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OPP IV Exam 1 part 1 > Obstetric Patient > Flashcards

Obstetric Patient Flashcards

1
Q

Pelvis Structure

A

A variety of pelvis shapes may alter function

Joints allow for mobility

  • Sacroiliac joint: In females, ligaments are more flexible
  • Pubic symphysis: Fibrocartilagenous joint
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2
Q

Pelvic Structure: Ligaments

A

True Pelvic Ligaments: Anterior Sacroiliac, Posterior Sacroiliac, Interosseous Sacroiliac

Accessory Pelvic Ligaments: Sacrotuberous, Sacrospinous, Iliolumbar Ligaments

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3
Q

Pelvic floor muscles

A 
Pelvic Diaphragm (Levator ani and coccygeus)
Diaphragm & pelvic diaphragm work together for breathing
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4
Q

Pelvic wall muscles

A

Piriformis

Obturator internus

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5
Q

Muscles of the trunk and lower extremity provide postural support and allow for locomotion

A 
Rectus abdominis
Transverse abdominis
Internal and external oblique
Quadratus lumborum
Iliopsoas
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6
Q

Autonomic Innervation to Uterus

A

Sympathetic Innervation:

  • T10-L2
  • Vasoconstriction
  • Uterine contraction
  • Decreased threshold for pain from the uterine body

Parasympathetic* Innervation:

  • S2-S4
  • Vasodilation
  • Relaxation of uterine muscle
  • Decreased threshold for pain from the cervix
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7
Q

Structure: Viscera

A

The pelvis is a container for pelvic organs
Ligaments (fascial condensations)
- Carry vessels & nerves
- Support & connect pelvic organs to the walls of the pelvis

Round ligament & Uterosacral ligaments:

  • Undergo increased forced and stretching due to expanding uterus
  • Contain smooth muscle
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8
Q

The round ligament

A

comes from the uterine hornes, through the deep inguinal ring and the inguinal canal, attaching to the labia majora and mons pubis. This ligament maintains the uterus flexed forward during pregnancy, but can stretch and cause pain.

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9
Q

Structure: Lymphatics

A

Lymph drainage from the pelvis follows corresponding arteries
External iliac lymph nodes
- Receive vessels from inguinal nodes, external genitalia, vagina, cervix, bladder
- Drain into the common iliac nodes

Internal iliac & sacral lymph nodes

  • Receive vessels from pelvic viscera (cervix, rectum) and from perineum, buttock, and thigh
  • Drain into common iliac nodes

Common iliac lymph nodes pass into the lumbar nodes which drain to the cisterna chyli, which dives under the diaphragm, next to the aorta, and up into the thoracic duct which drains into the venous system at the junction of the lymph subclavian vein and internal jugular vein

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10
Q

Chapman’s reflexes: ovaries

A

anterior: pubic tubercle

posterior intertransverse space between T9-T10 and T10-T11

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11
Q

Chapman’s reflexes Uterus

A

ant: Lateral to pubic symphysis, lower margin of obturator foramen

Post: Tip of TP of L5

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12
Q

chapman’s reflexes: broad ligament

A

From greater trochanter inferiorly on lateral edge of femur to 2” superior to knee joint

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13
Q

Chapman’s reflexes: Broad ligament, fallopian tubes, uterus, vagina

A

On sacral base between PSIS and SP of L5

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14
Q

Chapman’s reflexes: Vagina, clitoris

A

Superior, medial aspect of posterior thigh 3-5” long

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15
Q

Chapman’s reflexes: Fallopian tubes

A

Midway between acetabulum and sciatic notch

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16
Q

Normal Musculoskeletal Changes in Early Pregnancy

A

Posterior rotation of pelvis
Flattening of lordosis
Contraction in rectus abdominis

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17
Q

Normal Musculoskeletal Changes in Late Pregnancy

A 
Center of gravity shifts anteriorly
Increased lumbar and cervical lordosis
Increased thoracic kyphosis
Anterior pelvic tilt
Reduced diaphragmatic excursion
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18
Q

Increased lumar lordosis

A

increased load on facets, shearing of intervertebral disc spaces, posterior paraspinal muscles shorten and are unbalanced by overstretched abdominals, psoas muscles shorten

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19
Q

Anterior pelvic rotation: strains

A

SI joints

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20
Q

Pubic symphysis widens:

A

may refer pain to lower back or down medial thighs, worse with walking
Stress and strain joints and myofascial structures
This causes tissue irritation, inflammation, and pain that may present as back or pelvic pain

21
Q

The Role of Relaxin

A

A hormone produced by the ovary and placenta
Increases during 1st trimester, peaks at 14 weeks and at delivery
Mediates hemodynamic changes: increased cardiac output, increased renal blood flow, increased arterial compliance
Widens and causes increased mobility of sacroiliac joint and pubic symphysis
Back pain associated with increased levels of relaxin
Why?
-More instability of joints could lead to more pain

22
Q

The pelvis and sacrum shift to facilitate the birthing process. First Stage of Labor:

A

Lumbosacral flexion
Iliac crests diverge
Ischia converge
Sacrum counternutates to allow fetal descent into true pelvis

23
Q

The pelvis and sacrum shift to facilitate the birthing process. Second Stage of Labor:

A

Lumbosacral extension
Iliac crests converge
Ischia diverge
Sacrum nutates (sacral apex moves posterior) to allow for parturition

24
Q

Normal Systemic Physiologic Changes

A

Increased circulating blood volume by ~50% –> physiologic anemia, edema

Arterial vasodilation
–> Decreased systemic vascular resistance
Decreased MAP

Increased cardiac output

Increased minute ventilation
–> Sense of breathlessness

Increased renal blood flow and glomerular filtration rate–> Increased basal metabolic rate (increased O2 demand)

Substantial weight gain
–> Total body water increases
Growth of fetus, placenta, tissues

Decrease in insulin efficiency
–> Increased glucose availability for fetus

Smooth muscle relaxation
--> Uterus expansion
Urinary frequency
Slows GI motility
Increased nutrient absorption
Esophageal reflux, heartburn, and constipation

Venous engorgement of the pelvis
–> Varicosities, hemorrhoids
Pelvic congestion syndrome

Expanding uterus presses on vena cava
–> Supine hypotensive syndrome
Heartburn and constipation
Decreased diaphragmatic excursion

Fluid retention leads to compression of structures
–> Carpal Tunnel Syndrome

25
Q

Low Back and Pelvic Pain in Pregnancy

A

Incidence up to 76.4%
Begins as early as first trimester to as late as six months postpartum
Causes: hormonal, biomechanical, traumatic, metabolic, genetic, degeneration, circulatory, psychosocial
Risk Factors:
- Activity: strenuous work, sedentary or extremely active lifestyles
- Prior history of pain
- Increased age
- Multiple parity

Not associated with weight gain or increased infant weight

26
Q

Neuropathies in Pregnancy

A

Peripheral nerves are susceptible to injury via compression, traction, and ischemia
Causes
- Increased levels of fluid
— Carpal tunnel syndrome
- Uterus putting pressure on pelvic organs, ligaments, lumbosacral plexus, and lower limb peripheral nerves
— Meralgia paresthetica
——-Compression of the lateral femoral cutaneous nerve
Restless leg syndrome: need to move legs and calves, paresthesias in lower extremities, and worsening symptoms at night
Leg cramps

27
Q

Lumbosacral Plexopathies in Pregnancy

A

May occur from prolonged standing, sitting, or squatting
- Proximal or distal lower limb weakness may occur
Plexus-associated foot drop may be result of compression of the peroneal division of the sciatic nerve in the pelvis or compression of the common peroneal nerve at the fibular-head
True lumbar disc herniation is rare
Previous sciatica may become aggravated

28
Q

Spondylolisthesis

A

Women who have had children had a higher incidence at L4-5 than nulliparous woman

29
Q

Hip Pain

A

Referred from low back or pelvis or vice versa
Transient osteoporosis of the hip
Avascular necrosis of the femoral head
- Both rare

30
Q

Vascular stuff

A

Abnormalities or changes of the lumbar epidural venous plexus

  • May mimic radiculopathy
  • Ex: inferior vena caval thrombosis
  • Resolves with medical tx of the DVT

Posterior placental location
- Pain may occur as the enlarging uterus strains the vascular bed to which the placenta is attached

Placental abruption

  • Consider if a history of trauma like a fall or MVA
  • Requires emergent C-section
31
Q

Visceral

A

Urinary:

  • Pyelonephritis: dull, persistent pain often with fever and chills
  • Nephrolithiasis: colicky pain with palpatory tenderness of the costovertebral angle

GI:
- Constipation from slowed bowel function and decreased fluid intake

Obstetric:
Preterm labor from infection or irritation of the sympathetic nervous system on uterine activity
Endometriosis - may have sensitized neurons in the lower lumbar cord
Ectopic pregnancy in 1st trimester
Threatened spontaneous abortion
Ovarian cyst
Pelvic infection
Posterior uterine fibroid
Labor
32
Q

Psycho-emotional

A

Risk of Postpartum depression is increased 3xin women who have lumbo-pelvic pain
Pregnant women who were angry or depressed had increased pain and cortisol and epinephrine levels in their 2nd and 3rd trimesters
Vicious Cycle
- Pain alters the hypothalamic-pituitary-adrenal axis = increased cortisol and depression symptoms
- Clinical depression is associated with lowered tolerance for nociception, a heightened pain perception, and increased risk for developing chronic pain

33
Q

Evaluation of LBP in a Pregnant Patient

A

Postural adaptations to pregnancy cause biomechanical changes which will stress and potentially strain the involved joints and myofascial structures
This may cause tissue irritation, inflammation, and pain that may present as back or pelvic pain
A prior history of trauma or LBP predisposes to LBP during pregnancy

History
Physical Exam: evaluate both maternal and fetal health
Rule out urinary, colon, and uterine issues
Exclude red flags
Correlate with fetal activity

34
Q

Evaluation of LBP in a Pregnant Patient

Likely low risk:

A

Low anterior or posterior pelvic pain, aggravated by activity, relieved by rest
May radiate down one or both buttocks into posterior thighs or knees
No correlation with fetal activity

35
Q

Evaluation of LBP in a Pregnant Patient- Physical Exam:

A

Observation, palpation, ROM, muscle imbalances, leg length, DTRs, posture, gait, degree of lumbar lordosis

Osteopathic Structural Exam:
Lumbar segmental evaluation 
Sacrum/pelvic diagnosis
Hip joints 
Pubic symphysis 
Abdominal diaphragm
Spasm of paravertebral muscles
Palpatory tenderness over the SI joints
Pain with SI compression, FABERE, Patrick test
36
Q

Management of LBP in pregnancy

A 
Conservative approach
- Tylenol
- Avoid NSAIDs, opiates
- Avoid excess heat (hot tubs, hot baths, hot packs, etc)
- Avoid high heels 
OMT
PT
Nutrition
Exercise
Acupuncture
Back supports and SI belts
37
Q

OMT: Indications

A

Allow for ease of adaptation to the change in forces of the gravid patient, allowing for efficient changes in posture and mechanics

  • Address postural stressors
  • – Including premorbid factors: scoliosis, compensations for trauma
  • Address lymphatics
  • – Edema, congestion

Treat any specific somatic dysfunctions

38
Q

OMT: Contraindications

A 
Undiagnosed vaginal bleeding
Threatened or incomplete abortion
Ectopic pregnancy
Placenta previa (painless bleeding)
Placental abruption (painful bleeding)
Premature rupture of membranes (preterm)
Preterm labor 
- Relative contraindication
Prolapsed umbilical cord
Severe preeclampsia/eclampsia
- Low seizure threshold
Other surgical or medical emergencies
39
Q

Stages of Pregnancy and Approach to Treatment

A

Treat the obstetrical patient early, throughout, and after her pregnancy to help her body accommodate the structural and systemic changes that will occur
Incorporate OSE and treatment into regular obstetrical visits

Four Stages:

  1. Structural Stage
  2. Congestive Stage
  3. Preparatory Stage
  4. Recovery and Maintenance Stage
40
Q

The Structural Stage

A

1st visit – 28 weeks gestation
Somatic dysfunction could affect the patient’s ability to effectively compensate for the stress of pregnancy

0-12 weeks:

  • History: previous pregnancies, deliveries, family history, habits, trauma history
  • Premorbid somatic dysfunctions: short leg, sacral shear, scoliosis
  • Hyperemesis gravidarum

12-28 weeks:

  • Support of body structures and processes that are or will be under stress
  • Patient’s change in structure: Increased fat storage, growth of uterus, hypertrophy of breasts, blood volume expansion, shift in center of gravity, tissue congestion
  • Evaluate and treat: structural effects of mechanical stress
  • Carpal Tunnel Syndrome
41
Q

The Congestive Stage

A

28-36 weeks gestation
Fluid accumulation in tissues
- Mechanical, hormonal, biological

Growing Uterus

  • Leg edema of late pregnancy
  • Difficulty lying supine causes hypotension
  • Pushes on lower ribs and decreases diaphragm excursion

Evaluate and treat: mechanical decompensation to improve lymphatic drainage, including diaphragm

Loss of balance, back pain, gait changes, GERD, constipation, hemorrhoids, leg edema

42
Q

The Preparatory Stage

A

36 weeks- Delivery

Maintain structural balance and support lymphatic flow to help body function optimally during delivery

43
Q

Labor and Delivery

A

Teach birth partner how to perform thoracolumbar and sacral pressure
Gentle techniques
CV4 if indicated in stalled labor or postdates patients

44
Q

Labor and Delivery Position

A

Encourage women to adopt most comfortable position, to avoid lying supine or semi-supine

Upright position may be associated with shorter time to delivery, less pain, and reduced likelihood of obstetric intervention in women w/o epidurals

45
Q

Upright positions:

A
  • Sitting on obstetric chair or stool
  • Semi-recumbent with trunk tilted backwards 30 degrees to vertical
  • Kneeling
  • Squatting (unaided, with squatting bars, or with birth cushion)

Benefits:

  • Gravity
  • Less aortocaval compression
  • Improved fetal alignment
  • Increased A/P and transverse pelvic outlets
46
Q

other positions for labor

A

Hands and knees posture may decrease back pain

Water immersion associated with increased maternal satisfaction and does not appear to increase risk for adverse maternal or neonatal outcomes

47
Q

Lithotomy Position

A

Reduces and may limit space for sacral movements
Gravity causes baby’s head to stay in contact with posterior pelvic floor
Strains hips and pubis
Epidural may slow down contractions

48
Q

Recovery and Maintenance Stage

A

1-2 Days Postpartum
Relaxin present after delivery (and for weeks-months after)
Restore functional position of joints until ligaments return to usual tension and strength
Anterior sacral base dysfunction
Associated with fatigue, depression, low energy
Thoracic spine/axilla: breast engorgement

6 Weeks Postpartum:
To allow for complete recovery from delivery

OPP IV Exam 1 part 1 (8 decks)

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