1. ANTENATAL CARE

2. Antenatal period is the period during pregnancy Aims of adequate antenatal care: 1. To detect and treat any physical or psychological defect. 2. Prepare the parents for the birth and care of the baby. 3. Give confidence to the woman in her own abilities through an understanding of how her body functions and the various changes occurring during pregnancy and birth.

3. Psychological preparation for pregnant women It was established that most primigravidae and large number of multigravidae experience an increase in anxiety during pregnancy and have fears about childbirth. The most usual anxieties are that the baby will die in utero, will not be born normally and will not be healthy.

4. Physical Preparation for pregnant women It is important to have a clear conception of what can be achieved when starting to give instructions on the physical plane in order to help a young woman through phases of childbearing cycle. At the time when she conceives her first child, the development of certain anatomical structure must be given to her. This applies particularly to the bony pelvis, its shape and size. The importance of its position in the body in relation to posture, the attachment of pelvic inlet and outlet and the attachment of the muscles of the pelvic floor. The development of muscles, ligaments and interstitial tissue or of structures such as joints which depend for their function on the state of soft tissue that is influenced by physiological stimuli during pregnancy. The role of pelvic floor' muscles and abdominal muscles during labour must be explained. A selected number of illustrations will greatly assist the information given by the spoken word.

5. Role of physiotherapist during pregnancy: 1] Assess physical health and identify any musculoskeletal or neuromuscular problems that could be aggravated by pregnancy. The physiotherapist should identify and try to prevent any problem. e.g. pregnant woman should perform: leg exercises to prevent varicose veins. Abdominal contractions are taught to be practiced in sitting, lying and standing positions. Pelvic tilting and postural correction exercise from various positions. Pelvic floor contractions are taught in stride sitting with elbows resting on the knees.

6. 2] Advise on back care and lifting: back strain is minimized when the spine is held in its normal curves. So it is important to teach the woman how to adapt positions which minimize stress. So, Postural correction exercises are practiced from different positions: Standing. Sitting. Lying position. Crock lying position.

7. 3] Lifting advices: It involves lifting from a height and carrying as well as lifting from the ground level. The principles to follow when lifting are: Foot should be apart to increase the base of support. Any object to be lifted must be held close to the body. When lifting from the ground, it is important to ensure that the weight is light enough to be lifted comfortably. When lifting from a height, it is important to hold the object close to the body and to make sure that the height is easy reached

8. Treat any problem with appropriate physiotherapy skills: Pubis pain :is often related to diastasis of the rectus abdominis muscles due to repeated pregnancies. This pain is treated by pelvic support as a firm elastic corset which modified to fit under the main bulb of the baby. Lumbar pain: may be eased by soft tissue kneading and mobilization Cramp: occurs most commonly in the calf muscles. It can be relieved by slow, sustained stretch on the muscles, and by foot exercises.

9. Teach methods for controlling tension and pain: Neuromuscular tension: The physiotherapist must teach the pregnant woman how to recognize tension and how to deal with it though: Relaxation techniques that taught as a mean by reducing stress in all life situation. During labour, relaxation principles can reduce the severity of pain. Breathing awareness can help with relaxation during painful contraction of labour. Teaching positions that may be used for labour. Also, the different stages of labour must be explained for her. First stage (stage of cervical dilatation) The following instructions are helpful: -Walking and to leaning forward on a support during contractions using a back chair or a rocking chair.

10. As labour progress, fatigue sets in and rest is essential in side lying position. Relaxation techniques can be used to preserve energy between contractions. Second stage (expulsive effort of giving birth): The physiotherapist teach the woman how, can be used to relief pain during the birth and to bear down during uterine contractions to assist expulsion of the fetus. third stage (expulsion of the placenta, cord and membranes). - Relaxation and breathing awareness are useful in this stage.

11. Model of physical therapy program for normal pregnant women -From 4th to 6 the month of pregnancy: Not before the 4 th month to avoid abortion and if there is a history of habitual abortion No ante partum exercise is given. This includes: Instruction about the anatomy and physiology of female pelvis, pelvic joints and muscles especially pelvic floor. Instruction and training for:

12. Breathing exercises (deep breathing). Relaxation in any comfortable position chosen by mother, room must be calm, quite, warm, no air draft, no direct light, light music assist physical and mental relaxation. Postural correction to avoid postural problems.

13. 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

14. 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.

15. Advices 1. Exercise and Travelling: The pregnant woman must avoid vigorous exercises as swimming, tennis and cycling especially in the first part of pregnancy, the best exercise is walking in open fresh air, at least one hour daily. Travelling should be avoided, particularly during the last month especially on hard roads and for a long distances. If there is a history of habitual abortion or premature labours, travelling should be completely prevented.

16. 2. Sleep and Rest : Sleep for at leas8 hours every night Rest in a quiet room for 2 or 3 hours every afternoon. Avoid prone position to avoid intrauterine fetal death. 3. Breasts: Daily washes, massage the nipple with a mixture of glycerine and alcohol to reduce the incidence of cracking,

17. 4.bowel-habit: Avoid constipation because it leads to straining down, so, piles and genital prolapse may occur. This could be avoided by eating fresh vegetables, milk, performing pelvic floor exercise and taking mild laxatives, 5. Clothes: Should be loose, comfortable, avoid tight breast support. The shoes should be easily fitting, with low heels.

18. 6. Baths: The bath should be tepid and given by a shower, vaginal douching should be avoided because it leads to ascending infection. 7. Teeth: Regular cleaning at least in the morning and night. 8. Sexual intercourse: Should be avoided in the 1st trimester for fear of abortion and in the last two ·months for fear of ascending infection. If there is abortion tendency sexual intercourse should be avoided completely.

19. 9. Warning signs: As vaginal bleeding, abdominal pain, severe persistent headache, swelling in lower limbs which demand immediate physician calling. 10. Diet in pregnancy: Protein requirement is increased, starch, carbohydrates and fats should not be given in excess. Vitamin A and B are essential for growth of fetus and formation of fetal skeleton. Vitamin C and K reduce the incidence of abortion and either ante or post partum hemorrhage. Ca + and iron should be given. Sufficient fluids should be available.