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ECOS IV > Treating the Obstetric Patient > Flashcards

Treating the Obstetric Patient Flashcards

1
Q

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

A

structural and biomechanic
body fluid/circulation
hormones

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2
Q

what are effects of pregnancy on pre-existing scoliosis

A

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

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3
Q

what are the effects of pregnancy on rheumatoid arthritis

A

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

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4
Q

what are the effects of pregnancy on ankylosing spondylitis?

A

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

HLA B27

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5
Q

what is the mechanical stress caused by pregnancy

A

1 Low back pain

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6
Q

what are the physiological stresses the body causes during pregnancy

A

2 lymphatic, 3 venous, 4 hormonal

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7
Q

what MSK changes happen during pregnancy

12 weeks-

20 weeks-

28 weeks-

36 weeks-

40 weeks-

A

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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8
Q

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 _

A

ligaments

gravity

lordosis

veterbral facets

across the intervertebral discs

muscle controlled

extensor dissuse

and reliance on ligaments

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9
Q

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

A

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

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10
Q

what are some causes og LBP in pregnancy

A

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

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11
Q

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

microtauma/extensive connective tissue stretching

A

SI

extensors

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12
Q

posterior pelvic pain signs

A

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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13
Q

what are some red flags when a patient presents with LBP

A

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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14
Q

what are the causes of radicular pain

A

herniated disc, bulging disc

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15
Q

peripheral nerve compression presents as?

what is the nerve distribution?

A

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

decreased muscle strenght, loss of sensation

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16
Q

what are the risk factors of LBP during pregnancy

A

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

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17
Q

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

A

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

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18
Q

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

A

intersitial fluids

6.5 L increase

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19
Q

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

A

estrogen, progesterone, and adrenal hormones

fluid

tissue

lymphatics- contributes to fluid rentention

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20
Q

in pregnancy trends:

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

A

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

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21
Q

cardiovascular changes in the first trimester

A

maternal systemic vasodilation SVR decreases and CO increases

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22
Q

cardiovascular changes in the second trimester

A

SVR drops 40%, CO continues to increase

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23
Q

cardiovascular changes in third trimester

A

CO peaks, HR peaks, BP returns to normal levels

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24
Q

cardiovascular changes in the supine position during the thrid trimester

CO
SV
HR

A

CO: down
SV: down
HR: up

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25
Q

cardiovascular changes intepartum

A

CO increases 50% during pushing/contractions

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26
Q

cardiovascular changes post partum

A

Hr and BP return to normal

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27
Q

lymphatic stresses in pregnancy results in reduced interstitial fluid _

A

removal

6.5 L fluid increase with decreased removal

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28
Q

why is intersitial fluid not removed as quickly in pregnancy

A

due to decreased lymphatic flow causes by diaphragm restrictions, organ hypertophy, fasical torsions

LESS EFFECTIVE PRESSURE GRADIENT

closing of lymphatic channels

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29
Q

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

A

lower CO
reduced preload
reduced SVR
increased HR (compensatory)

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30
Q

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

A

20 weeks

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31
Q

when pregnanct cardiac output is higher lying on _ side

A

left

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32
Q

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

A

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

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33
Q

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

A

communicating veins

to the azygous/hemiazyous system

to the SVC

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34
Q

_ cage motion helps drives pressure gradient of venous system

A

thoracic

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35
Q

_ excursion of the diaphragm is not impaired

A

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

36
Q

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

A

cardiac output and respiration changes

37
Q

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

A

increase

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

38
Q

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

A

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

39
Q

_ (hormone) stimulates respiration and respiratory drive

A

progesterone

40
Q

more _ gets into the tissues than can be removed by the venous and lymphatic systems in the _ trimester

clinical manifestations of this:

A

fluid

3rd

hemorrhoids, varicosities (sluggish venous return)

41
Q

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

A

osmotic

decreased

hypoxia

delayed

42
Q

what is relaxin

A

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

43
Q

women incapacitated by LP have higher levels of?

A

relaxin

44
Q

_ changes the mechanical configuration of the thoracic cage

circumference changes
subcostal angle
diaphragm
tidal volume

A

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)

45
Q

progesterone promotes _

A

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)

46
Q

indications for OMM in pregnant patients

A

somatic dysfunction, scoliosis or structural condition, edema , congestion

47
Q

relative contraindications of OMM on a pregnant patient

A

premature rupture of membranes

premature labor

48
Q

what is premature labor

A

contractions with resultant cervical change before 37 weeks

49
Q

what are some absolute containdications to OMM in pregnancy

A

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)

50
Q

goals of treatment in a pregnant patient

A

address postural stressors

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

51
Q

what are the 5 models of osteopathic treatment

A

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

52
Q

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

A

exercise

53
Q

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

A

treat at Junctions!

treat sacrum, treat innominates

can position them seated, lateral recumbent, supine okay early on

less forceful treatments (OB roll)

54
Q

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

A

treat the fascial diaphrams

use effleurage/petrissage

DO NOT USE PEDAL PUMP

55
Q

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

A

seated rib raising to decrease sympathetic tone

56
Q

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

A

at home stretches for lumbar/LE and pelvic girdle

57
Q

treatment areas for hyperemesis gravidarum

A

OA-C2

and T5-T9

58
Q

how to influence pelvic organs

sympathetic

parasympathetic

A

sympathetic: T10-L2 (decrease this- usually has a vasoconstriction and decreased estrogen affect)

parasympathetic: S2-S4 (increase this- vascular dilation)

59
Q

during the second trimester there are _ visits

A

monthly

60
Q

what do you expect to find in the second semester

A

pelvis anterior rotation/forward torsion

increased pelvic tilt

increased lumbar lordosis

compensatory thoracic kyphosis

round ligament pain, contraction of psoas muscles

61
Q

look for _ in second trimester

A

carpal tunnel (common due to a edematous state)

62
Q

third trimester visits are _

A

biweekly

63
Q

what complaints are common in third trimester

A

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

64
Q

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

A

hypotensive

65
Q

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

A

interstitial

uterus

musculoskeletal complaints

66
Q

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

A

upper GI : T5-T9

67
Q

treat the _ diagragm for constipation

A

pelvic

68
Q

avoid _ because it can provoke uterine contractions

A

CV4

69
Q

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

A

adrenals: lowers catecholamines

ovaries: increases ovarian blood supply

70
Q

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

A

pregnant

weekly

maintain structural balance and lymphatic flow

71
Q

in the last 4 weeks what does the OB do

A

evaluate the pelvic diameters

(inlet, mid pelvis, outlet)

72
Q

how do you measure the inlet

A

iliopectineal line/pube to sacrum

73
Q

midpelvis diameter

A

structures between the inlet and outlet

74
Q

outlet diameter

A

pubic bone, ischial tuberosities, coccyx

75
Q

what are the signs of a ruptured pubic symphysis

A

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

76
Q

causes of ruputure of pubic symphysis

A

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

77
Q

treatment of ruptured pubic symphysis

A

bed rest, pelvic binder, OMM

78
Q

when should you start addressing muskuloskeltal SD postpartum

A

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

79
Q

infant and lithotomy position encourages an _ sacral base

A

anterior

80
Q

the lithotomy position is associated with symptoms of?

A

fatigue, depresison, and low energy

81
Q

what should you do 4 weeks post partum

A

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

82
Q

when should you palpate post C section?

A

as soon as tissue integrity is achieved

use finger pads, palpate at pubic tubercle and above, test fascial ROM

83
Q

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

A

directional

84
Q

relative contraindications of aerobic excercise

A

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

85
Q

absolute contraindications to aerobic excercise

A

incompetent cervis

multiple gestations at risk for premature labor
IUGR

persistent bleeding

placenta previa

premature labor

ruptured membranes

preeclampsia

ECOS IV (9 decks)

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