Antenatal Patient Physiotherapy Education — Comprehensive Guide

1. Introduction and Rationale

"We suggest all patients have an early prenatal evaluation of pelvic floor muscle function and receive pelvic floor muscle exercise instruction during pregnancy for the prevention of urinary incontinence in late pregnancy and up to 6 months postpartum." — Management of Pregnancy (p. 39)

2. Core Components of Antenatal Physiotherapy Education

2.1 Pelvic Floor Muscle Training (PFMT)

• Correct muscle identification (avoid co-contraction of gluteals, thighs, or abdominals)
• Avoid breath-holding (Valsalva manoeuvre) during contractions
• Incorporate into daily routines (e.g., lifting, sneezing, coughing)
• Continue postpartum regardless of delivery mode

2.2 Exercise and Physical Activity Guidance

• Group class led by a physiotherapist once weekly (30–35 min)
• Home exercise program twice weekly (20–25 min)
• 12-week duration
• Components: strengthening for limbs, back extensors, deep abdominals, pelvic floor; light stretching; breathing; relaxation (Management of Pregnancy, p. 36)

• Ruptured membranes / premature labour
• Placenta praevia after 26 weeks
• Preeclampsia / pregnancy-induced hypertension
• Incompetent cervix
• Persistent second/third trimester bleeding
• Severe anaemia

2.3 Posture and Body Mechanics Education

• Increased lumbar lordosis
• Anterior pelvic tilt
• Upper thoracic kyphosis / forward head posture
• Ligamentous laxity at sacroiliac joints and pubic symphysis

• Standing: Weight equal through both feet, neutral pelvis, shoulder blades gently retracted
• Sitting: Lumbar roll support, feet flat, avoid crossing legs
• Lifting: Squat technique, engage pelvic floor and deep abdominals before lifting, keep load close to body
• Getting up from lying: Roll to side first, push up using arms (log roll technique) — critical to prevent diastasis recti worsening
• Sleeping: Left lateral position recommended after 28 weeks (reduces aortocaval compression)

2.4 Deep Abdominal / Core Training

• "Drawing in" manoeuvre: gentle inward movement of lower abdomen without spinal movement
• Performed in supine (first trimester), side-lying, sitting, standing, and 4-point kneeling
• Integrated with PFMT (co-contraction of TrA and pelvic floor)

• Occurs in up to 100% of women by late third trimester
• Patients taught to avoid exercises that increase intra-abdominal pressure (crunches, double leg raises, sit-ups)
• Log-roll technique when rising from bed
• Functional bracing strategies for daily activities

2.5 Breathing and Relaxation Techniques

• Taught from first trimester
• Promotes relaxation of pelvic floor
• Reduces physiological stress responses
• Enhances oxygen delivery to fetus

• Progressive muscle relaxation (Jacobson's technique)
• Guided imagery and mindfulness-based approaches
• Positions of comfort: left lateral, semi-reclined, forward lean

• First stage: Slow, rhythmic diaphragmatic breathing during contractions; focus on exhalation
• Second stage (pushing): Physiological pushing — exhalation push vs. Valsalva; evidence favours open glottis / exhalation pushing to protect pelvic floor
• Between contractions: Recovery breathing — slow deep nasal breath in, slow mouth exhale

2.6 Hydrotherapy / Aquatic Physiotherapy

• Buoyancy reduces gravitational load on joints and pelvic girdle
• Hydrostatic pressure provides venous return support (reduces oedema)
• Core temperature management — water temperature should not exceed 33–34°C
• Particularly beneficial for SPD, lumbopelvic pain, and obesity in pregnancy
• Contraindications: Ruptured membranes, placenta praevia, vaginal bleeding

2.7 Preparation for Labour and Delivery

• Upright and forward-leaning positions (standing, kneeling, all-fours) reduce pain and duration of first stage
• All-fours position reduces occipito-posterior presentation and back pain
• Squatting and semi-squatting facilitate fetal descent in second stage

• Commencing from 34–36 weeks
• Reduces risk of third- and fourth-degree perineal tears and episiotomy
• Technique: digital massage of posterior perineum with oil for 5–10 minutes daily
• Cochrane review (Beckmann & Stock, 2013): Perineal massage reduces likelihood of perineal trauma requiring suturing

• Explained and sometimes taught prenatally for pain management in early labour
• Applied to T10–L1 and S2–S4 dermatomes
• Contraindicated in pre-term labour, over abdomen, or if cardiac pacemaker present

2.8 Oedema Management

• Elevation of lower limbs
• Ankle pumps and foot circles throughout the day
• Compression hosiery (Class I or II)
• Regular low-impact walking
• Hydration and sodium reduction

2.9 Postural and Occupational Advice

• Workstation ergonomics: Lumbar support, monitor height, frequent position changes, avoiding prolonged standing
• Rest positions: Left lateral lying with pillow between knees; use of full body pregnancy pillow
• Driving: Seat adjusted to avoid extreme hip flexion; take breaks every 1–2 hours on long journeys

3. Trimester-Specific Physiotherapy Education Framework

4. Group vs. Individual Antenatal Physiotherapy Classes

5. Special Populations and Considerations

6. Key Book References

7. Key Paper References

8. Summary of Physiotherapy Education Goals by Domain