEEK 6 : PARENTHOOD & GETTING BACK INTO SHAPE :
 Care of the new baby --- a 24 hour job
 Transition to parenthood, adjustment to relationships
 Postnatal depression
 Postnatal exercises
ANTENATAL SELF HELP STRATEGIES FOR GOOD
MATERNAL POSTNATAL ADJUSTMENT

 Advice can include :

 Try to make friends with couples who have young children or who are also expecting
 Reduce housework & its importance
 Continue your outside interests, but reduce your responsibilities
 Give yourself permission to slow down as pregnancy advances
 Go to parent education classes with your partner
 View maternity leave as a time of relaxation & rest rather than an extended holiday
with large schedules & to-do-lists
 Try not to move house less than 6 months before or 6 months after the birth
 Think about organizing someone to babysit occasionally & maybe to help out at
home too if possible