OMT In Pregnancy – NYSOMS

OMM in Pregnancy
Myra Cummings Mabry, MEd, MBA, DO

Osteopathic Manipulative Medicine
(OMM) is a body-based modality in
which the patient is evaluated and
treated as a whole to improve
physiologic functioning and remove
impediments to optimal health and
functioning

Discovering you’re pregnant…

And then reality sets in….

Physiologic Changes
in Pregnancy

Cardiovascular
• Elevated progesterone causes
smooth muscle relaxation
• Cardiac output h
• SVR i
> 24wks, return to normal

Pulmonary
• Tidal volume h
- progesterone
• Total Lung Capacity i
-elevation of diaphragm
• Dyspnea of pregnancy
-h CO2 gradient between mother and fetus

Gastrointestinal
• Nausea, vomiting
- h estrogen, progesterone, hCG
• Reflux
- h gastric emptying time,
- i sphincter tone
• Constipation
- i motility,
- h water absorption

Renal
• Kidneys enlarge
• Ureters dilate
pyelonephritis
• h GFR, i BUN , i Cr
• h Renin – h Angiotensin - h Aldosterone

Hematology
• Plasma volume h
- hemodilutional anemia
• WBC h
- mean = 10.5
• Slight i platelets
• Hypercoagulability
-h fibrinogen and Factors VII-X

Endocrine
• h Estrogen
- by placenta, ovaries lesser degree
• h Progesterone
- relaxation of smooth muscle
• h hCG
- first by the corpus luteum, then by the placenta
• h hPL
- insulin antagonist
• Breast swelling/tenderness

Key Points for OMM in Pregnancy
• OMM can be used throughout pregnancy, during
labor and post partum
• Always treat patient in whichever position they are
most comfortable!
• Usually supine or side-lying is best
• Diagnose, then treat the side that is worst
• Use patient’s own body weight to help you and
help patient to relax
HVLA is a relative contraindication in pregnancy!

Routine Problems During Pregnancy
• Back pain
• Constipation
• Edema
• Gastroesophageal
Reflux Disease
• Hemorrhoids
• Round Ligament Pain
• Urinary Frequency
• Varicose Veins
• Headaches/migraines
• Sinusitis
• Neck aches
• Joint pain (carpal
tunnel syndrome)
• Sciatica
• Hip pain/ Low back
pain
• Pubic pain

Back Pain
• Shift center of gravity increase in lumbar
lordotic curve
• As uterus grows, there is dextrorotation of
uterus into pelvis
• Subtle rotational component causes torsional
stress pattern up the spine to restrict motion of
chest, ribs, and diaphragm

Common Findings in Back Pain
• Increased lumbar lordosis
• Myofascial strains
• Paraspinal muscle strain or muscle spasm
• Lumbar-sacral junction compression

OMM Treatment of Back Pain
Soft tissue techniques
• Myofascial release
• Facilitated positional release
• Balanced ligamentous tension
- direction of ease
• Lumbo-sacral decompression
• Modified lumbar roll

Hip pain/Sciatica
Anatomy:
• Sciatic nerve roots L4-L5-
S1-S2-S3
• Exits out greater sciatic
notch along with piriformis
muscle (innervated by S1-S2)
• In pregnant females, likely
due to same rotational
component from
enlargement of uterus

Common Findings in
Hip pain/Sciatica
• L5 slides anterior
• ASIS compression
• Sacral-iliac compression
• Interosseous sacral compression sciatica
• Sacral Somatic Dysfunction
• Sacral torsions,
• Sacral base anterior/posterior,
• Unilateral sacral flexion/extension

Treatment of Hip pain/Sciatica
• Sacral Rock
• Sacral-iliac decompression
• Interosseous sacral decompression
• Sacral inhibition at S2-S3
• L5-S1 decompression
• Cupping the sacrum place palms on sacral
poles and take bone into direction of ease

Pubic pain
• Relaxin and progesterone help to loosen ligaments
extra laxity and pelvic pressure during pregnancy
• Pain from excessive levels of hormones, extra
sensitivity to hormones, pelvic misalignment, or
combination of above
• Symptoms:
• pubic bone very tender to palpation,
• pain when lifting one leg at a time or parting the
legs, walking, turning over in bed, strong round
ligament pain,
• may recur or progress with each pregnancy

Pubic pain
• Risk factors:
• Multiparity
• h/o macrosomic infant
• Pre-existing problems with joint
• Past pelvic or back pain
• Past trauma (including obstetric or gynecological)

Findings in Pubic Pain
• One iliac more superior than other
• ASIS/PSIS more superior on one side
• One pubic bone more superior than other
• Leg length discrepancy
• Named by side of (+) ASIS compression
• Also check for inflare or outflare

Treatment of Pubic Pain
• Long lever technique - gap
sacral-iliac, slight
adduction, then lean body
up or down to counteract
dysfunction
• Counterstrain – anterior
tenderpoint L5 is 1 cm
lateral to pubic symphysis
on superior ramus pt
supine, knees and hips
flexed and rotated away

Treatment for Pubic Pain
Superior Pubic dysfunction
Inferior Pubic dysfunction
*For innominate shears, add subtle abduction component

Other Common Problems & Treatments
• Headaches/migraines
• condylar decompression
• occipital-mastoid suture release
• cervical soft tissue
• Sinusitis
• venous sinus drainage
• inhibition of confluence of sinuses
• Neck Pain
• condylar decompression
• facilitated positional release,
• counterstrain

Other Common Problems & Treatments
• GERD/nausea & vomiting
• r/o other causes first
• balance sympathetics
• check T5-T9 for TART changes treat by
putting segments into direction of ease
• chapman points (anterior along ribs 5-9)
• Constipation
• hydrate first and modify diet
• release of sacrum and pelvic splanchic nerves to
the rectum

Other Common Problems & Treatments
• Dyspnea
• r/o other causes
• check for posterior diaphragm restriction
diaphragm release
• check T2-T7 for TART balanced ligamentous
tension
• Check ribs for restriction rib raising
• Edema in legs or varicose veins
• Increase lymphatic return and release diaphragm
• spreading of lymph behind knee, thoracic inlet
release, lymphatic pump if tolerable

Sympathetic Nerve Innervation
Head and Neck
Heart
Respiratory
Upper GI Tract
Stomach, Liver, GB, Spleen, head of Pancreas,
beg. portion of Duodenum
Middle GI Tract
Rest of pancreas, Duodenum, Jejunum, Ilium,
Ascending colon, prox 2/3 of transverse colon
Lower GI Tract
Distal 1/3 transverse colon, Descending colon,
Sigmoid colon, Rectum
Kidneys
Adrenal Medulla
T1 – T4
T1 – T5
T2 – T7
T5 – T9
T9 – T12
T12 – L2
T11 – L1
T10

Sympathetic Nerve Innervation
Upper Ureters
Lower Ureters
Bladder
Gonads
Uterus and cervix
Erectile tissue of penis/clitoris
Extremities
Upper (arms)
Lower (legs)
T10 – L1
L1 – L2
T11 – L2
T10 – T11
T10 – L2
T11 – L2
T5 – T7
T10 – L2

OMM in Prenatal Care: Research
King et al, JAOA, December 2003
• Study conducted in 4 cities: Chicago; Kirksville;
Bangor, Maine; San Diego
• Randomly selected equal numbers of women to receive
OMT or not receive OMT (160 vs. 161)
• Techniques applied: muscle energy, myofascial release,
ligamentous articular strain, balanced membranous
tension, HVLA, counterstrain, cranial

OMT Research Results
# Women Avg. Age # times
OMT
160
161
28.32
26.39
4.0
0
Primigravida
59
66
Received
OMT
# MSAF PTD Forceps C/S
160 12 6 10 26
No OMT 161 34 19 17 29
* MSAF- meconium stained amniotic fluid,
PTD- preterm delivery, C/S- Cesarean section

During Delivery
• OMM can improve body mechanics to help
reduce the amount of time needed to push
• Prevent need for vacuum assisted vaginal
delivery, forceps assisted vaginal delivery,
episiotomy
• Prevent weakening of pelvic floor
• Leads to uterine prolapse, bladder prolapse,
incontinence or other bladder/bowel problems
as women reach menopause

Treatments during delivery
• Limited by how relaxed patient is and whether
she had an epidural
• Sacral-iliac decompression
• expands pelvic outlet
• allows leg muscles to release (prevent cramping)
• allows patient to relax so may feel it is easier to push
• Sacral Rock

Post Partum
• OMM can help correct structural and postural
imbalances that developed during delivery
• patients feet not placed evenly in stirrups
• patient lying asymmetric to relieve pressure on
buttocks
• pubic dysfunction
• muscle spasm in back and shoulders

Post partum
• Osteopathic structural exam to make sure
vertebrae are in line – neck and spine sitting
correctly on top of hips, check for scoliosis
• Prevent back pain and other musculoskeletal
problems from developing
• Decrease risk of post-partum depression

THANK YOU

References
Callahan TL, Caughey AB, Heffner LJ. Pregnancy and Prenatal Care.
Blueprints Obstetrics and Gynecology (3 rd edition). pp 2-6.
Clofine R. OMT in Pregnancy. http://www.milleniumhealthcare.com/newweb/articles/drclofine/omt_in_pregnancy.htm
DiGiovanna EL, Schiowitz S. An Osteopathic Approach to Diagnosis and
Treatment (2 nd edition). pp 184, 227.
King HH, Tettambel MA, Lockwood MD, Johnson KH, Arsenault DA,
Quist R. Osteopathic Manipulative Treatment in Prenatal Care: A
Retrospective Case Control Design Study. JAOA (12): Dec 2003.
Kmom. Pubic pain. http://www.plus-size-pregnancy.org/pubicpain.htm
Saverese RG. OMT Review: A Comprehensive Review in Osteopathic
Medicine. pp 21-26, 58-59, 69-77.
Tettambel MA.Related Articles, Links An osteopathic approach to treating
women with chronic pelvic pain.
J Am Osteopath Assoc. 2005 Sep;105(9 Suppl 4):S20-2. Review.