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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

Oxford Handbook of Midwifery (34 page)

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During pregnancy ligaments become softer under the influence of the relaxin and stretch to prepare the body for labour.
This is particularly focused on the pelvic joints and ligaments which become more supple to accommodate the baby at delivery.
The effects can put a strain on the joints of the lower back and pelvis, which can cause backache.
As the baby grows, the curve in the lumbar spine may increase as the abdomen is thrust forward and this may also cause backache.
The following advice can be given to the woman to alleviate backache:
Avoid heavy lifting and use a good lifting technique, bending the knees and keeping the back straight when lifting or picking something up from the floor. The woman should take care when picking up a heavy older child.
Heavy weights should be held close to the body.
Any working surface used should be high enough to prevent stooping.
When carrying loads such as shopping the weight should be equally
balanced on both sides of the body.
The woman can be shown how to sit and stand with her spine in a neutral position so that good posture is maintained.
A firmer mattress gives better support during sleep. Using a bed board can make a soft mattress more supportive.
Some women find relief from using pillows to support their pregnant abdomen while lying down.
¹
Rest as much as possible as the pregnancy progresses.
If the backache is very painful and debilitating the woman can be referred to an obstetric physiotherapist for advice on lumbar support and helpful exercises.
1
Pennick V, Young G (2007). Interventions for preventing and treating pelvic and back pain in pregnancy.
Cochrane Database of Systematic Reviews
2
, CD001139.
CHAPTER 6
Minor disorders of pregnancy
112‌‌
Constipation
Increased progesterone levels decrease gastrointestinal movement during pregnancy. A recent systematic review reported two studies, which showed that fibre supplements in the form of bran or wheat fibre increased the frequency of defecation and led to softer stools. It appeared that stimulant laxatives were more effective than bulk-forming laxatives, but may have caused more side-effects.
¹
Women who were constipated prior to pregnancy may find that this condition becomes more problematic when they become pregnant.
It may be due to displacement of the bowel by the growing uterus or a side-effect of oral iron therapy.
If possible, it is best to try to relieve constipation by natural means before resorting to medication during pregnancy, and the advice given by the midwife should reflect this.
Advice should include:
- Eating regular meals.
- Drinking extra water, fruit juice, or herbal tea. This should be up to 2L of fluid per day, more in hot weather.
- Eating five portions of fruit and vegetables per day.
- Eating foods containing a high fibre content, such as wholemeal bread,
  breakfast cereals, and prunes.
- Taking gentle exercise, 20–30min, three times per week.
A mild laxative, such as lactulose (15mL twice a day), may be prescribed if the above advice does not relieve the symptoms.
1
Jewell DJ, Young G (2007). Interventions for treating constipation in pregnancy.
Cochrane Database of Systematic Reviews
2
, CD001142.
FREQUENCY OF MICTURITION
113‌‌
Frequency of micturition
Around 60% of women develop frequency of micturition early in preg- nancy. This appears to be a more common symptom for nulliparas. The urgent need to empty the bladder, even small amounts, throughout the day and night is caused by pressure from the enlarging uterus on the bladder.
Reassure women that this is normal as urine production in the kidney increases during pregnancy
This generally improves by the 14th week as the uterus grows out of the pelvis
Advise them not to drink a large amount before going to bed.
No treatment is needed for urinary frequency alone, but if micturition becomes painful, urinary infection should be excluded.
The symptoms may return during the last 4 weeks of pregnancy, when the presenting part enters the pelvis and creates pressure on the bladder, diminishing its overall capacity.
Pregnant women are also at risk of developing stress incontinence during pregnancy, related to physiological changes, hormonal influences and also mechanical stresses provoked by the enlarged uterus.
All pregnant women need to be taught how to perform pelvic floor
exercises correctly, as improved pelvic floor tone prior to delivery can
influence the return of good pelvic floor function after delivery.
Explain how to locate the pubo-coccygeous (PC) muscle, by asking the woman to attempt to stop urine flow while urinating.
Once the PC muscle is identified, the exercises should be carried out with an empty bladder.
The initial exercise involves squeezing and holding the PC muscle for 3–5s, relaxing, and then repeating this until the muscle tires.
The woman should attempt three sets of five squeezes once or twice a day for a week, then build up to three sets of 8, 10, 15, and then 20 squeezes.
Once a routine is established, maintenance is achieved by attempting three sets four times a week.
The exercise can be varied by including slow or rapid squeezes, and by exercising at different times of the day.
CHAPTER 6
Minor disorders of pregnancy
114‌‌
Indigestion and heartburn
During pregnancy, 30–50% of women experience indigestion or heart- burn. The discomfort is caused by acid reflux from the stomach through the oesophageal sphincter as a result of the relaxing effects of proges- terone. Later in pregnancy the growing uterus displaces the stomach, increasing intragastric pressure, which makes acid reflux more likely when lying down.
A Cochrane review
¹tried to assess the best interventions for heartburn during pregnancy. The authors were unable to draw conclusions about different treatments and recommended lifestyle changes first for mild heartburn in pregnancy women.
Advice should include:
- Eating several small meals a day
- Avoiding coffee, alcohol, and spicy foods
- Not to combine solid food with a drink, but take drinks separately from meals
- Sleeping with an extra pillow at night to raise the head and chest level above the level of the stomach
- Taking a calcium- or calcium-magnesium-based antacid to relieve symptoms
  •
  Wearing loose clothing so that there is no undue pressure on the abdominal area.
  1
  Dowswell T, Neilson JP (2008). Intervention for heartburn in pregnancy.
  Cochrane Database of Systematic Reviews
  4
  , CD007065.
  NAUSEA AND VOMITING
  115‌‌
  Nausea and vomiting
  Nausea and vomiting are common in pregnancy, with about 80% of preg- nant women experiencing anything from mild nausea on awakening, to nausea throughout the day with 50% experiencing some vomiting, during the first half of pregnancy.
  ¹
  For many women, the symptoms subside after the 12th–14th week of pregnancy, coinciding with the ability of the placenta to take over support of the growing embryo.
  The reasons for nausea are not known but it has been associated with:
Increased levels of hCG
Hypoglycaemia
Increased metabolic demand
The effects of progesterone on the digestive system. Advice to women should include: