Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download File
Transcript
Osteopathy and Obstetrics for the BSO Clinical Masters Elective Dr Steve Sandler PhD DO EVALUATION OF THE OBSTETRIC PATIENT Evaluation of The Obstetric Patient EXPECTANT MOTHERS CASE HISTORY Date: Patient's surname Address Osteopath: First Name Age Date Of Birth Weight (Kg/ Stones) Weight Gain Telephone numbers and email Children including names and ages Occupation and interests GP or Midwife name and address Evaluation of The Obstetric Patient OBSTETRIC DETAILS Expected date of delivery: Number of weeks: Type of care: ( shared care; GP, community midwives; Consultant care Where booked: Scans: (dates and results) Blood tests: (dates and results) Miscarriages and terminations:( including dates and number of weeks) Problems with previous pregnancies: Length of previous labour: Forceps Venteuse or other interventions: Evaluation of The Obstetric Patient TISSUE DIAGNOSIS (Based on questions) Presenting Symptoms: History Onset and Treatment: Aggravating Factors Relieving Factors Non Affecting Factors Evaluation of The Obstetric Patient MEDICAL HISTORY ILLNESS AND OPERATIONS ACCIDENTS GENERAL HEALTH 1. DIET 2. GIT 3. RENAL AND URINARY 4. CVS AND RESPIRATORY 5. ENDOCRINE 6. GYNAE BEFORE PREGNANT MEDICATIONS:( to include proprietary medicines, vitamins, herbal preparations and prescribed medications) SMOKING/ ALCOHOL REMARKS AND IMPRESSIONS IMPORTANT SOCIAL FACTORS Evaluation of the Obstetric Patient Evaluation of The Obstetric Patient EVALUATION To include tissues causing local and general pathology, aetology, predisposing and maintaining factors. Why did this patient present with this problem at this time? Aim of management in the short term: Aim of management in the long term: Special precautions: Further examinations to be performed: First visit treatment given: Instructions to patient: Prognosis both long and short term: Name: Date Signature: Weight Gain on the Case Sheet ◦ It is good practice to include weight gain as well as her current weight. ◦ Midwives use weight gain as an indicator of good obstetric health. ◦ It is common at the beginning of a pregnancy for the patient to lose weight especially if she is vomiting a lot, but continued weight loss may be a sign that all is not well with the foetus which might lead them to request further tests and scans to assess the growth of the baby. http://embryology.med.unsw.edu.au/WWWHuman/FetalWeight.htm Obstetric Details on the Case Sheet Expected date of delivery / Number of weeks You need both pieces of information to avoid having to work it out Obstetric Details on the Case Sheet Type of care: Shared care; GP care community midwives; Consultant care Shared care is where she is healthy and well but the GP who is looking after her ante natal care elects to have the patient delivered by the local hospital staff before he resumes the post natal care. GP care is where he looks after her for the delivery too Community midwives are employed by the GP or local authority to see normal routine ante and postnatal.They will also be involved in home births or birhs in the GP unit. Consultant care is either high risk NHS patients or private hospital and private consultant care. What happens at the ante natal visits? The first antenatal appointment will probably be the booking-in appointment and usually happens at about eight to 12 weeks. In some areas, this is done at home by a community midwife; in others, the patient may be asked to visit the hospital. If she plans to have her baby at home, she will almost certainly have this appointment at home or at her local health centre. What happens at the ante natal visits? At the booking visit she will be asked a number of questions about her health, family history and any previous pregnancies. The aim is to get a basic picture of her health and her pregnancy so far. What happens at the ante natal visits? Routine checks at other appointments are likely to include blood pressure, weight, listening to her baby's heart ,questions about the baby's movements, urine tests for protein and infections, and checking for any swelling in the legs, arms or face. This is oedema and high blood pressure ,oedema and protein in the urine constitute the clinical triad called pre eclampsia a potentially serious condition which would require immediate referral by an osteopath to the labour ward. What happens at the ante natal visits? Follow up tests at the clinic or the hospital will depend on how she is doing and how well the baby is growing. Not counting appointments for scans or other hospital-based tests, she can expect to have appointments every four weeks after week 12, every two weeks from week 32, and every week during the last three or four weeks. What happens at the ante natal visits? The National Institute for Health and Clinical Excellence (NICE) guidelines recommend that healthy women have up to ten check-ups for a first pregnancy, including the booking visit. For second and subsequent pregnancies seven visits is common. NICE clinical guideline 55 Intrapartum care: care of healthy women and their babies during childbirth . 2007 What happens at the ante natal visits? Major Ante Natal Complications: ◦ Isoimmunisation ◦ Bleeding ◦ Polyhydraminos ◦ Oligihydraminos ◦ Associated clinical conditions that pregnancy interferes with such as cardiac problems or kidney problems What happens at the ante natal visits? Minor Ante Natal complications : ◦ Vomitting ◦ Gastric Reflux ◦ Constipation ◦ Pruritis vulvae ◦ Vaginal discharge ◦ Cramps ◦ Varicose veins ◦ Haemorrhoids ◦ Back pain ◦ Fainting ◦ Parasthesia Blood tests and ultra sound scans during pregnancy Normally, a small sample of her blood is taken at the first antenatal appointment. she may also be asked to give a sample in later pregnancy.The first test can: Identify her blood group See whether her blood is rhesus positive or negative Check for conditions that could affect her health or her baby's (this may or may not include HIV) Check for immunity to rubella (German measles) Check for anaemia Blood tests and ultra sound scans during pregnancy Blood tests can also be used to estimate the risk of Down's syndrome. A blood sample is taken at about 16 weeks to measure three substances: alpha-fetoprotein (AFP), unconjugated oestriol and human chorionic gonadotrophin. Together with the mother's age, these give an estimate of risk. The level of AFP can also be used to assess the risk of a neural tube defect, such as spina bifida. Ultra sound scans A scan at about six to eight weeks is used to confirm/date the pregnancy, see if it's ectopic (developing in the fallopian tubes, not the uterus) and check the foetus is alive by looking for a heartbeat A scan at about ten to fourteen weeks is used to confirm and date the pregnancy, to check for twins ( especially if this is an IVF pregnancy) and when offered alongside a nuchal scan (which looks at a pad of skin at the back on the baby's neck) assess the risk of Down's syndrome or other chromosomal conditions Ultra sound scans A scan at about twenty to twenty three weeks is used to check for spina bifida and other possible abnormalities, look in detail at the baby's major organs and skeleton, check the health of the placenta and monitor the baby's growth Later scans monitor the baby's growth and check the position of the placenta and the baby A 2D scan used routinely this is at 18 weeks A 3D scan will show much more detail This is at 24 weeks Labour At around forty weeks most women will go into labour. Regular contractions, the show or loss of the mucous plug, or the breaking of her waters are all accepted as signs that she has started to give birth. During a first-time birth, a first labour lasts 16 hours on average, however, this can vary tremendously. Labour can be divided into three stages. Stage one, where the cervix dilates, is subdivided into three phases, early, active and transition Labour Early labour is the longest part, lasting eight to 10 hours plus. In this phase, the cervix opens from 0 to 3 cm. Contractions are mild and between five and 20 minutes apart. She may notice that it takes some effort to get through the contractions as she goes from early labour into active labour. In active labour, contractions last about one minute and are about two to five minutes apart. Active labour lasts about three to five hours and the cervix dilates from 4 to 7 cm. Labour The most intense phase of labour is transition. Contractions are only about a minute apart and may last up to 90 seconds as her cervix opens from 8 to 10 cm. This is the shortest phase of labour and she will soon be ready to push. Labour Stage two is the part of labour where she pushes the baby out. Some women have a little resting period after the cervix opens all the way and before they get the urge to push. Contractions can be about five minutes apart during pushing and last for about a minute. During this phase the baby descends through the pelvis, down through the birth canal and crowns on the perineum, and is then born. Pushing may last anywhere from 15 minutes to two hours on average. Labour The third stage of labour is the delivery of the placenta. This may happen anywhere from 15 minutes to an hour after the baby is born. Caesarean section There are two types of caesarean section, elective section where the decision is made a long while before the birth process starts and an emergency section where labour has started and for various reasons the obstetrician decides that there is a problem and operates to deliver the child surgically. Delivery by caesarean section has been the subject of intense debate in recent years. One thing that is for certain is that it is always better to deliver with a section that is planned rather than have an emergency operation. Caesarean section Her obstetrician might advise an elective Caesarean if: ◦ She have serious pre eclampsia mentioned before ◦ She have a serious medical condition which means that she should avoid the stress of labour ◦ She are expecting a multiple birth ◦ The placenta is positioned across the neck of the womb, making it impossible for she baby to be born vaginally. This is known as placenta previa. ◦ The baby is laying transverse across the uterus and cannot be turned to a head down position ◦ The baby is too big to be able to get through she pelvis. This is known as Cephelo Pelvic Disproportion ( CPD). Breech Deliveries Whether all breech babies should be delivered by Caesarean is a matter of obstetric debate. Some obstetricians prefer to turn babies into a head down position at the end of pregnancy (this is called external cephalic version or ECV), or to give the mother the chance to try for a vaginal delivery with her baby in the breech position. The research is currently unresolved about whether it is safer to deliver breech babies vaginally or by Caesarean. External Cephalic Version Caesarean section An emergency Caesarean might become necessary after labour has started because: ◦ The baby’s heartbeat shows that he is not coping well with contractions (in medical terms, the baby is described as being ‘distressed’) ◦ The cervix stops dilating or dilates very slowly so that both mother and baby become exhausted ◦ The placenta starts to come away from the wall of the uterus and there is a risk of haemorrhage (bleeding) this called an abruption. ◦ The baby does not move down into the pelvis, indicating that the pelvis is too small for the baby to get through (CPD). The Post Partum Period It is good practice having taken care of your patient during her pregnancy to offer her a post natal visit at six weeks to check her and to ensure that any problems you treated during the pregnancy have resolved and that she can be discharged from your care. Of course if she is still suffering from any pains that she consulted you about during the pregnancy or if there have been issues that arose as a course of the labour she can and should be offered the earliest possible appointment for treatment as long as she has been seen by the midwives and or the health visitor. At six weeks if you treat new born babies ask them to bring the baby along for a post natal visit too. QUESTIONS TO BE ASKED AT EVERY VISIT WHEN TREATING A PREGNANT PATIENT TO SEE IF ANYTHING IMPORTANT HAS CHANGED 1. EDD? 2. Number of weeks? 3. Last ante natal visit? 4. Any further scans or blood tests? 5.Any obstetric abnormalities? 6. Are they fit and well? 7. Any abnormal vaginal discharge? 8. Any vaginal bleeding? 9 Any abdominal cramping? 10. Is the patient still fit to treat or should she be referred back to the doctor or midwife as a matter of urgency? Structural Diagnosis The commonest problems you are going to be called upon to treat in pregnancy are still mechanical low back problems as the first presenting symptom. SIJ lesions ,facet joint pain, and disc lesions are all common and your Q and A are the same as for a non pregnant patient. Structural Diagnosis Low back pain in pregnancy is common. It has been estimated that up to 72% of pregnant women will develop back pain in pregnancy. Other studies put the figures around the 50% mark. . Low Back Pain of Pregnancy. Orvieto R, Achiron A, Ben-Rafael Z, Gelernter I, Achiron R. 1994. Acta Obstet Gynaecol Scand 73(3) 209-14. . Pain patterns in pregnancy and “catching” of the leg in pregnant women with posterior pelvic pain. Sturesson B, Uden G, Uden A, 1977. Spine 22(16): 1880-3 Low back pain and pelvic pain during pregnancy: prevelance and risk factors. Mogren IM, Pohjanen AL 2005.xSpine 30(8):983-991 One researcher maintains that during pregnancy, serious pain occurs in about 25%,of patients studied and severe disability in about 8% of patients. After pregnancy, problems are serious in about 7%. Pregnancy-related pelvic girdle pain (PPP), I:Terminology, clinical presentation, and prevalence. Wu WH, Meijer OG,et al .Eur Spine J. 2004 Nov;13(7):575-89. Epub 2004 Aug 27. Structural Diagnosis Disc pain has the following characteristics ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Morning pain and stiffness Weight bearing component Age of the patient Increased abdominal pressure Sleep not usually disturbed Daily pattern History of repeated micro trauma Movement eases pain but not for long they tend to fidget. ◦ Going uphill ◦ Getting out of a chair ◦ Supermarket type shopping Structural Diagnosis Facet Joint pain has the following characteristics ◦ ◦ ◦ ◦ NOT weight bearing Related to movement specifically rotation Does not like lateral compression History of relatively small injury in relation to great pain ◦ Eased by rest ◦ Referred to an extremity ◦ Not affected by coughing or sneezing Structural Diagnosis SIJ pain has the following characteristics ◦ Definite laterality to pain ◦ Pain does not cross midline ◦ Can be referred or root pain ◦ Turning in bed provokes pain ◦ Getting in or out of bath lifting leg is painful ◦ Getting out of the car causes pain ◦ Going upstairs i.e. taking the whole weight of the body against gravity causes pain ◦ Pain referred to groin or genitals ◦ Pain goes over hip not to the hip ◦ Pain with opening legs for sexual intercourse ◦ Pain related to menstruation prior to pregnancy Structural Diagnosis It would be usual to begin the osteopathic examination with a postural examination standing just as in the majority of our patient examinations in regular practice. However in pregnancy her posture is going to change during the three trimesters if it is able to do so. The postural changes of pregnancy During the different phases of pregnancy because of the weight gain and how this extra weight is carried, a pregnant woman's posture in the A/P plane will change radically three times over 40 weeks. There have been many papers investigating the relationship between low back pain and postural changes in pregnancy but results have been inconclusive. Exercise, posture, and back pain during pregnancy : Part 1. Exercise and posture this article.G. A. Dumas, J. G. Reid, L. A. Wolfe, M. P. Griffin and M. J. McGrath Queen's University, Kingston, Canad Clinical Biomechanics, Volume 10, Issue 2, March 1995, Pages 98-103 The relationship of low back pain to postural changes during pregnancy JE Bullock, GA Jull, MI Bullock - Aust J Physiother, 1987 An analysis of posture and back pain in the first and third trimesters of pregnancy. Franklin ME, Conner-Kerr T. J. Orthop Sports Phys Ther. 1998 Sep;28(3):133-8. Not every woman gets back pain during a pregnancy, it is the body's inability to cope with the change that produces the problem. Osteopaths should be capable of analysing the patient in front of them and assessing how her body is trying to change. Then by treating the areas responsible for governing that change such as the CD and the TL junctions to facilitate that change as her baby grows, we can be capable of reducing the amount of back pain significantly during pregnancy. The posture at the end of the first trimester During the first twelve weeks as the uterus grows it starts to rise out of the pelvis. It pushes the abdominal contents in front of it and an increased tension is noted in the rectus abdominus muscles as the uterus "leans" against them. These muscles are attached between the xiphoid process and the pubic symphasis. As they contract in response to the stretch imposed upon them by the expanding uterus ,there is a flattening of the lumbar lordosis and a posterior rotation of the pelvis. The success of this change allows more room for the uterus and the foetus to develop. It relies on normal mobility of the lumbar spinal segments especially the L5/S1 segment. Unfortunately anomalies of spinal segments are common and this can alter the relationship between the vertebrae and thus the ability of them to change under conditions of changing demand. The thoraco lumbar junction too is an important area. The attachments of the ribs and the differing demands of muscles attached in this region such as the diaphragm, quadratus lumborum, and the inter costal muscles will again affect the ability of the TL junction to allow normal change with advancing pregnancy. Likewise the increase in thoracic kyphosis can lead to rib muscle or diaphragm pain at this time Posture at the end of the second trimester The shape of the spinal curves at the end of the second trimester in a patient with a deep lumbar lordosis and a patient with a shallow lordosis. It is at this time that the shape of the thoracic kyphosis is influenced. The breasts will change in shape and size at any time during the pregnancy but by the end of the second trimester they can cause an anterior rotation of the arms around the chest wall and a deepening of the cervical lordosis bringing the eyes up to the horizontal plane. Thoracic spinal muscle pain is common at this time. Posture at the end of the third trimester There are two distinct and different postures that can develop at the end of the third trimester. Both are dependent on her pre pregnancy posture. Approximately 75% of women will develop the typical deep lordosis of pregnancy. This is especially so if she is of Afro Caribbean origins. Posture at the end of the third trimester The increase in lumbar lordosis will put strain on the lumbar spinal facet joints and cause them to become symptomatic. The increase in lumbar lordosis will put strain on the lumbar spinal facet joints and cause them to become symptomatic. The joints at L5 /S1 are not usually weight bearing joints, but if they are forced to carry weight they can develop symptoms. If she has a congenital defect at the pars inter articularis, she can develop back pain due to a spondylolisthesis at this time. Likewise the extra weight on the Sacro Iliac joints can cause problems. If she carries the bulk of the developing abdomen on her pubic symphasis this can cause pubalgia or Symphasis pubis dysfunction. This is a common problem and one which can vary from being very painful indeed (8-10 on a VAS scale) to just a minor discomfort when walking. Patients report not being able to turn over in bed, not being able to take weight on their feet for the first few steps and needing elbow crutches or a walking frame in order to get about. The evaluation of the whole pelvic ring is of maximal importance at this time. ( see later) The increase in lumbar lordosis will also cause increased pressure on the bladder and may lead to stress incontinence. It is important to quiz the patient about the sort of incontinence she has. Does she leak when she coughs laughs or sneezes ,and how much does she leak? Is she losing a few drops and thus absorbed by a panty liner or has she had episodes where she is neurologically incontinent ,wetting herself without warning and losing control of the bladder completely. If the pressure on the last lumbar segments is such that she disturbs an otherwise stable spondylolisthesis then it is possible that the loss of urinary control is a cauda equina symptom and the patient must be referred immediately to the local Accident and Emergency department for assessment as this can be a neurosurgical emergency and you may be the first person to see it. The sway back posture at the end of the third trimester. This patient was at the end of her pregnancy!!! This is seen in approximately 25% of patients and at the end of the pregnancy they appear hardly pregnant at all. Tall thin women are more likely to be seen with this posture. There is nothing inherently wrong with this posture, but tall thin women do have a tendency towards hyper mobility anyway, and so fatigue of the postural muscles as they protect the joints from overstrain is the main problem to be overcome in these cases. The lateral plane posture A curve in the lateral plane is a scoliosis If the tilt is such that a scoliosis is exaggerated then the effects on the descent of the diaphragm and the flaring of the rib cage may mean that she develops difficulty in breathing in the middle of the pregnancy rather than at the end . The altered weight bearing can cause extra weight to be delivered to the hips knees and feet on one side, again causing them to become symptomatic when they might otherwise have been compensating for the scoliosis well. Foot pain can develop if the longitudinal arches collapse under the increased weight and ligamentous laxity. The standing exam The standing exam starts as in the non pregnant with the patient standing in her underwear with her back towards you. Do not stand too near as you will not see the whole picture. Look for the features of interest in the AP and Lateral planes just as in the non pregnant patient and record them on the chart in the usual way. The integrity of the abdominal muscles is important. If the patient has had previous abdominal operations the scar tissue will be resistant to stretch and this could prevent the lordosis from developing. Also, if the patient has had several children in a short space of time her abdominal muscles are more likely to have lost tone and thus not support the weight of the growing foetus. This could lead to the establishment of the lordosis too early with all of the attendant problems. Global listening assess where her centre of gravity lies, either anterior or posterior to the normal point of balance. Is there is a tendency for the hands to be pulled one way or the other according to the drag of the fascial chains? If her breasts are large and the shoulders rotated around the chest wall this will cause an anterior pull. If there is a deep lordosis this might cause a posterior pull. Assessment of the A/P fascial pulls through the upper part of her body. Now moves the hands below the diaphragm with one hand on her belly and the other at the T/L junction. The postural muscle and fascial pulls are assessed as before. Thirdly place one hand under her swollen abdomen and the other over the spinal muscles. The abdominal hand lifts the bump taking the weight and the spinal hand palpates the response to this movement in the spinal muscles. The muscles immediately relax as the task of holding the weight of the gravid uterus is temporarily taken by the abdominal hand. Assessment of the A/P fascial pulls through the lower part of her body. The examination proceeds with an account of active movements done in the standing and/or the sitting positions in the usual way. In the Expectant Mothers Clinic here at the BSO we use the circle system of notation to record findings both in a quantitative and qualitative manner. The Triangle Test This is a standing exam used to make a differential diagnosis between pain coming from the SIJ the lumbar facets and the posterior fibres of the annulus Examination of the patient laying down The first problem we face with pregnancy is that we cannot examine the patient face down for obvious reasons. We do not want her supine for too long as any undue pressure from the gravid uterus in this position will cause pressure and hence congestion in the great vessels taking blood back to the heart from the lower extremities and the pelvis. This can cause dyspnoea and dizzyness if her BP drops and the effect can be very disturbing and dramatic! Single leg flexion to assess spinal movements in the S/L position The best position is to have the patient on her side, and to use just one leg to assess flexion and extension again to avoid compressing the abdomen. Evaluation of the Sacro Iliac Joints The joint can be assessed in the standing position ( triangle test ) Standing and then sitting to assess pelvic points( ASIS PSIS Iliac crest) And side lying as in the test before , a movement test A/P. Side lying can also be assessed as a shearing and compression test at both the superior and inferior poles of the joint. You are looking to compare movement and a painful response to motion. Supine testing for the SIJ ◦ Be careful of innominate rotation. ◦ If you lift the leg from the table then you encourage total pelvic bone rotation. Attached between the iliac crest and the TP of L5 is the ilio lumbar ligament, a structure full of nocioceptive fibres, so any rotation puts this on stretch and now you lose the differential diagnostic test because pain could be coming from either structure Hip flexed is wrong as no D/D test Keep the foot flat on the table for pure SIJ motion The Abduction test The adductor magnus muscle is inserted onto the ramus of the pubic bone ,and if the sacro iliac joint is in lesion there will be a restriction in full opening on that side. The Pelvic Ring Syndrome The pubis should be assessed Look for any up slip or down slip on one side Any gaps between the pubic bones anteriorly and superiorly Inferiorly and posteriorly can only be checked with a PV technique and this is almost never done by the osteopath during pregnancy THE EXAMINATION Consent Forms, and the offer if not the use of a chaperone are now mandatory. Verbal consent for the examination are no longer sufficient. According to a recent GOsC ruling ,the superior border of the ramus of the pubis including the pubic symphasis is now designated an intimate genital area. PALPATING THE PUBIC SYMPHASIS 1 PALPATING THE PUBIC SYMPHASIS 2 PALPATING THE PUBIC SYMPHASIS 3 PALPATING THE PUBIC SYMPHASIS 4 PALPATING THE PUBIC SYMPHASIS 5 PALPATING THE PUBIC SYMPHASIS 6 PALPATING THE PUBIC SYMPHASIS 7 Cranio Sacral Evaluation What are you palpating ◦ ◦ ◦ ◦ Bone Ligamentous tension Fluid The PRM ◦ It is very important to have an understanding of what you are trying to feel just as in the spine. What qualitative motion can you feel? Cranio Sacral Evaluation Having the patient S/L with the occiput in one hand and the sacrum in the other can be a much easier way of feeling things. Concentrate on one hand and then the other before you can feel the full flexion extension motion of the whole system. Cranio Sacral Palpation Summary The evaluation of the pregnant patient is not just the evaluation of the structural mechanical system. This will form the major part of what can be done with pregnant women, but it is by no means the only things we assess. An evaluation of the fascial chains both above and below the diaphragm and into the pelvis is essential if we are to comprehend the effects this is having on our patient during the pregnancy. Just how much change is taking place and how successfully? Are the tissues supporting the viscera and organs being overstretched because of the growing foetus? The organs themselves have to be assessed where possible given that the position of the organs is going to change because of the rising bulk of the gravid uterus. Changes in the cardio vascular and respiratory systems, changes in the position of the abdominal organs and the uterus and bladder which should take place physiologically as she progresses through the pregnancy will all have a part to play in how comfortable she is and how she is coping with the incredible demands that pregnancy places on her. The osteopath is ideally placed to evaluate these changes and to see if his techniques can improve and facilitate that change and play their part in the structure function equation.
