Treating the Obstetric Patient Flashcards by Deja Gause

what are the three main changes that influence somatic dysfunction in pregnant patients

structural and biomechanic
body fluid/circulation
hormones

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what are effects of pregnancy on pre-existing scoliosis

the curvature does not increase
can be more painful and there is an increased risk of premature birth

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what are the effects of pregnancy on rheumatoid arthritis

improved symptoms due to hormonal changes (conception to 6 weeks post partum)

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what are the effects of pregnancy on ankylosing spondylitis?

aggravated by pregnancy with an increase in pain caused by stress on sacroiliac joint

HLA B27

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what is the mechanical stress caused by pregnancy

1 Low back pain

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what are the physiological stresses the body causes during pregnancy

2 lymphatic, 3 venous, 4 hormonal

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what MSK changes happen during pregnancy

12 weeks-

20 weeks-

28 weeks-

36 weeks-

40 weeks-

12 weeks; lordosis of lower back, anterior tilt of the pelvis, compression of structure due to fluid retention

20 weeks- widening of joints with increased mobility of SI and pubic symphysis

28 weeks- flexion of the upper back and lower neck (this is compensatory to changes in the pelvis and lower back)

36 weeks- laxity of anterior and posterior longitudinal ligament (surrounding the vertebrae)

40 weeks- ligament lacity, weakness/seperatin of abdominal muscles, internal shoulder rotation

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normally _ and and disc balance give you posture; in pregnancy the center of _ changes which leads to increased _ of the lumbar spine as counterbalance. This causes increased stress across the _ _ and increased shear forces across the _ _ _ . There is a shift to _ controlled balance for posutre which leads to _ dissuse and reliance on _

ligaments

gravity

lordosis

veterbral facets

across the intervertebral discs

muscle controlled

extensor dissuse

and reliance on ligaments

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if the pain goes down the leg but doesnt pass the knee, is better with rest, and is worse at night what is this indicative of

probably a mechanical issue you could expect a decreased range of motion

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what are some causes og LBP in pregnancy

postural changes, muscle weakness, stretching of connectice tissue and microtrauama, posterior pelvic pain, visceral disease, radicular pain, peripheral n. compression

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LBP in pregnancy is usually in the _ region and the trunk _ attempt to blanace increased pelvic tilt

microtauma/extensive connective tissue stretching

extensors

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posterior pelvic pain signs

pain distal and lateral to the lumbosacral junction

radiated down posterior thigh to the knee ( not past the knee)
no muscle weakness, no sensory impairment
normal reflexes 2/4
pain due to relaxatio of ligaments

usually starts second trimester , mechanical strain from walking/weight on the SI joint

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what are some red flags when a patient presents with LBP

severe pain that is not positional, increased pain with cough, sneezing, or valsalva (increased abdominal pressure)

neurological deficits: bladder incontinence, loss of strength, weakness, sensory defectis, abnormal reflexes and strength

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what are the causes of radicular pain

herniated disc, bulging disc

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peripheral nerve compression presents as?

what is the nerve distribution?

parathessias in the ilioinguinal and genitofermoral nerve distribution with lightening pains (shooting pains)

decreased muscle strenght, loss of sensation

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what are the risk factors of LBP during pregnancy

previous history of LBP
multiparity
higher BMI
smoking (literally complicates everything)
age (old)
strenuous work
painful periods

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LBP resolves in 80-95% OF CASES IN POST PARTUM BUT???

dont fall into the complacency trap because we want to address this issue

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in pregnancy there is an increase in _ fluids, there is a _ L increase over the course of pregnancy due to the pelvic organs and metabolic needs of the fetus

intersitial fluids

6.5 L increase

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there is an increase in _ , _ , and _ hormonas in pregnancy. They all promote _ retention leading to _ edema.

estrogen, progesterone, and adrenal hormones

fluid

tissue

lymphatics- contributes to fluid rentention

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in pregnancy trends:

cardiac output:
blood volume:
systemic vascular resistance:
blood pressure:
plasma volume:
hematocrit:

cardiac output: up
blood volume: up
systemic vascular resistance: down
blood pressure: down
plasma volume: up
hematocrit: down

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cardiovascular changes in the first trimester

maternal systemic vasodilation SVR decreases and CO increases

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cardiovascular changes in the second trimester

SVR drops 40%, CO continues to increase

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cardiovascular changes in third trimester

CO peaks, HR peaks, BP returns to normal levels

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cardiovascular changes in the supine position during the thrid trimester

CO
SV
HR

CO: down
SV: down
HR: up

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cardiovascular changes intepartum

CO increases 50% during pushing/contractions

cardiovascular changes post partum

Hr and BP return to normal

lymphatic stresses in pregnancy results in reduced interstitial fluid _

removal ## Footnote 6.5 L fluid increase with decreased removal

why is intersitial fluid not removed as quickly in pregnancy

due to decreased lymphatic flow causes by diaphragm restrictions, organ hypertophy, fasical torsions LESS EFFECTIVE PRESSURE GRADIENT ## Footnote closing of lymphatic channels

when supine the uterus can compress on the IVC leading to ?

lower CO reduced preload reduced SVR increased HR (compensatory)

supine complications on the IVC and cardiac output is most pronounced after _ weeks

20 weeks

when pregnanct cardiac output is higher lying on _ side

left

the spinal cord, the veterbral column, the chest and abdominal walls all drain into ?

venous plexuses that have no valves it is a closed system that relies on pressure gradients

blood normally drains into the _ veins to the _ system then to the _

communicating veins to the azygous/hemiazyous system to the SVC

_ cage motion helps drives pressure gradient of venous system

thoracic

_ excursion of the diaphragm is not impaired

diaphragmatic the diaphragm will rise 4cm, and the rib cage widens by 4cm but the movement of the diaphragm will stay the same during pregnancy

_ and _ change alter the pressure gradients between the abdomen and thorax

cardiac output and respiration changes

in pregnancy the changes in CO (increase - unless supine) and respiration will _ abdominal cavity fluid pressure

increase **increase in volume of abdominal organs (get heavier)

how does the venous system play a role on on the CNS in pregnancy

venous stress/congestion leads to headache, nausea, and light headedness

_ (hormone) stimulates respiration and respiratory drive

progesterone

more _ gets into the tissues than can be removed by the venous and lymphatic systems in the _ trimester clinical manifestations of this:

fluid 3rd hemorrhoids, varicosities (sluggish venous return)

dependent edema moves back into the vasculature due to _ gradient at the same time there is still direct pressures on IVC by uterus, this causes _ flow in the pelvis and stagnant _ of the neural and vertebral tissues resulting in _ LBP

osmotic decreased hypoxia delayed

what is relaxin

this is an adrenal hormone that is elevated in the 1st trimester and aids in the widening and mobility of the SI joints and pubic symphysis stays stable throughout pregnancy

women incapacitated by LP have higher levels of?

relaxin

_ changes the mechanical configuration of the thoracic cage circumference changes subcostal angle diaphragm tidal volume

progesterone circumference changes: increases about 6 cm subcostal angle: widens to 103 degrees diaphragm: raises 4cm superiorly tidal volume : increases by 40% TV( volume of air moved with each inhalation and exhalation)

progesterone promotes _

fluid retention ( causing congestion with a decrease in oxygen and metabolism at a cellular level) with decreased metabolism there is an increase in waste products)

indications for OMM in pregnant patients

somatic dysfunction, scoliosis or structural condition, edema , congestion

relative contraindications of OMM on a pregnant patient

premature rupture of membranes premature labor

what is premature labor

contractions with resultant cervical change before 37 weeks

what are some absolute containdications to OMM in pregnancy

AUB prolapsed umbilical cord ( descend into the birth canal before the baby) placental abruption (placenta detaches from the wall of the uterus before or during birth) ectopic pregnancy placenta previa threatened or incomplete abortion severe pre-eclampsia/eclampsia (can induce seizure)

goals of treatment in a pregnant patient

address postural stressors treat specific somatic dysfunctions to allow for better compensatory changes and energy retention

what are the 5 models of osteopathic treatment

biomechanical - postural aspects neurological - influence nervous system respiratory circulatory - use MS system to affect Arterial, venous, and lymphatic flow metabolic energetic immune- cellular metabolism behavioral- "touch on patient", personal goals

if mom already has an established _ routine before pregnancy this decreases the likelihood of LBP and faster return to normal post partum

exercise

in general what are the concepts for treating biomechanical issues in pregnancy

treat at Junctions! treat sacrum, treat innominates can position them seated, lateral recumbent, supine okay early on less forceful treatments (OB roll)

in general what are the concepts for treating lymphatic issues in pregnancy

treat the fascial diaphrams use effleurage/petrissage DO NOT USE PEDAL PUMP

in general what are the concepts for treating neurological issues in pregnancy

seated rib raising to decrease sympathetic tone

in general what are the concepts for treating behavioral issues in pregnancy

at home stretches for lumbar/LE and pelvic girdle

treatment areas for hyperemesis gravidarum

OA-C2 and T5-T9

how to influence pelvic organs sympathetic parasympathetic

sympathetic: T10-L2 (decrease this- usually has a vasoconstriction and decreased estrogen affect) parasympathetic: S2-S4 (increase this- vascular dilation)

during the second trimester there are _ visits

monthly

what do you expect to find in the second semester

pelvis anterior rotation/forward torsion increased pelvic tilt increased lumbar lordosis compensatory thoracic kyphosis round ligament pain, contraction of psoas muscles

look for _ in second trimester

carpal tunnel (common due to a edematous state)

third trimester visits are _

biweekly

what complaints are common in third trimester

loss of balance, back pain, gait changes, constipation, GERD

in third trimester some may become _ in supine position therefore avoid

hypotensive

there is increased _ fluid, increase in _ size, and increased _ complaints in third trimester

interstitial uterus musculoskeletal complaints

how do you treat heart burn/reflux (GERD) in the third trimester?

upper GI : T5-T9

treat the _ diagragm for constipation

pelvic

avoid _ because it can provoke uterine contractions

CV4

targeting T10-L2 does what to the adrenals and the ovaries

adrenals: lowers catecholamines ovaries: increases ovarian blood supply

the last 4 weeks of pregnancy women are feeling _ and _ visits the main OMT goal is to?

pregnant weekly maintain structural balance and lymphatic flow

in the last 4 weeks what does the OB do

evaluate the pelvic diameters (inlet, mid pelvis, outlet)

how do you measure the inlet

iliopectineal line/pube to sacrum

midpelvis diameter

structures between the inlet and outlet

outlet diameter

pubic bone, ischial tuberosities, coccyx

what are the signs of a ruptured pubic symphysis

a palpable gap an audible crack separation greater than 1cm with tissue edema pain raditating to the back or the thighs wadling gait increased pain with walking or bending

causes of ruputure of pubic symphysis

fetal macrosomia, percipitous labor, intense uterine contractions, forceps delivery

treatment of ruptured pubic symphysis

bed rest, pelvic binder, OMM

when should you start addressing muskuloskeltal SD postpartum

day 1 prior to resolution of hormonal changes to ligamentous stuctures (relaxin)

infant and lithotomy position encourages an _ sacral base

the lithotomy position is associated with symptoms of?

fatigue, depresison, and low energy

what should you do 4 weeks post partum

review structural changes, screen for SD, assess need for contraception, and follow up for chronic problems

when should you palpate post C section?

as soon as tissue integrity is achieved use finger pads, palpate at pubic tubercle and above, test fascial ROM

post C section look for _ pull to or from the uterus, umbilical ligament, ureters, bladder, abdominal wall

directional

relative contraindications of aerobic excercise

intrauterine growth resitriction, unevaluated maternal cardiac arrythmia, severe anemia, poorly controlled chronic disorders, underweight, history of sedentary lifestyle

absolute contraindications to aerobic excercise

incompetent cervis multiple gestations at risk for premature labor IUGR persistent bleeding placenta previa premature labor ruptured membranes preeclampsia