Obs and Gynae 2
Breech:
 No issue on the NHS. Private will perform a C-section due to
risk/insurance.
 Major issue is unknown breech which presents as one foot out one
foot in.
 Previously baby used to be turned – now deemed unsafe without
US before/during/after. So isn’t performed > cord around neck >
death.
 Babies which are turned usually turn back because the cord is
short or stuck to the placenta.
 Moxibustion/Chinese acupuncture can turn babies and can keep
them there.
Above diaphragm techniques cont:
Seated upper thoracic flexion/extension (spinsters thrill)
 Patient at end of table with feet on floor so you don’t throuw patient
forward.
 Can do it on a chair at edge of chair/plinth
 “Hold onto your biceps”.
 Hands through the arms onto back – don’t pressure fingers.
 Lean back and then up with an arc onto toes.
 Breathe in and stretch diaphragm as it lowers.
 Contraindications: spondylolithesis and shoulder issue.
Diaphragm lift techniques for the thoracic and ribs:
 Patient sits with hands on hips to stabilise.
 Open the costal margin > diaphragm to descend > giving more
volume to breathe > baby will descend into new space south > ribs
descend laterally > maximum rib excursion and respiratory effort.
 Operator one foot in front of the other. Patient leans back with
head onto operator. Lean back gathering up soft tissue under the
xiphyoid process. Rock back and forth using lateral borders of
hands. Rock and gather hands go laterally.
 Push patient forward roll her down with head forward by putting
feet side by side.
 Breathe in with ulnar borders of hands into costal margins and go
lateral and then patient extends. Hands now on lateral borders.
 Breathe out with hands on lateral border and support expiration by
pushing down gently.
 Repeat the rock and gather > breathe in and breathe out.
 Contraindication: no consent, be careful of breast tissue, explain
the technique, offer withdrawl.
Myofascial release for the thorax and the mediastinum:
 Mediastinum is a space. Parietal pleural membranes are lateral
borders, anterior is posterior sternum and posterior is the thoracic
vertebrae.
 Mediastinum contents are the hearts, pericardium, great vessels
(e.g. aorta), oesophagus, nerves (symps, phrenic, vagus n).
 Mediastinal technique for torsions through the pericardium, the
serous membrane sac around the heart, allowing heart free
movement.
 Pericardium has 3 layers: serous, fibrous and muscular.
 Pericardial attachments to sternum/diaphragm/vertebrae of thorax,
CSp and base of occiput.
 Idea is to unwind the fascias through the pericardium.
 Do not have patient supine as it can impinge on inferior vena cava
> BP drop > faint.
 Have patient SL on Left or sitting.
Technique set up:
 Diaphragm hold on anterior sternum and posterior vertebra, hands
both pointing towards opposite hip.
 Consent for technique due to closeness in breast tissue.
 Connect to the tissue. Be soft hand. Use body weight to create
pressure – do not push.
 Be interested in the space between your hands.
 Both techniques listed work on MM, ligaments, bone, CT.
 Both are POE and BLT: one is follow, the other hold the tension.
1. FUNCTIONAL TECHNIQUE:
 6 parameters of movement: up/down, AP, sideshift, SB,
FLEX/EXT, ROT. Find balance between each vector. Wait.
Breathe in. wait. Then follow as release unwinds passively.
 This is harder to achieve with a pregnant patient
2. Myofascial Technique:
 Stacking the vectors in 3D. Choose with is the most dominant
vector eg EXT or FLEX > add all vectors. Wait for 90 seconds and
hold that space. Each vector gets fatigued > warmth as blood
rushes in and tensional release. Tissue might fight a little.
Breathing issue and “stuck feeling” may occur > wait for release.
HVLA Thrust techniques:
 Do not press on abdomen.
 Do not keep pregnant at EOR in wind up.
 All these techniques are at minimal lever at fast speed- short and
crisp.
 Seated techniques are better for BP than supine and dog.
 Short lever and short impulse.
 Lift off is not lifting patient but lifting vertebrae off the other.
Lift off seated Tspine:
 Lift off – V of arms. For top TSp have hands either side of neck, for
lower Tsp have hands on the side of thorax. This creates a W.
creates more focus.
 Can adapt the same thing for the Dog technique.
 Combination of levers into SB, flexion, reverse rotation, extension.
As you approach extension you drive the force through the single
elbow toward your chest as a pectoral squeeze.
 Get patient to go through the movement circles let them lean back
and be floppy. Get speed. And when wound up thrust.
Dog technique:
 Be careful of breast tissue and power through the abdomen.
 No different to seated technique – except gravity and fulcrum.
 Examine: get patient away from you a little more.
 Roll patient from shoulder and pelvis onto her side. Put elbow into
her bottom. Now examine into each segment going back towards
the table.
 Technique: release facet above by holding the facet below. Use of
fist or flat palm. Better way is an open hand with the thumb
gripping the SP to make a sulcus with slight wrist extension.
 Move the vertebrae below north and move the vertebrae above
south with applicator.
 Put pillow to increase the tension around the fulcrum.
 Flex beyond the lesion. Grip vertebra below and hold. Hold
position of arms with chest. Introduce SB and ROT through the
shoulder.
 Thrust through the shoulder with no chest compression.
Below the diaphragm
 Weight gain pregnancy –used as a guide by obstretrician and
midwives as an indicator of health. No weight gain
(anorexic/lack of nutrition) or too much (obese e.g. gestational
diabetes from too much GH) is a concern. Diabetic mothers can
have a 9/10 lbs baby.
 PCOS > ↑ androgens and ↑ oestrogen > masculine features.
PCOS can lead to DM. Patient given metformin which
desensitizes the tissue oestrogen receptors are desensitized)
so the hyperandrogenaemia does not take place.
 Somatotrophin > parallel levels > not sure what was said. GH
and androgenaemia. See Netter’s book on internal medicine.
Fluid changes:
 Pregnant patient is Hyperhydrated > renal function changes and
altered sensitivity of the control mechanisms. GFR ↑ 50%.
 Glomerulus: high pressure blood from the aorta to the renal artery
> small arteriole > Knot of arterioles and then continue on their
way. It is contained inside the cup with a filter which drips into the
draining descending tubule > connecting duct > ascending tubule.
 The cup and knot is the glomerulus. The bit beside the glomerulus
is the juxtaglomerulus which deals with the pressure going into the
glomerulus. The same afferent arteriole and efferent arteriole wires
around the tube before going to the renal vein.
 Small filtrate goes through the glomerulus > eg NA and CL etc into
the tube > reabsorbed in the tubules. Urine dilution and
concentration changes > into ureters > bladder.
 Glomerulus works to change the body’s water balance and the
concentration of urine.
 Disease processes that effect the basement membrane of the
glomerulus > oedema (SLE/collagen settling disease/rheumatoid
disease). With large proteins in urine > basement membrane is
damaged letting proteins through (pre-eclampsia).
 Urine – glycosuria can be present due to increased glucose in
blood – not a sign of DM.
 Late stages of pregnancy > increased calcium absorption >
parathyroid hormone regulation of calcium > blood calcium
increases > filtrate of calcium > calculi in kidney > teeth and nails
fall out.
 Reninangiotensin system stimulated > Aldosterone secretion in
adrenal cortex is stimulated > ACTH from anterior pituitary
secreted increases > 40% pituitary gland enlargement.