case management of common pregnancy related · pdf filecase management of common pregnancy...

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©Dr. Karen Gardner Bagnell www.pregnancychiropractic.com

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Case Management of Common Case Management of Common Case Management of Common Case Management of Common Pregnancy Related ComplaintsPregnancy Related ComplaintsPregnancy Related ComplaintsPregnancy Related Complaints


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We will be covering the following topics…

– Case management of common pregnancy related complaints

• Nursing Mother’s Neck ™

• Nausea and morning sickness

• Heartburn

• Constipation

• Water retention

• Hemorrhoids

• Leg cramps


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Nursing Mother’s Neck Syndrome™

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• In other words, lower cervical subluxation and interference of the brachial plexus.

• Be sure also to check the shoulders, elbows and wrists for fixations. Vitamin B6 has also shown to be effective for symptomatic relief as it helps with nerve conduction.


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• In addition to neck pain and discomfort – compression of the brachial plexusoften leads to carpal tunnel syndrome.

• Vitamin B6 has been shown to help with

these symptoms.



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• In several research studies, vitamin B6 deficiency has been associated with carpal tunnel syndrome.

• A study by the Portland Hand Surgery and Rehabilitation Center in Oregon examined 441 people and found that higher levels of vitamin B6 were associated with fewer carpal tunnel syndrome symptoms.


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Food Sources of vitamin B6 include

•sweet potatoes•avocados

•brown rice

•sunflower seeds

•chick peas•salmon

•pork

•chicken

•turkey

•potatoes•bok choy

•barley

• bananas

•mangoes


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• Risk factors for vitamin B6 deficiency:

– diet lacking in vitamin B6

– use of oral contraceptives or HRT

– consumption of foods containing yellow dye #5, such as some types of macaroni and cheese and pickles

– Stress



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• A typical dose of vitamin B6 for carpal tunnel syndrome is 50 mg 2 to 3 times a day.

• Side effects may include increased urination.

• It can take up to 6 weeks to notice an improvement.

• The maximum intake from all sources should be less than 200 mg a day


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• Enzyme supplements such as bromelain may help to reduce tissue swelling associated with carpal tunnel syndrome.

– It can take several weeks to notice results.

– The main food source of bromelain is in the stem of a pineapple.



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Case Management of Common Complaints of Pregnancy

• Nausea/Morning Sickness

– Although most people consider pregnancy related nausea to occur primarily in the morning it can happen at any time of day


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Case Management of Common Complaints of Pregnancy

• The most common chemical cause of this nausea is the dramatic increaseof estrogen, progesterone and human chorionic gonadatropin (hCG) in the

first trimester.

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Nausea/Morning Sickness

• Be sure to check L3/L4, sacrum & coccyx for

nausea during the first trimester.

• If the nausea continues past the first trimester be

sure to check T5/T6 for subluxation.


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Nausea/Morning Sickness

• Have mom take her pre-natal vitamins before she goes to bed.

• Some women tolerate some brands better than others and different ones

from pregnancy to pregnancy.

– Changing brands may be helpful


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Heartburn

• Very different from nausea.

• Always check T5/T6 for

subluxation.

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Heartburn

• Another cause is due to the positioning of the fetus.

• If it is putting pressure on the diaphragm it can cause a “pseudo”

hiatal hernia effect.


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Heartburn

• With the patient in a supine position, gently pull down (superior to inferior line of correction) on the diaphragm just below the xiphoid process as the patient exhales.

• This maneuver can often eliminate this pain. It is usually only temporary but does give much needed relief.

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Pseudo Hiatal hernia

Hiatal hernia occurs

when a part of the stomach or intestine

protrudes through the

small opening in the

diaphragm

Can cause heartburn

as a result of stomach

acid flowing back up

through the opening.


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Heartburn

• Assure the mother that once the baby “drops” into the pelvic cavity this

discomfort will disappear.


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Hormonal Causes of Heartburn

• An increase in progesterone relaxes the cardiac sphincter, and an increase in estrogen decreases the peristaltic action in the stomach.

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• Eat RIPE papaya fruit (never green, un-ripened) or chew papaya enzyme tablets after eating to help aid in digestion and alleviate heartburn.

– papain –

• enzyme found in Papaya that helps to break down peptide bonds in proteins


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• What about pineapple & Bromelain?

– Not as good because just eating pineapple will not give you a great deal of extra bromelain

– Bromelain is mostly concentrated in the stem, which is not nearly as tasty (but it is still edible).


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• Also eating several small meals per day instead of a few BIG ones will help alleviate this discomfort.

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Heartburn

• Do not use antacids-

– Many contain lead and can affect calcium absorption.

– Can also lead to increased acid production and therefore a dependency on them.


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Constipation

• Very often a pregnant woman’s digestive processes slow down because of hormones and the physical abdominal crowding.


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Constipation

• Looking closely to L1/L2 , L3/L4 as well as sacrum to facilitate a more normal functioning elimination process.

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Constipation

• The iron in mom’s pre-natals will cause constipation 100% of the time. She must have iron so it isn’t really recommended that she stop taking it.


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• I tell moms to get a vitamin with a lower dosage of iron and start cooking everything in a cast iron skillet.


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• Increase dark green leafy veggies like spinach and Kale.

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• Drink plenty of quality water

•and walk, walk walk.


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Swelling of ankles, legs and feet

• Increased estrogen causes an increase in blood volume, a decrease in peripheral vascular resistance and an increase in sodium retention.

• Therefore the fluid easily escapes the blood vessels and is retained by the tissues of the legs and feet..


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• Besides avoiding excessive salt intake and advising to elevate feet whenever possible, it is vital to check T10-T12 for subluxation.

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• Remember if this is accompanied by high BP and headaches, to refer her to see her midwife or OB/GYN as it could be toxemia related


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Hemorrhoids

• Anatomic changes that compress lower bowel, decreased lower GI motility and decreased activity all contribute to the formation of hemorrhoids.


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Hemorrhoids

• Homeopathic witch hazel (aka Hamamelis) by mouth is most effective for symptom control, as well as witch hazel compresses applied externally as

needed.

• Homeopathic Paeonia can obliterate hemorrhoids and fissures within hours.

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Hemorrhoids

• Be sure to check the coccyx for subluxation if this complaint presents.


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Hemorrhoids

• Sitz baths can also be helpful

• Juniper and lavender essential oils added to bath are beneficial as well.


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Hemorrhoids

• What is a sitz bath?

– a sitz bath can help reduce hemorrhoids and speed recovery.

– Fill a tub with warm water.

– Fill it so water reaches hips or stomach, 6-8 inches. Then add 22 drops of juniper and

22 of lavender essential oils into the bath.

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Hemorrhoids

• Stir the oils • Sit in the bath with

knees raised for 10-15 minutes three times a day.

• This position helps to bring more blood into the hemorrhoid area,– brings in more

nutrients and pulls out toxic waste.


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Hemorrhoids

• Sitz bath using Shepherd’s Purse

– The herb Shepherd’s Purse can be

used in sitz bath ONLY After childbirth and NOT during pregnancy.


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Hemorrhoids

This herb is useful in treating hemorrhoids by reducing Internal and external bleeding

• Reducing blood pressure

• Relieving hemorrhoids

• Repairing wounds

• Reducing prolapsed rectum

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Hemorrhoids

• Place 1 oz of shepherd’s purse in two quarts of distilled water and let it sit for 12 hours. In the morning or evening, boil this mixture for 2-3 minutes and then strain it. Pour the liquid into a sitz tub or into a full bathtub. Stay in the tub for around 20 minutes and do this 2-3 times a day.


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Hemorrhoids

• After the sitz bath take a cold shower to stimulate blood circulation in the hemorrhoid area.


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Hemorrhoids

• Witch Hazel Sitz bath

• Add some warm distilled (if possible) water. Add 1/4 cup of witch hazel liquid to the water.

• Sit in the small tub for 15-20 minutes.

• Do this as often as possible.

• Relieves hemorrhoids in 3 to 4 days.

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Hemorrhoids

• Freeze witch hazel into small ice cubes,

• Wrap them with cheesecloth and press them against hemorrhoids for 10-15 minutes every hour. This will also

reduce the pain and swelling of hemorrhoids.


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Leg Cramps

• Can be caused by

– mal-absorption of calcium

– disturbance of the calcium/phosphorus ratio

– pressure of the pregnant uterus on blood vessels

– and of course subluxation.


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• There is some speculation that too little calcium, too little potassium, or too much phosphorus can cause leg cramps. – Increase calcium intake

– Avoid phosphorus • (found in processed meat, snack foods and soda),

• Too much phosphorus has the same effect as not getting enough calcium

• It can prevent your body from absorbing the calcium you do ingest.

Leg Cramps

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• Advice for mom-to-be

– Don’t stand or sit with legs crossed for long periods of time.

– Stretch calf muscles during the day and before bed.

– Rotate ankles and wiggle your toes sitting.

Leg Cramps


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• Advice for mom-to-be (cont’d)

– If doctor or midwife allows it, take a walk each day.

• Even a short 10 minute walk can help.

– Lie on left side to improve circulation

– Rest when tired and elevate legs when possible.

• Wear supportive stockings –

– But not ones that constrict the blood flow.

Leg Cramps


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• Drink plenty of water.

• If doctor or midwife allows it, take a magnesium supplement in addition to

prenatal vitamin.

– Magnesium has been proven to be

beneficial in the treatment of leg cramps.

Leg Cramps

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Leg cramps

Pay close attention to L3 and especially Sacral rotation when a woman is complaining of leg cramps.


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Pubic Bone

• Ice is generally helpful for pain control.

• A pregnancy support belt is of great importance with this complaint.

– it helps in stabilizing an otherwise unstable pelvis.


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Pubic Bone

• This support belt gives some “lift” to the abdomen and thus creates less direct pressure on the pubic bones themselves.

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Pubic Bone

• As the abdomen enlarges pain at the pubic bone increases dramatically due to the added weight and change in the center of gravity.

• Many OB’s will tell an expectant mother that a c-section will be necessary in order to avoid further damage to the front of the pelvis….this is not true.


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Pubic Bone

• Chiropractors are the only people who can help moms with this painful condition


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Pubic Bone Pain

• Subluxation and even

diastasis (separation) of the pubes is not

uncommon during pregnancy. Inability to

raise legs (as in marching or stair

climbing) due to pain is the most frequent

complaint.

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Pubic Bone Pain

• This pain is excruciating

and is greatly exacerbated by the

change in the center of gravity and the weight of

the protruding abdomen


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• Any pelvic misalignment alters the pelvic

opening.

• A greatly distorted opening can and does

alter the course of labor and delivery.

Pelvic alignment


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Diastasis Symphysis Pubis

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• Diastasis symphysis pubis is the separation of normally joined pubic

bones, ie. dislocation of the bones, without a fracture.


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• This abnormally wide gap can be diagnosed by radiologic studies such

as x-ray, MRI, CT scan or bone scan.

• Since we don’t expose the mother-to-be to radiation in our office, we rarely

know for sure if she has a dysfunction or a true diastasis.


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• At the symphysis, the non-pregnant gap is 4-5mm.

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• In pregnancy there will be an increase of at least 2-3mm due the ligaments which surround and

insert into the joint as they remodel under the influence of hormones.


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• A total width of up to 9mm

between the two bones is normal for a pregnant woman.


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Pubic Bone

• This natural extra gapping decreases within days following the delivery,

although the supporting ligaments will take three to five months to fully return to their normal state.

• An abnormal gap is considered to be

1cm or more.

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• If there is a complete separation, that is, a traumatic tear, the joint will be

completely unstable.

• This tear can be felt and sometimes heard by the woman.

• There will be intensive pain followed by swelling and inflammation.


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• The woman is unable to move her back, trunk, hips and legs without

causing severe pain.

• When lying supine, her legs may involuntary move apart and she won’t be able to close them together.


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• This type of pelvic fracture needs to be treated as such and investigations

into possible involvement of the sacroiliac joints should be addressed.

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Symphysis Pubis Dysfunction

•Symphysis Pubis Dysfunction or SPD

is characterized by severe pubic bone pain due to excessive ligament laxity and excessive mobility at the symphysis.


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• The most common sign of SPD is the inability to raise one leg at a time as

in stair climbing or marching in place without excruciating pain.

• Sometimes the pain is so severe a woman suffering with SPD cannot

perform this movement at all.


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• Round ligament pain is also a common complaint concomitant with

SPD.

– It’s no wonder really, knowing of the relationship between the pubic bones and the round ligaments.

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Case management

• Besides chiropractic adjustments to the pubic bone (using an instrument)

– ice applied externally to the effected area is helpful for symptomatic relief of both

diastasis symphysis pubis and symphysis pubis dysfunction.


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Case management

• Natural anti-inflammatories such as

– vitamin C

– essential fatty acids

• Both can help to reduce inflammation.


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Case management

• Glucosamine is a fantastic anti-inflammatory.

– the Arthritis Association cautions the use of this supplement during pregnancy or

lactation

– lack of scientific data supporting its use.

– There has also been some concern that Glucosamine may elevate blood

glucose

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Case management

• Certain homeopathic remedies are also helpful here.– Chamomilla– arnica montana– apis mellifica– All 3 have been shown to have good anti-

inflammatory properties

• As with all recommendations, be sure that these or other remedies that are offered are not contraindicated for use during pregnancy.


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Resources

• Use Essential Oils And Herbs In A Sitz Bath For Hemorrhoid Relief - Mario

Carini

• Kidshealth.org – Nutrition and weight

• March of Dimes - Your Healthy Diet During Pregnancy April 2008

• Leg cramps during pregnancy - causes, treatment and prevention by Angie

Younce

• Childbirth classes – Bobbie Posmontier, C.N.M.

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