Transcript File

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
◦
◦
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◦
◦
◦
◦
◦
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
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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
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What are you palpating
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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.
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Cranio Sacral Palpation
Summary
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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?
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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.
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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.
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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.