Osteopathic Considerations for the Obstetrical Patient Flashcards
What are 3 general areas of SD in OB pts?
- change in maternal structure and biomechanics
- Body fluid circulation
- hormonal changes
What are some changes that take place during preggo?
- center of gravity forward
- inrceased lumbar lordosis
- increased thoracic kyphosis
- shortened paraspinal muscles
- overstretched abdominal muscles
Effect of preggo on scloliosis?
- curvatures do not increase
- may develop more pain
- possible increased risk of premature birth
effect of preggo on RA
-improved symptoms actually
Effect of preggo on ankylosing spondylitis
- aggravated by preggo
- due to increased stress on SI joints
What are some etiologies of back pain in preggo?
- postural changes
- excessive CT stretching and microtrauma (SI region)
- Posterior pelvic pain
- Radicular pain
Difference between herniated disc and bulging disc
- herniated has a tear
- bulging does not
where will we find paresthesia’s in a preggo woman?
- ilioinguinal and genitofemoral nerve distribution
- Lightning pains
What are some risk factors for LBP during preggo?
- multiple preggos
- increaed maternal age
- young gravida
- heavy manual labor
- previous history of low back pain
What happens to a lady’s fluid level during preggo?
- increase 6.5 L over course of preggo
- increased demand to pelvic organs for metabolic needs
- also increase in Estrogen, progesterone, and adrenal hormones… promotes fluid retention
What happens to the lymphatic flow during preggo?
-decreases
Causes of decreased lymphatic flow
- fascial torsions
- organ hypertrophy
- diaphragm restriction
- most symptoms occur in 3rd trimester
What can we tell a preggo person to do to limit the pressure on her vena cava?
-limit the time that she is supine
Why are there venous stresses in a pregnant lady?
-more blood gets to the tissues than can be returned or removed by the venous and lymphatic systems… so it backs up
Why might a woman have back pain at night that wakes her up?
- increased venous return at night
- the dependent edema moves back into vasculature do to osmotic force changes
- direct pressure on vena cava by uterus/fetus…. decreased venous flow in pelvis
- develop a stagnate hyyposia of neural and vertebral tissues
- results in delayed low back pain that awakens the patient
When is relaxin elevated?
- during the first trimester and decline early in second trimester
- widens and mobilizes the SI joints and pubic symphysis
What do women incapacitated by LBP have higher levels of?
-relaxin!
How does progesterone affect a pregnant woman?
- increases the circumfrence of thoracic cage
- widens subcostal angle
- pushes diaphragm superiorly
- increased tidal volume
- promotes fluid retention….congestion happens
Indications for OMT in OB pt?
- SD
- Scoliosis or structural condition associated with preggo
- edema, congestion, or other pregnancy associated condition amendable to OMT
Relative contraindication to OMT for ob pts?
- premature rupture of membranes
- premature labor
absolute contraindications to OMT for OB pts?
- undiagnosed vaginal bleeding
- prolapsed umbilical cord
- placental abruption
- ectopic preggo
- placenta previa
- threatened or incomplete abortion
- severe pre-eclampsia/eclampsia….low seizure threshold
What are the goals of tx for OB pts OMM
- address all postural stressors
- treat any specific somatic dysfunctions
What are the 5 models of osteopathic treatment?
- Biomechanical
- Neurological
- Respiratory/circulatory
- Bioenergy
- Psychobehavioral
When talking about stages of treatment, what do we want to do in the first trimester (0-13 weeks)?
- complete history
- physical
- just make sure we know everything to start off with about them
What tx do we do in 1st trimester?
- tx any SD’s that are found
- hyperemesis gravidarum: treat areas C2 and T5-9
- Home exercise… maintain good ab tone
What are ACOG recommendations for Home exercise?
- avoid activityes that could risk falling or abdominal trauma
- avoid scuba diving
- 30 minutes or more, moderate exercise, most/all days of the week
What are some warning signs to terminate exercise?
- vag bleeding
- dyspnea prior to exertion
- dizziness
- headache
- chest pain
- muscle weakness
- calf pain or swelling
- preterm labor
- decreased fetal movement
- amniotic fluid leakage
What doe we do with these pts in the 2nd trimester?
- Monthly visits
- evaluate for SD
What can we expect to find in 2nd trimester?
- pelvis rotating anterior about a right/left axis (forward torsion)
- increased pelvic tilt
- increase in lumbar lordosis
- Compensatory increase of thoracic kyphosis: may produce cervical strain
What treatments do we do in 2nd trimester (14-26 weeks)?
- fascial release (indirect/direct): good for ab wall pain
- Tx sacrum and pelvis- use any modality that is comfortable for the patient
- Carpal Tunnel Syndrome: common in preggo due to edematous state, so just stretch it or something
What happens in the 3rd trimester with the pt?
- mechanical and structural changes maximal
- increased complaints
- increase in interstitial fluids
- increase in uterus size
What do we do for tx in the 3rd trimester (27-40 weeks)?
- address edema: MFR, ST, lymphatics (eff and petrassage)
- Viscerosomatics
- pelvic diaphragm for constipation
What do we need to avoid because it can provoke uterine contractions?
-Avoid cranial!!!!
What are the viscerosomatics for upper GI?
-T5-9
-
viscerosomatics for adrenal and ovaries?
-T10-L2
What do we need to do for the preparatory stage (last 4 weeks)?
- evaluate pevic diameters: inlet, mid pelvis, outlet
- anticipate delivery problems
What is the inlet?
-iliopectineal line/pube to sacrum
What is the mid-pelvis
-structures beween the inlet and outlet
What is the outlet?
-pubes, ischial tuberosities, coccyx
What do we do for labor?
- evaluate lumbosacral region and pelvis
- thoracic spine ST may regulate uterine contractions via sympathetics
- expect df’s in: innominates, sacrum, pubic symphysis
- women do not tolerate aggressive modalities during labor
Diagnosis of rupture of pubic symphysis?
- separation> 1 cm
- audible crack (jesus)
- due to wedging effect of head at birth
- acute pain radiating to back and/or thighs
- palpable gap wtih local tissue edema
What will the gait look like with people who have rupture of pubic symphysis?
-waddling gait
Tx of rupture of pubic symphysis
- conservative
- bed rest-lateral recumbent
- pelvic binder- reduces separation
- OMM as needed
- may cause pain in subsequent preggos
What do we do on first visit 2 days postpartum?
- screen for SD
- tx prior to resolution of hormonal changes on ligamentous structures: relaxin
- evaluate sacral mechanics: lithotomy position encourages anterior sacral base (cranial extension)
What symptoms are associated with cranial extension df?
- fatigue
- depression
- low energy
What do we do at the 2nd visit 6 weeks post-partum?
- review structural changes
- screeen for SD
- assess need for future contraception*
- advise any follow up care for chronic problems
What was the PROMOTE study by Dr. Hensel?
- sees if OMT works in 3rd trimester
- 7 txs over 9 weeks
- goal was to reduce LBP and improve functioning
- significant tx effects for pain and functioning in OMT and ultrasound group
- no higher likelihood of conversion to high-risk status in OMT group
What did the study show with regards to hemodynamic control
-BP increased and HR decreased in OMT group after heel raise
