Obstetric Patient Flashcards
Pelvis Structure
A variety of pelvis shapes may alter function
Joints allow for mobility
- Sacroiliac joint: In females, ligaments are more flexible
- Pubic symphysis: Fibrocartilagenous joint
Pelvic Structure: Ligaments
True Pelvic Ligaments: Anterior Sacroiliac, Posterior Sacroiliac, Interosseous Sacroiliac
Accessory Pelvic Ligaments: Sacrotuberous, Sacrospinous, Iliolumbar Ligaments
Pelvic floor muscles
Pelvic Diaphragm (Levator ani and coccygeus) Diaphragm & pelvic diaphragm work together for breathing
Pelvic wall muscles
Piriformis
Obturator internus
Muscles of the trunk and lower extremity provide postural support and allow for locomotion
Rectus abdominis Transverse abdominis Internal and external oblique Quadratus lumborum Iliopsoas
Autonomic Innervation to Uterus
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
Structure: Viscera
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
The round ligament
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.
Structure: Lymphatics
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
Chapman’s reflexes: ovaries
anterior: pubic tubercle
posterior intertransverse space between T9-T10 and T10-T11
Chapman’s reflexes Uterus
ant: Lateral to pubic symphysis, lower margin of obturator foramen
Post: Tip of TP of L5
chapman’s reflexes: broad ligament
From greater trochanter inferiorly on lateral edge of femur to 2” superior to knee joint
Chapman’s reflexes: Broad ligament, fallopian tubes, uterus, vagina
On sacral base between PSIS and SP of L5
Chapman’s reflexes: Vagina, clitoris
Superior, medial aspect of posterior thigh 3-5” long
Chapman’s reflexes: Fallopian tubes
Midway between acetabulum and sciatic notch
Normal Musculoskeletal Changes in Early Pregnancy
Posterior rotation of pelvis
Flattening of lordosis
Contraction in rectus abdominis
Normal Musculoskeletal Changes in Late Pregnancy
Center of gravity shifts anteriorly Increased lumbar and cervical lordosis Increased thoracic kyphosis Anterior pelvic tilt Reduced diaphragmatic excursion
Increased lumar lordosis
increased load on facets, shearing of intervertebral disc spaces, posterior paraspinal muscles shorten and are unbalanced by overstretched abdominals, psoas muscles shorten
Anterior pelvic rotation: strains
SI joints
Pubic symphysis widens:
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
The Role of Relaxin
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
The pelvis and sacrum shift to facilitate the birthing process. First Stage of Labor:
Lumbosacral flexion
Iliac crests diverge
Ischia converge
Sacrum counternutates to allow fetal descent into true pelvis
The pelvis and sacrum shift to facilitate the birthing process. Second Stage of Labor:
Lumbosacral extension
Iliac crests converge
Ischia diverge
Sacrum nutates (sacral apex moves posterior) to allow for parturition
Normal Systemic Physiologic Changes
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
Low Back and Pelvic Pain in Pregnancy
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
Neuropathies in Pregnancy
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
Lumbosacral Plexopathies in Pregnancy
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
Spondylolisthesis
Women who have had children had a higher incidence at L4-5 than nulliparous woman
Hip Pain
Referred from low back or pelvis or vice versa
Transient osteoporosis of the hip
Avascular necrosis of the femoral head
- Both rare
Vascular stuff
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
Visceral
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
Psycho-emotional
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
Evaluation of LBP in a Pregnant Patient
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
Evaluation of LBP in a Pregnant Patient
Likely low risk:
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
Evaluation of LBP in a Pregnant Patient- Physical Exam:
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
Management of LBP in pregnancy
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
OMT: Indications
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
OMT: Contraindications
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
Stages of Pregnancy and Approach to Treatment
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:
- Structural Stage
- Congestive Stage
- Preparatory Stage
- Recovery and Maintenance Stage
The Structural Stage
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
The Congestive Stage
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
The Preparatory Stage
36 weeks- Delivery
Maintain structural balance and support lymphatic flow to help body function optimally during delivery
Labor and Delivery
Teach birth partner how to perform thoracolumbar and sacral pressure
Gentle techniques
CV4 if indicated in stalled labor or postdates patients
Labor and Delivery Position
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
Upright positions:
- 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
other positions for labor
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
Lithotomy Position
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
Recovery and Maintenance Stage
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
