Back Care & Lifting
Back strain is minimized when the spine is held in its normal curves, but spinal posture has to change with pregnancy. The center of gravity moves forwards and there is a tendency to an increased lumbar curve with consequent stress on the posterior muscles and ligaments. It is important to teach the woman how to adopt positions which minimize stress and to change position regularly posture advice is given in different positions. Attention to good posture has been shown to reduce the incidence of backache in pregnancy. Standing– stretch head up out of shoulders. Feel baby sit in the pelvis, pull in abdominal muscles, tighten buttocks. Feel poised, release tension without sagging. Avoid transferring the weight through one leg for long periods of time. Lean back against a wall or chair back for support if standing is essential and try to go up and down on the toes several times to keep the circulation moving and ease muscle tension.

Sitting–Practice sitting back into the chair so that it feels as if the weight of the baby is taken on the seat, and try to have the feet well supported–on a little stool if necessary. A small cushion should be placed in the back to preserve a slight lumbar curve and reduce the stretch on the posterior spinal structures. It is also important when resting in sitting to have the legs supported in slight elevation or at least horizontal.

Sleeping positions–In pregnancy, sleeping positions may have to be altered because of the body's weight gain and altered shape (lying prone is not possible). For most women, quarter–turn from prone (recovery position) is acceptable as the weight of the baby is taken on the bed. When a pillow under the abdomen and another under the top knee the position can be very comfortable. Sleeping supine should be avoided but, if necessary, a pillow under the thighs and another under the head and shoulders will ensure flattening and support of the lumbar spine. When changing position in bed, e.g. turning, keeping the flexed knees together reduces the strain in the sacroiliac joint. While getting in and out of bed the woman should go into side–lying and avoid abdominal strain from sitting up or lying straight down.

Lifting advice–This involves lifting from a height and carrying as well as lifting from the ground level. The principles to follow are never stoop, feet should be apart to increase the base, and any object to be lifted must be held close to the body (if held at arm's length the leverage on the spine causes high loading of the spinal extensors ). When lifting from the floor, it is important to ensure that the weight is light enough to be lifted comfortably. It may be advisable to lift in stages such floor to chair and then chair to upright. Later in the pregnancy, it is inadvisable to stand on high stools or to climb step–ladders because balance is less secure with the center of gravity moved forward.

Cramp–This occurs most commonly in the calf muscles often at night or after a period of rest. It can be relieved by slow sustained stretch on the muscles pushing the foot and ankle into dorsiflexion. Some people find that it is possible to prevent cramp by performing foot exercises just after getting into bed and when turning in bed to keep the feet in dorsiflexion. Bladder control–Strong pelvic floor muscles are needed to support the ever–increasing weight. If these muscles are weak a slight dribble of urine can occur when the abdominal pressure is increased, for example in coughing, sneezing laughing or lifting. Previous pregnancies make the woman more likely to have this problem.

The Treatment is Pelvic Floor Exercises:
The woman is instructed to tighten and pull up muscles, hold for a count of 4 and rest; repeat six times. Since these muscles fatigue easily with voluntary exercise only 4–6 isometric contractions should be performed at any one time, but frequent practice throughout the day is essential. Once mastered, the exercise can be performed with the woman in any position; but to start with sitting on a hard chair with knees apart, leaning forwards so that the perineum is in contact with the chair seat.

Relaxation Techniques
Antenatal care
Neuromuscular tension control. The physiotherapist must leach the woman how to recognize tension and how to deal with it. At first it is helpful to practice relaxation in lying. The woman is taught to tighten the muscles opposing the tension position:

1. Push the legs into the supporting surface, feel the support, now stop pushing and register the comfort.
2. Stretch the hands and elbows, push the arms into the floor, feel the support and then stop pushing.
3. Push the shoulders down, feel that they are comfortable and stop pushing.
4. Push the head down into the pillow, stretch the head out of the neck (feel that this is comfortable) and then stop pushing and stretching.
5. Face and jaw. Feel smoothness over the face and up over the head. Open mouth like a yawn and rest, to release clenching of the teeth.

Physiotherapy for Antenatal Care
Teaching Positions for Labor
First stage (waiting for cervical dilatation)
Remaining upright and mobile with gravity assisting fetal descent can make contractions more effective and possibly less painful. The following may be helpful:

• Walking about, changing to leaning forwards on a support during contractions when necessary.
• Sitting comfortably, leaning on a table or using the chair back and sitting astride the chair seat or use a rocking–chair.
• Kneeling leaning forward with the forearms and trunk on a back of pillow, Big bean pillow or bed backrest.

As labor progresses fatigue sets in and rest is essential in side–lying, quarter–turn from prone or tailors position. Relaxation techniques can then be used as already described to preserve energy between contractions. It is helpful to imagine a contraction coming on and to practice breathing, rocking or touch and massage techniques already described.

Second stage (expulsive effort of giving birth)
Midwife and physiotherapist together describe the sensations of the expulsive effort and of giving birth. Most women sit supported in bed in a modified squat position, but some use side–lying and a few use kneeling or a childbirth chair. The midwife explains the various type of obstetric assistance available (episiotomies, caesarean section, forceps delivery) as well as the forms of pain relief (pethidine injection, nitrous oxide plus oxygen inhalation, spinal epidural). This enables the woman to understand the effects and implications of these procedures and to participate in the choice when the time comes. The physiotherapist may teach the woman how transcutaneous electrical nerve stimulation (TENS) may be used to relieve pain during the birth.