Treating the Obstetric Patient Flashcards
what are the three main changes that influence somatic dysfunction in pregnant patients
structural and biomechanic
body fluid/circulation
hormones
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
what are the effects of pregnancy on rheumatoid arthritis
improved symptoms due to hormonal changes (conception to 6 weeks post partum)
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
what is the mechanical stress caused by pregnancy
1 Low back pain
what are the physiological stresses the body causes during pregnancy
2 lymphatic, 3 venous, 4 hormonal
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
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
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
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
LBP in pregnancy is usually in the _ region and the trunk _ attempt to blanace increased pelvic tilt
microtauma/extensive connective tissue stretching
SI
extensors
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
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
what are the causes of radicular pain
herniated disc, bulging disc
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
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
LBP resolves in 80-95% OF CASES IN POST PARTUM BUT???
dont fall into the complacency trap because we want to address this issue
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
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
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
cardiovascular changes in the first trimester
maternal systemic vasodilation SVR decreases and CO increases
cardiovascular changes in the second trimester
SVR drops 40%, CO continues to increase
cardiovascular changes in third trimester
CO peaks, HR peaks, BP returns to normal levels
cardiovascular changes in the supine position during the thrid trimester
CO
SV
HR
CO: down
SV: down
HR: up
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
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
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
anterior
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
