OSTEOPATHIC OBSTETRICS

CAN BE A REALITY
Dr. Diane M. Aslanis, FACOOG
April 18, 2013

No Financial Disclosures

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

OVERVIEW:
Pregnancy Changes
Relative Contraindications for OMM
Osteopathic Medicine Applied

PREGNANCY CHANGES BY SYSTEM:

Cardiovascular
Body Water Metabolism
Hormonal
Respiratory
Musculoskeletal

CARDIOVASCULAR CHANGES IN PREGNANCY:

Heart:

Changes

are consistent with a chronic

strain on the heart
Heart Sounds
96% females have Systolic Ejection Murmur
18% females have Diastolic Murmur

(warrants

further evaluation)

CARDIOVASCULAR (CONT):
Cardiac Output: (CO = SV x HR)
CO 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)

CARDIOVASCULAR (CONT)

Normal Changes in Preg that Mimic HT Dz:

DYSPNEA:

COMMON

75%

women exp by 3rd Trim

Most 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

CARDIOVASCULAR (CONT)

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

CARDIOVASCULAR (CONT)
Organ Volumes
Cavity Pressures
Relative reversal of
venous blood flow
Vascular Congestion

Causes

edema,
constipation, bladder
pressure, varicosities,
hemorrhoids

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

BODY WATER METABOLISM

Chronic Volume Overload

6.5-8.5L total body water by end of pregnancy

3.5L =
1.5-1.6L =
1.2-1.3L =
300-400mL =

Fetus, Placenta, Amniotic Fluid

Maternal Blood Volume
Plasma Volume
RBC

HORMONAL

Relaxin causes:

weakening of muscles and ligaments

fluid

retention
Estrogen
Progesterone

Estrogen
Progesterone

RESPIRATORY

Pt in state of Chronic Hyperventilation

Mechanical Changes of Up Resp System

Subcostal angle from 68 to 103
Chest transv diam by 2cm
Chest circumference by 5-7cm
Level of diaphragm rises 4cm

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

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

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 in

standing position

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)

CHANGES BY EGA
Structural Stage 0-28 wk
28-32 wk
Congestion Stage 28-36 wk
Delivery
Postpartum

STRUCTURAL STAGE (0-28WK EGA)

INC fat storage

Uterus growth
Shift in center of gravity
Pelvis rocks forward
Mm and lig more vulnerable to mechanical
stresses
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 movements

of bones when walking

CONGESTIVE STAGE (28-36WK EGA)

Mechanical, hormonal,
biological
a/w oxygenation and
cellular nutrition
More fluid accum than can
be removed
Expanding Uterus:

ball valve between veins

of legs and IVC
Hypotensive when supine
Limits chest volume
Diaphragm must work
harder

CHANGES IN PREGNANCY

A. Leibovitz Vanity Fair Demi Moore, 7 months pregnant

DELIVERY

Position Dorsal Lithotomy:

Sacral

nutation

Sacrum

flexes its mid-transverse axis

=> widening of pelvis

RELATIVE CONTRAINDICATIONS FOR OMT

DURING PREGNANCY

Pre-Eclampsia
Premature ROM
Premature Labor
Abruptio Placenta
Ectopic Pregnancy

RELATIVE OMM
TECHNIQUE
CONTRAINDICATED

CV4
Craniosacral

technique
May potentially induce
premature labor

(Gitlin RS, Wolf DL, Uterine Contractions

Following Osteopathic Cranial Manipulation: a
pilot study, J. Amer. Osteop. Assoc. 1992;
92:1183)
Study limited by use of post-date pregnancy

OSTEOPATHIC APPROACH TO THE PREGNANT

PATIENT
Osteopathy

Potential:

Symptomatic

relief from

somatic pain;
Assistance of homeostasis
through structural, fluid
and hormonal changes of
pregnancy;
Support of labor and
delivery

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

LYMPHATICS
Freeing restrictions a/w transverse diaphragms
Thoracic, Abd diaphragm
Potentially help peripheral edema and congestion

COMMON COMPENSATORY PATTERN

LRLR
L

=
R =
L =
R =

OA (SB and ROT same side (L))

C7-T1 (SB and ROT same side (R))
T12-L1 (SB and ROT same side (L))
L5 S (SB and ROT same same side (R))

APPROACH TO PREGNANT PATIENT

H&P
Review

past trauma (MVA, etc)

Review current pregnancy

Review Ultrasound (placenta)

EXAM AND TX; SACRUM

Supine:

sacrum usu L on L;

Shorter left leg (check ankles)

Check ASIS for innominate dysf

Pt supine

Pt prone (if can)

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)
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

ME:

In case of torsion POSITIVE movement is OPPOSITE involved oblique axis

Up-Up-Up

EXAM AND TX; LUMBAR

L5-S:

Usu opposite sacral torsion;

Most

common ROT w/ same side SB

Rot (R), SB (R)

Check

for EXT (wont go into flexion)

or FLEX (wont go into extension)
TX: HVLA: Lumbar Roll (dysf side up)

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

TX: LYMPH

Diaphragm Doming Myofascial Release:

Pt

supine
Grasp lower aspects of ribcage w/ palms
Keep fingers apart, thumb and thenar eminences just
below costal margins
Pt takes deep breath and exhale
Follow pts exhalation to gently exaggerate motion of
diaphragm
Repeat 3-5 times

TX: LYMPH (CONT)

Thoracic Pump:

Pt supine
Stand at head, thumbs near sternum, inferior to clavicles, hands
over ribs 2-5
Pt take deep breath and exhale
Exert force to exaggerate exhalation, pump 2 pump/sec to
thoracic 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

EXAM AND TX; THORACICS

Thoracics:

Fryettes laws

Type I = SB, then Rot away (usu group dysf)

Type II = Rot FIRST, then SB towards (usu segmental
dysf)
Exam with myofascial release, parallel w/ erector
spinae, checking segmental abn, tissue texture abn
Treat segmental (often peak of group), then group dysf
will 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

EXAM AND TX; RIB, CERV, EXT

First Rib:

Cervical:

Maintain symmetry of thoracic inlet

HVLA seated, SB toward dysf, ROT away

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

EXERCISES IN PREGNANCY

MOVE, MOVE, MOVE!

EXERCISES IN PREGNANCY

EXTERNAL SUPPORT

DELIVERY

Post Delivery prevent SI joint dysfunction

Flex

hips
ADDuction of LE
Internal Rotation
Extension

POSTPARTUM
Lymph Flow Rocking Feet Pump
Iliopsoas Stretch

VCOM HONDURAS TRIP 2012

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. 3rd ed. Baltimore, MD: Lippincott
Williams & Wilkins, 2011. Print.
DiGiovanna, Eileen L., and Stanley Schiowitz, eds. An Osteopathic Approach to Diagnosis and
Treatment. 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. 4th ed. 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 and
Augmentation of Labor: A Case Report. The AAO Mar. 2008: 27-29. Print.
King, Hollis H., et al. Osteopathic Manipulative Treatment in Prenatal Care: A Retrospective Case
Control Design Study. JAOA 103.12 (2003): 577-582. Print.
Licciardone, John C., et al. Osteopathic Manipulative Treatment of Back Pain and Related Symptoms
during Pregnancy: A Randomized Controlled Trial. Am J Obstet Gynecol. 2010 Jan; 202(1). Print.
Nicholas, Alexander S., and Evan A. Nicholas. Atlas of Osteopathic Techniques. 2nd ed. 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 Lifelong
Problems. The DO Jun. 1999: 44-45. Print.