Osteopathy and Obstetrics

Stephen Sandler

• Publisher: Handspring Publishing
• Year: 2021
• ISBN:
  9781913426248
• Edition: 2
• Topic: Medicine
• Subtopic: Alternative & Complementary Medicine

Osteopathy and Obstetrics is already well-established as a textbook for postgraduate and undergraduate students of osteopathy. In this new edition, now in full color throughout, the original text has been revised to emphasise the physiological need for change that every pregnant woman undergoes, as well as showing the consequential anatomical developments.

This revised and expanded version also gives greater emphasis in every chapter to safety issues, and to ensuring safe practice in diagnosis and treatment

The text is divided into three main sections:

• Above the Diaphragm
• Below the Diaphragm
• The Pelvis.

It describes and explains the use of all types of osteopathic techniques including structural techniques, myofascial techniques, cranial techniques and visceral techniques. Osteopaths, chiropractors, physical therapists, and others working in the manual therapy field, will find the book invaluable for reference as a practical technique manual. The information it offers on how osteopaths can work safely and effectively to treat the common problems often suffered by pregnant women, and the potential solutions, will also be of interest and value to midwives, obstetricians, and family practitioners.

Based on Dr Sandler's lifetime work, teaching and treating throughout the world, Osteopathy and Obstetrics is a unique contribution to the body of knowledge within the world of osteopathic manual treatment.

Introduction

1

“Structure governs function” is often quoted as being one of the more important tenets of osteopathy. According to Caroline Stone, a leading lecturer and practitioner in the field of osteopathic obstetrics, it is better written as “Motion relates to physiology.”¹

As a philosophy, osteopathy shares this principle with many other natural or ancient therapies, including Ayurveda and traditional Chinese medicine. The concept is more easily understood if one thinks of a machine. If the machine is built correctly and regularly maintained, it will not break down. So it is with the human body, with its capacity for adaptation and autoregulation: we have the facility for enormous modification of our physiology according to the external circumstances or environment.

According to McKone,² the relationship between structure and function is one of the most basic of biological concepts. From insects to mammals, structure denotes an ability to function in a certain way, and function is limited or controlled by structure. McKone goes on to say that changes in the structure–function relationship can be influenced by the interaction of the external and internal environments acting individually or in combination.

Pregnancy and the immediate postpartum period are excellent examples of the capacity to change, and of the ability of a woman to change back to how things were physiologically before pregnancy once she has had her baby. Her body structure adapts to facilitate the physiological changes that she is undergoing. A “normal” pregnancy needs little medical intervention in what is essentially a physiological event. A “normal” pregnancy requires the services of the midwife, not the doctor.

However, if the patient has an underlying disease process to contend with during the pregnancy, then she may well need the attentions of the obstetric team, so that early anticipation of a medical problem that may adversely affect the pregnancy can be managed, leading to a successful outcome.

Examples include certain cardiac patients, people taking long-term medication for whatever reason, and those who are diabetic or have long-term thyroid disease. Likewise, from the obstetric point of view, for those women who demonstrate adverse changes to their structure – such as cephalopelvic disproportion, where the birth canal is too narrow to allow the presenting part to pass through – a planned elective cesarean section is always safer and better than an emergency operation.

Facilitating Change

One of the principal tenets of osteopathic medicine is that, given the correct set of circumstances, the body should be in a position to maintain health. If a patient has a bacterial infection, all an antibiotic drug will do is kill the bacteria and allow the body to heal. After a fracture, an orthopedic surgeon will pin plate or set broken bone, allowing a cast to be applied for structural stability, and then the healing takes place naturally.

In cases of neoplasia, normal growth is altered beyond normal physiology and metabolic demand, eventually leading to a situation where normal adaptation and physiological health become unattainable. The body is more likely to succumb to secondary disease processes, life becomes compromised, and death supervenes. Likewise, if the immune system is severely disturbed by diseases such as AIDS or any other immune-suppressing process, secondary infection can arise and the normal process of adaptation and defense will fail, leading to eventual death.

When we treat a pregnant patient, she is in a physiological, not a pathological, state. We examine her and evaluate how she is undergoing that physiological change. We look principally at the musculoskeletal system because, being osteopaths, this is where we have been trained to place our emphasis. However, we do not do this exclusively. We question her about her general health and her pregnancy health because she may well be in a subclinical state where symptoms have not yet made themselves felt. Also, as we are primary care practitioners, many patients self-refer to us, and thus we have to be in a position to know if it is safe to treat them or whether we need to refer them for further care. Just because a patient has thoracolumbar pain, it does not mean that the pain is of mechanical origin. It might be, but it might not. Questioning her about her renal function and history might make you suspect that she has a kidney problem: for example, an infection that is giving her loin pain, and which needs to be referred to her family physician/GP or midwife.

We should examine each body system in turn and see how that system is dealing with the changing demands of pregnancy. The pregnant patient’s cardiovascular system is changing, as are her cardiac output and peripheral resistance. How is her body coping with that change and the potential new demands? Is there something mechanical in the fascias, the respiratory mechanisms, or the rib cage which might be compromising these changes? How can the practitioner encourage her body to adapt by dealing with the factors that might impede that change?

Take a woman who, before pregnancy, had a short right leg, which gave her a minor organic scoliosis that changed direction at the thoracolumbar and cervicothoracic junctions. There may be rib crowding on the concavity of the curves as a result. What effect, if any, is this going to have on her ability to change during the pregnancy? Osteopathic evaluation will highlight these areas of altered structure, and the judicious use of techniques aimed at improving areas that need to change will facilitate it happening. If we can do this in advance of that change being needed, then when it does eventually become necessary, it will be easier and more likely to happen without adverse events. Thus, our ambition to improve the potential for change, so as to reduce or remove any compromise to it, will have been achieved.

The Importance of Motion to the Ability to Change

Every living thing, and every cell within every living thing, possess and display certain biological characteristics of life (Box 1.1), and no one of them is any more important to life than any other. However, the presence or absence of motion is often used as a defining characteristic within medicine, as, for example, when a pediatrician uses the APGAR score when a child is born. He assesses the heart rate via the pulse beat, the breathing rate and effort via motion in the chest, and the degree of activity or motion in the child in general, together with muscle tone. All of these factors use motion to define normality in that child.

BOX 1.1

The biological characteristics of life (“GRENRIM”)

•Growth

•Reproduction

•Excretion

•Nutrition

•Respiration

•Irritability

•Movement

We understand death to be the ultimate absence of motion at a macro and a micro level.

The process of autoregulation ensures that the organism minimizes cell damage by allowing motion only within preset physiological parameters. Using the example of a synovial joint, quality and quantity of motion are governed by the shape, plane, and integrity of the articular surfaces. The joint capsule and the intra- and extra-articular ligaments are designed to limit motion at the end of the joint’s normal physiological range. The skeletal muscles and their accompanying tendons guide motion and control its speed, as well as providing postural stability and control. The force, speed, and direction of pull of the muscles all contribute to the control of motion. The central nervous system controls the whole, relating the postural and proprioceptive functions to the body’s desire for motion. All of the factors above are controlled by a remarkable system of hormones, enzymes, and other biological and psychological factors which contribute towards motion control.

The qualitative assessment of motion – as it relates to the musculoskeletal system, for example – is further subdivided into hypomobility, normal mobility, and hypermobility.

In order to adapt and change, therefore, the tissue, and the organism that contains that tissue, have to able to move. In pregnancy, as a patient grows and changes shape, so her body has to adapt to that change in order for it to take place. If, for example, she had a cesarean section to deliver her first child, in second and subsequent pregnancies the scar tissue is going to have to soften and undergo change in order for the uterus to grow for the second time. As the organs below her diaphragm are squeezed and compressed, they will end up in a very different position from their pre-pregnant state. This means that the fascia and organs supporting that change in position will have to undergo change, too. And so it goes on. These changes are aided by alterations in hormones during pregnancy: notably, relaxin and estrogen. The function of these hormones is not just exerted on the structures related to her reproductive system; they effect global changes to every tissue in her body, aiding and facilitating their potential to change during the 40 weeks of normal gestation. It is our job to work with these changes and to encourage them with skillful techniques and an intelligent application of osteopathic concepts and principles. As osteopaths, we use the quality and quantit...