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🤰 Pregnancy Patient Exam Map

Assessment • Safety • Red Flags • Treatment • Advice

🧬 Hormones 🔍 Assessment 🚨 Red Flags 💪 Treatment 📋 Cheat Sheet

🗺️ Topic Overview

🧬 Hormones

  • Relaxin
  • Oestrogen
  • Progesterone

🔍 Assessment

  • History
  • SIFT / Stork
  • SIJ tests

🚨 Red Flags

  • Bleeding
  • Pre-eclampsia
  • DVT / SOB

💪 Treatment

  • Side-lying
  • MET / Shotgun
  • Lymphatics

🚫 Contraindications

  • No supine T2/T3
  • No elbow ribs
  • Slow releases

👶 Postpartum

  • Relaxin 12 months
  • Pelvic floor
  • Breastfeeding

🚨 Red Flags — Know These Cold

🆘 Refer Urgently (999/112)

  • Vaginal bleeding (any trimester)
  • Sudden / severe SOB or chest pain → 999/112
  • Pre-eclampsia signs: severe headache, blurred vision, upper abdominal pain, swelling of hands/face/feet
  • Suspected DVT — red, swollen, hot calf
  • Decreased foetal movements → maternity hospital
  • Hyperemesis gravidarum with dehydration
  • Mental health crisis

⚠️ Also Refer

  • Hyperemesis gravidarum
  • Placenta praevia
  • Placental abruption
  • Ectopic pregnancy
  • Premature labour signs (<37 weeks)
  • Foetal distress
  • Eclampsia

⚠️ Pre-Eclampsia — Signs to Memorise

Severe headache  +  blurred vision  +  upper abdominal pain  +  nausea  +  swelling of hands / feet / face

🩺 Clinical Assessment Pathway

Step 1

📋 History

  • Hormonal history (pregnancy, postpartum, OCP)
  • Viscerosomatic: dysmenorrhoea, IBS, UTIs, incontinence
  • Pelvic scar tissue (surgery, infection, traumatic labour)
  • True LLDs (fracture, hip arthroplasty)
  • Habitual torsions (leg crossing, sleep position, ergonomics)
  • Sports: concussive/rotatory, swimming, horse-riding
  • Labour history: traumatic deliveries, pelvic floor tears, symphysiotomy
Step 2

👁️ Observation

  • Postural changes: reduced lumbar lordosis, posterior innominate rotation
  • Rib flare and elevation
  • Pelvic obliquity
  • Gait changes
Step 3

🏃 Movement Testing

  • Standing flexion test (SIFT)
  • Seated flexion test
  • Stork / Gillet test
Step 4

🔬 Special Tests

  • ASIS compression
  • Pubic rami palpation — flat hand, move medially from ASIS (very tender)
  • Sacral sulci depth (bilateral)
  • ILA position
  • Leg length assessment
  • SIJ mobility: rocking, squish / squash / gapping
Step 5

🛡️ Safety Checks

  • Screen all red flags before treatment
  • Check trimester — T2/T3 = avoid supine
  • Consent before touching pubic / pelvic area
  • Explain all techniques before applying
Step 6

🧠 Clinical Reasoning

  • Identify dysfunction type: SIJ, pubic, sacral, rib, diaphragm
  • Consider ligamentous laxity (relaxin)
  • Consider trimester-specific precautions
  • Plan treatment: position, technique, duration
  • Set goals and review

💪 Treatment Principles

✅ Safe

  • Side-lying preferred
  • Seated rib / diaphragm techniques
  • Pubic symphysis reset (shotgun)
  • SIJ MET (prone modified)
  • Sacral MET
  • Pelvic diaphragm technique
  • Lymphatic: clavicular pump, thoracic pump

⚡ Modify

  • Prone: stay up and over, never lie on bump
  • Supine: pillow under knees, limit duration
  • Hip mobilisation: avoid if too painful — use rock-and-roll instead
  • Diaphragm inhibition: release slowly (risk of spasm)
  • Visceral techniques: release slowly

🤍 Positioning

  • Avoid supine T2/T3 (aortocaval compression)
  • Side-lying = preferred position
  • Seated for rib / diaphragm work
  • Prone: knees flexed, stay clear of bump
  • Roll patient with knees flexed at all times

🚫 Contraindications & Precautions

🚫 Avoid

  • Supine for extended periods (T2/T3)
  • Prone without modification
  • Elbow contact on ribs (fracture risk)
  • Aggressive compression on bump
  • Sudden release of diaphragm inhibition
  • Sudden release of visceral techniques
  • Full hip flexion if painful

⚠️ Be Careful

  • Ligamentous laxity — joints are loose
  • Relaxin persists postpartum up to 12 months
  • Breastfeeding prolongs relaxin effects
  • Exercise advice — ligaments still loose postpartum
  • Pubic rami palpation — very tender, approach gently

➡️ Refer

  • Any red flag listed above
  • Pre-eclampsia
  • DVT
  • Premature labour
  • Foetal distress
  • Eclampsia
  • Placenta praevia
  • Placental abruption

🤕 Common Pregnancy Presentations

🦴 Pelvic Girdle Pain PGP

Cause: relaxin-induced laxity

  • Pain: pubic bone, lower back, perineum, inner thighs
  • Triggers: stairs, getting out of car, changing position in bed, standing on one leg
⚠️ Relaxin elevated postpartum — caution with exercise

🔗 SIJ Dysfunction

Cause: ligamentous laxity

  • Tests: standing flexion, seated flexion, sacral sulci, ILA
  • Pelvic floor tears weaken muscles ~1/3
  • Increase elasticity ~25%

🦷 Pubic Symphysis Dysfunction

Diastasis: 1 in 300–3,000 vaginal deliveries

  • Causes: pressure during childbirth, forceps
  • Treatment: shotgun technique

🦴 Coccydynia

Palpation approach

  • Gluteal fold: 1 cm medial, 1 cm posterior, push up gently
  • Seated: slide under ischial tuberosities, slightly medial and posterior
  • Deviated coccyx: bony one side vs. squidgy ligamentous other

😬 Low Back Pain

Multifactorial

  • Increased lumbar loading
  • Weight gain, postural changes
  • Disc issues, facet joint dysfunction
  • Piriformis syndrome

🫁 Rib Pain

Ribs flared and elevated in pregnancy

  • Commonly restricted: ribs 8, 9, 10
  • Treatment: rib raising (seated)
  • Rib mobilisation (seated)

💪 Neck / Shoulder Pain

Postural changes: forward head, rounded shoulders

  • Associated: carpal tunnel syndrome
  • Oedema + hormonal changes
  • Treatment: MET, soft tissue, posture advice

📅 Trimester Changes

🟣 T1 — First Trimester

Weeks 1–12
  • Nausea & tiredness
  • Mood swings
  • Breast tenderness
  • Constipation
  • Headache
  • Urinary frequency
  • Heartburn
⚠️ Miscarriage risk highest (weeks 12 & 16) — gentle approach

🟢 T2 — Second Trimester

Weeks 13–28
  • Weight gain +5 kg (total ~8 kg)
  • Often feels well
  • Wk 16: back/groin/thigh/pelvic pain begins
  • Oedema → carpal tunnel
  • Wk 20: quickening (foetal movements)
  • Postural changes more significant
⚠️ Begin avoiding supine for extended periods

🔴 T3 — Third Trimester

Weeks 29–40
  • Total weight gain ~12.5 kg
  • Cardiac output ↑ 30–50%
  • Avoid supine (aortocaval compression)
  • SOB common
  • Ribs flared and elevated
  • Pelvic diaphragm dips into dome shape
🚨 No supine — side-lying only

🎓 Likely Exam Questions

Oestrogen and Relaxin. These hormones cause softening and laxity of ligaments throughout the body, particularly in the pelvis, to prepare for childbirth.

Supine position causes the gravid uterus to compress the inferior vena cava (IVC) and descending aorta → reduced venous return → reduced cardiac output. Risk in T2 and T3. Avoid supine positioning.

1. Sudden SOB / chest pain → 999
2. Vaginal bleeding (any trimester)
3. Pre-eclampsia signs: severe headache, blurred vision, upper abdominal pain, swelling
4. Suspected DVT: red, swollen, hot calf
5. Decreased foetal movements → maternity hospital

Side-lying is preferred. Avoid supine (aortocaval compression risk). Use seated position for rib and diaphragm work. If prone is necessary, modify with bolsters to stay clear of the bump.

Relaxin remains elevated for up to 12 months postpartum (longer if breastfeeding). Ligaments are still lax → joints remain vulnerable. Avoid aggressive techniques, advise gradual return to exercise, and caution against high-impact activities.

📋 One-Page Cheat Sheet

✅ 5 Things to Check

  1. Red flags: bleed, SOB, pre-eclampsia, DVT, foetal movements
  2. Trimester — T2/T3 = no supine
  3. Relaxin status: pregnant or postpartum?
  4. Labour / delivery history
  5. Consent before pelvic / pubic palpation

🚫 5 Things to Avoid

  1. Supine in T2/T3 — aortocaval compression
  2. Prone without modification
  3. Elbow contact on ribs
  4. Sudden release of diaphragm / visceral techniques
  5. Aggressive hip mobilisation if painful

💡 5 Things to Remember

  1. Relaxin stays elevated up to 12 months postpartum
  2. Pelvic floor weakened ~1/3 after vaginal delivery
  3. King et al. (2003): osteopathy improves pregnancy outcomes
  4. Folic acid 400 mcg/day until week 12 (prevents spina bifida)
  5. Cardiac output ↑ 30–50% in T3
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