Obstetric Patient

Question 1

Pelvis Structure

Answer 1

A variety of pelvis shapes may alter function

Joints allow for mobility

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

Question 2

Pelvic Structure: Ligaments

Answer 2

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

Accessory Pelvic Ligaments: Sacrotuberous, Sacrospinous, Iliolumbar Ligaments

Question 3

Pelvic floor muscles

Answer 3

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

Question 4

Pelvic wall muscles

Answer 4

Piriformis

Obturator internus

Question 5

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

Answer 5

Rectus abdominis
Transverse abdominis
Internal and external oblique
Quadratus lumborum
Iliopsoas

Question 6

Autonomic Innervation to Uterus

Answer 6

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

Question 7

Structure: Viscera

Answer 7

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

Question 8

The round ligament

Answer 8

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.

Question 9

Structure: Lymphatics

Answer 9

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

Question 10

Chapman’s reflexes: ovaries

Answer 10

anterior: pubic tubercle

posterior intertransverse space between T9-T10 and T10-T11

Question 11

Chapman’s reflexes Uterus

Answer 11

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

Post: Tip of TP of L5

Question 12

chapman’s reflexes: broad ligament

Answer 12

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

Question 13

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

Answer 13

On sacral base between PSIS and SP of L5

Question 14

Chapman’s reflexes: Vagina, clitoris

Answer 14

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

Question 15

Chapman’s reflexes: Fallopian tubes

Answer 15

Midway between acetabulum and sciatic notch

Question 16

Normal Musculoskeletal Changes in Early Pregnancy

Answer 16

Posterior rotation of pelvis
Flattening of lordosis
Contraction in rectus abdominis

Question 17

Normal Musculoskeletal Changes in Late Pregnancy

Answer 17

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

Question 18

Increased lumar lordosis

Answer 18

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

Question 19

Anterior pelvic rotation: strains

Answer 19

SI joints

Question 20

Pubic symphysis widens:

Answer 20

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

Question 21

The Role of Relaxin

Answer 21

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

Question 22

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

Answer 22

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

Question 23

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

Answer 23

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

Question 24

Normal Systemic Physiologic Changes

Answer 24

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

Question 25

Low Back and Pelvic Pain in Pregnancy

Answer 25

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

Question 26

Neuropathies in Pregnancy

Answer 26

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

Question 27

Lumbosacral Plexopathies in Pregnancy

Answer 27

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

Question 28

Spondylolisthesis

Answer 28

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

Question 29

Hip Pain

Answer 29

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

Question 30

Vascular stuff

Answer 30

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

Question 31

Visceral

Answer 31

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 ```

Question 32

Psycho-emotional

Answer 32

Risk of Postpartum depression is increased 3x in 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

Question 33

Evaluation of LBP in a Pregnant Patient

Answer 33

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

Question 34

Evaluation of LBP in a Pregnant Patient | Likely low risk:

Answer 34

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

Question 35

Evaluation of LBP in a Pregnant Patient- Physical Exam:

Answer 35

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 ```

Question 36

Management of LBP in pregnancy

Answer 36

``` 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 ```

Question 37

OMT: Indications

Answer 37

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

Question 38

OMT: Contraindications

Answer 38

``` 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 ```

Question 39

Stages of Pregnancy and Approach to Treatment

Answer 39

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

Question 40

The Structural Stage

Answer 40

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

Question 41

The Congestive Stage

Answer 41

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

Question 42

The Preparatory Stage

Answer 42

36 weeks- Delivery | Maintain structural balance and support lymphatic flow to help body function optimally during delivery

Question 43

Labor and Delivery

Answer 43

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

Question 44

Labor and Delivery Position

Answer 44

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

Question 45

Upright positions:

Answer 45

- 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

Question 46

other positions for labor

Answer 46

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

Question 47

Lithotomy Position

Answer 47

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

Question 48

Recovery and Maintenance Stage

Answer 48

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