osteopathic obstetrics rev..pdf

8/10/2019 OSTEOPATHIC OBSTETRICS rev..pdf

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OSTEOPATHIC OBSTETRICS

CAN BE A REALITY

Dr. Diane M. Aslanis, FACOOG

April 18, 2013

No Financial Disclosures


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OBJECTIVES:

Describe common somatic dysfunctions which

are unique to pregnancy, labor, delivery and the

postpartum period

Describe relative contraindications for

Osteopathic Manipulative Medicine (OMM)

during pregnancy

Describe OMM techniques which are

appropriate during pregnancy


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OVERVIEW:

Pregnancy Changes

Relative Contraindications for OMM

Osteopathic Medicine Applied


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PREGNANCY CHANGES BY SYSTEM:

Cardiovascular

Body Water Metabolism

Hormonal Respiratory

Musculoskeletal


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CARDIOVASCULAR CHANGES IN PREGNANCY:

Heart:

Changes are consistent with a chronicstrain on the heart

Heart Sounds

96% females have Systolic Ejection Murmur

18% females have Diastolic Murmur

(warrants further evaluation)


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CARDIOVASCULAR (CONT):

Cardiac Output: (CO = SV x HR)

O ave 30-50 above non-preg

Dep on Maternal Position

after 24wk IVC completely occluded when supine

(5-10% preg pt w/ supine hypotensive syndrome)


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CARDIOVASCULAR (CONT)

Normal Changes in Preg that Mimic HT Dz:

DYSPNEA: COMMON

75% women exp by 3rd

TrimMost women c/o dyspnea PRIOR to 20wk

How to Distinguish from Cardiac Dz?

Nml occurs early in preg

Nml does not worsen sig as preg progresses(sx of HT dz usu worsen in latter of preg)

Physiologic dyspnea usu mild

Doesnt stop woman from ADLs

Doesnt occur at rest


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Other Normal Changes that Mimic HT Dz:

exercise tolerance

Fatigue

Occasional Orthopnea

Mild tachycardia

Syncope

Chest Discomfort

Peripheral edema

JVD after 20wk

Lat displ of (L) vent apex


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Organ Volumes

Cavity Pressures

Relative reversal of

venous blood flow

Vascular Congestion

Causes edema,

constipation, bladderpressure, varicosities,hemorrhoids


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VENOUS PRESSURE

Upper Extremities:Unchanged (carpal tunnel?)

Lower Extremities:

Pressure rises progressively=> Edema, Varicose Veins, risk DVT

Lymphatics:

Essential to prevent tissue congestion[Abdominal Diaphragm] extrinsic pump for

drainage

Efficiency due to diaphragmatic changes

secondary to spinal curve changes


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BODY WATER METABOLISM

Chronic Volume Overload

6.5-8.5L total body water by end of pregnancy

3.5L = Fetus, Placenta, Amniotic Fluid

1.5-1.6L = Maternal Blood Volume1.2-1.3L = Plasma Volume

300-400mL = RBC


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HORMONAL

Relaxin causes: weakening of muscles and ligaments

fluid retention

Estrogen

Progesterone

Estrogen

Progesterone


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RESPIRATORY

Pt in state of Chronic Hyperventilation

Mechanical Changes of Up Resp System

Subcostal angle from 68 to 103Chest transv diam by 2cm

Chest circumference by 5-7cm

Level of diaphragm rises 4cm


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MUSCULOSKELETAL

Centers of Gravity:

Main = L5-S1

Subsidiary = C7-T1, T12-L1

Ant/Post balance

Iliopsoas Mm:

Key mm for erect posture

Origin = iliac fossa, spine

Insertion = lesser trochanter of

femur

Action = hip flexion

Used to compensate imbalance

between ANT abd mm and

POST spinal mm to stabilize

lumbar portion of spine


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MUSCULOSKELETAL (CONT)

Abdomen Size:Drag on mm, fascia and ligaments=> abd muscles and fascia stretch and pull

=> results in depression of ANT thorax

=> ANT/POST and transv chest dim

ANT/POST Spinal Curves:

Lumbar Lordosis

Thoracic Kyphosis

Cervical Lordosis


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MUSCULOSKELETAL (CONT)

Changes:

ANT convexity of lumbar spine Keeps center of gravity over legs

Prevents shift of gravity by enlargening uterus

Pelvic Bowl tilts forward

=> weight is on posterior leg and pubic region

Gait steadied by sep of feet and legs while instanding position


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EXTREMITIES

Carpal Tunnel Syndrome:

Incidence 2-35% preg women

Cause: poss fluid compression of median nerve

Tend to occur last trimester

(can occur at any time)


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CHANGES BY EGA

Structural Stage 0-28 wk

28-32 wk

Congestion Stage 28-36 wk

Delivery

Postpartum


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STRUCTURAL STAGE (0-28WK EGA)

INC fat storage Uterus growth

Shift in center of gravity

Pelvis rocks forward

Mm and lig more vulnerable to mechanicalstresses

INC lumbar lordosis => compensatory thoracic kyphosis

Widening of pubic symph from 3.4mm to 7.5-7.9mm

Results in pain near symphysis Referred pain down inner thigh when standing

Results in maternal sensation of snapping or movementsof bones when walking


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CONGESTIVE STAGE (28-36WK EGA)

Mechanical, hormonal,biological

a/w oxygenation andcellular nutrition

More fluid accum than canbe removed

Expanding Uterus:

ball valve between veinsof legs and IVC Hypotensive when supine

Limits chest volume

Diaphragm must workharder


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CHANGES IN PREGNANCY

A. Leibovitz Vanity Fair Demi Moore, 7 months pregnant


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DELIVERY

Position Dorsal Lithotomy:

Sacral nutationSacrum flexes its mid-transverse axis

=> widening of pelvis


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RELATIVE CONTRAINDICATIONS FOR OMT

DURING PREGNANCY

Pre-Eclampsia

Premature ROM

Premature Labor

Abruptio Placenta

Ectopic Pregnancy


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REL TIVE OMM

TECHNIQUE

CONTR INDIC TED

CV4Craniosacral technique

May potentially inducepremature labor

(Gitlin RS, Wolf DL, Uterine ContractionsFollowing Osteopathic Cranial Manipulation: apilot study, J. Amer. Osteop. Assoc. 1992;92:1183)

Study limited by use of post-date pregnancy


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OSTEOPATHIC APPROACH TO THE PREGNANT

PATIENT

Osteopathy Potential:

Symptomatic relief fromsomatic pain;

Assistance of homeostasisthrough structural, fluidand hormonal changes of

pregnancy;

Support of labor anddelivery


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AUTONOMIC NERVOUS SYSTEM

Sympathetic Spinal Referral Region

T10-L2(ROT vert, TART) Tenderness, Asymmetry, ROM restrictions, Tissue texture abnormalities

Uterus, ovaries

Parasympathetic Spinal Referral Region

S2-S4(sacral torsion, SI joint pain)

Uterus, ovaries


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LYMPHATICS

Freeing restrictions a/w transverse diaphragms

Thoracic, Abd diaphragm

Potentially help peripheral edema and congestion


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COMMON COMPENSATORY PATTERN

LRLR

L = OA (SB and ROT same side (L))

R = C7-T1(SB and ROT same side (R))

L = T12-L1(SB and ROT same side (L))

R = L5S (SB and ROT same same side (R))


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APPROACH TO PREGNANT PATIENT

H&P

Review past trauma (MVA, etc)

Review current pregnancy

Review Ultrasound (placenta)


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EXAM AND TX; SACRUM Supine: sacrum usu L on L;

Shorter left leg (check ankles) Check ASIS for innominate dysf

Pt supine Check levels of each ASIS if level, then sacral dysf

Thenar eminences over each ASIS

Apply posterior compression to each ASIS, one at a time

Positive for dysfunction on side LEAST mobile

(can be either sacral or innominate dysf)

Pt prone (if can)

Check Inferior Lateral Angle (L) on (L) will have (L) ILA more posterior

Check Sacral Sulcus

(L) on (L) will have deeper (R) sulcus, more tender to palpation

Seated or standing flexion test Checking PSIS the one that MOVES the furthest is the POS side

Positive when Standing -> THINK INNOMINATE

Positive when Seated -> THINK SACRUM (side that does NOT move)

Pt seated Locate PSIS; place thumb under inferior notch of PSIS

Pt bends forward slowly

Positive if one PSIS moves more superiorly than the other at the end of bending

In case of torsion POSITIVE movement is OPPOSITE involved oblique axis

ME: Up-Up-Up


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EXAM AND TX; THORACOLUMBAR

T12-L1: Relax Thoracolumbar junction

(diaphragmatic attachment)

Usu Opposite above, Rot (L), SB (L)

TX: HVLA: High Lumbar Roll or seated ME


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TX: LYMPH (CONT)

Thoracic Pump: Pt supine

Stand at head, thumbs near sternum, inferior to clavicles, handsover ribs 2-5

Pt take deep breath and exhale

Exert force to exaggerate exhalation, pump 2 pump/sec tothoracic cage for 3-5 sec

Pt inhale, with doc resistance of inhalation

Repeat above 3-5 times

Last inhalation release rib cage quickly and completely

Lower Extremity Foot Pump:

Pt supine, rocks on heels moving entire body


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EXAM AND TX; THORACICS

Thoracics: Fryettes laws Type I = SB, then Rot away (usu group dysf)

Type II = Rot FIRST, then SB towards (usu segmentaldysf)

Exam with myofascial release, parallel w/ erectorspinae, checking segmental abn, tissue texture abn

Treat segmental (often peak of group), then group dysfwill often resolve

START w/ myofascial release

perpendicular mm tx,then: HVLA if able to be prone

ME if not

Upper Thor: Prone tx if possible


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EXAM AND TX; RIB, CERV, EXT

First Rib: Maintain symmetry of thoracic inlet

HVLA seated, SB toward dysf, ROT away

Cervical: Exam while performing myofascial release,

OA hold and release

TX: HVLA or ME Supine (SB tow, ROT away)

Carpal Tunnel:

Dx: Phalens, Tinels

TX: Wrist splints, exercises, lymphatic drainage


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EXERCISES IN PREGNANCY

MOVE, MOVE, MOVE!


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EXERCISES IN PREGNANCY


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EXTERNAL SUPPORT


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DELIVERY

Post Delivery prevent SI joint dysfunction

Flex hips

ADDuction of LE

Internal Rotation

Extension


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POSTPARTUM

Lymph Flow Rocking Feet Pump

Iliopsoas Stretch


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VCOM HONDURAS TRIP 2012


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REFERENCES

Channell, Millicent and David C. Mason. The 5-Minute Osteopathic Manipulative Medicine Consult.Baltimore, MD: Lippincott Williams & Wilkins, 2009. Print.

Chila, Anthony G., ed. Foundations of Osteopathic Medicine.3rded. Baltimore, MD: LippincottWilliams & Wilkins, 2011. Print.

DiGiovanna, Eileen L., and Stanley Schiowitz, eds.An Osteopathic Approach to Diagnosis andTreatment.Philadelphia, PA: J.B. Lippincott Co., 1991. Print.

Dowling, Dennis J.An Illustrated Guide to OMT of the Neck and Trunk.USA, 1985. Print.

Gabbe, Steven G., Jennifer R. Niebyl, Joe Leigh Simpson, eds. Obstetrics: Normal and Problem

Pregnancies.4thed. Philadelphia, PA: Churchill Livingston, 2002. Print. Gehin, Alain.Atlas of Manipulative Techniques for the Cranium & Face.Seattle, WA: Eastland Press,

1985. Print.

Jones, Austin L., and Michael D. Lockwood. Osteopathic Manipulative Treatment in Pregnancy andAugmentation of Labor: A Case Report. The AAOMar. 2008: 27-29. Print.

King, Hollis H., et al. Osteopathic Manipulative Treatment in Prenatal Care: A Retrospective CaseControl Design Study.JAOA103.12 (2003): 577-582. Print.

Licciardone, John C., et al. Osteopathic Manipulative Treatment of Back Pain and Related Symptomsduring Pregnancy: A Randomized Controlled Trial.Am J Obstet Gynecol. 2010 Jan; 202(1). Print.

Nicholas, Alexander S., and Evan A. Nicholas. Atlasof Osteopathic Techniques.2nded. Philadelphia,PA: Lippincott Williams & Wilkins, 2012. Print

Pratt-Harrington, Dale. Except for OMT A Board Review Book for Osteopathic Principles & Practice;Parts 1, 2, & 3.Independence, MO: 1996. Print.

Tettambel, Melicien A. OMT Benefits Mothers, Babies: Structural Imbalances Lead to LifelongProblems. The DOJun. 1999: 44-45. Print.

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