Osteopathy and Obstetrics for the BSO Clinical Masters Elective Dr Steve Sandler PhD DO

1. Osteopathy and Obstetrics for the BSO Clinical Masters Elective Dr Steve Sandler PhD DO EVALUATION OF THE OBSTETRIC PATIENT

2. Evaluation of The Obstetric Patient EXPECTANT MOTHERS CASE HISTORY Date: Osteopath: Patient's surname First Name Address 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

3. 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:

4. Evaluation of The Obstetric Patient TISSUE DIAGNOSIS (Based on questions) Presenting Symptoms: History Onset and Treatment: Aggravating Factors Relieving Factors Non Affecting Factors

5. 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

6. Evaluation of the Obstetric Patient

7. 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: Signature: Date

8. 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.

9. http://embryology.med.unsw.edu.au/WWWHuman/FetalWeight.htm

10. 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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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

23. A 2D scan used routinely this is at 18 weeks A 3D scan will show much more detail This is at 24 weeks

24. 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

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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).

31. 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.

32. External Cephalic Version

33. 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).

34. 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.

35. 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?

36. 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.

37. 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.

38. 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

39. 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

40. 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

41. 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.

42. 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.

43. 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.

44. 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.

45. 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.

46. 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

47. 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.

48. 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.

49. 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.

50. 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.