Clinical Considerations

Dorn Spinal Therapy

Spine Healing Therapy

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A. Pelvic relaxation is the weakening or loss of support of the pelvic organs because of damage to the pelvic diaphragm, urogenital diaphragm, transverse cervical ligament, uterosacral ligament, or pubocervical ligament. It may result in cystocele (prolapse of the urinary bladder into the anterior vaginal wall), rectocele (prolapse of the rectum into the posterior vaginal wall), or uterine prolapse (prolapse of the uterus into the vaginal vault). Pelvic relaxation may result from multiple childbirths; birth trauma; increased intraabdominal pressure because of obesity, heavy lifting, or chronic cough; or menopausal loss of muscle tone. Clinical signs include: a heavy sensation in the lower abdomen that is exacerbated by heavy lifting or prolonged standing; increased frequency of urination with a burning sensation as a result of urine stagnation and bacterial proliferation; and urine leakage with coughing or sneezing (stress incontinence).

B. Pudendal nerve block (Figure 16-2) is used to provide perineal anesthesia during forceps delivery in childbirth. A pudendal nerve block is performed in the following

Rectal Nerve Block

Figure 16-2. (A) Administration of a pudendal nerve block transvaginal^ and lateral to the labia majora. The ischial spine (not shown) is a good anatomic landmark. (B) The path of the pudendal nerve (curved arrow) as it passes out of the pelvic cavity through the greater sciatic foramen (posterior to the ischial spine) and returns to the pelvic cavity through the lesser sciatic foramen as it proceeds to the perineum. SS = sacrospinous ligament; ST= sacrotuberous ligament. (C) The perineum in the lithotomy position. The posterior labial (PL) and inferior rectal (IR) nerves are terminal branches of the pudendal nerve. In addition, the ilioinguinal nerve (/L), genitofemoral nerve (GF), and perineal branch of the posterior femoral cutaneous nerve (PFC), which also must be anesthetized by cutaneous injection of 1% lidocaine to obtain complete anesthesia of the perineal region, are shown. Labels L1, L2, L3, S2, S3, S4, and S5 indicate the dermatomes of the perineal region. (A reprinted with permission from Scott DB: Techniques of Regional Anaesthesia. East Norwalk, CT, Appleton & Lange, 1989, p 159; Band C adapted from Olson TR: A.D.A.M. Student Atlas of Anatomy. Baltimore, Williams & Wilkins, 1996, p 169.

Figure 16-2. (A) Administration of a pudendal nerve block transvaginal^ and lateral to the labia majora. The ischial spine (not shown) is a good anatomic landmark. (B) The path of the pudendal nerve (curved arrow) as it passes out of the pelvic cavity through the greater sciatic foramen (posterior to the ischial spine) and returns to the pelvic cavity through the lesser sciatic foramen as it proceeds to the perineum. SS = sacrospinous ligament; ST= sacrotuberous ligament. (C) The perineum in the lithotomy position. The posterior labial (PL) and inferior rectal (IR) nerves are terminal branches of the pudendal nerve. In addition, the ilioinguinal nerve (/L), genitofemoral nerve (GF), and perineal branch of the posterior femoral cutaneous nerve (PFC), which also must be anesthetized by cutaneous injection of 1% lidocaine to obtain complete anesthesia of the perineal region, are shown. Labels L1, L2, L3, S2, S3, S4, and S5 indicate the dermatomes of the perineal region. (A reprinted with permission from Scott DB: Techniques of Regional Anaesthesia. East Norwalk, CT, Appleton & Lange, 1989, p 159; Band C adapted from Olson TR: A.D.A.M. Student Atlas of Anatomy. Baltimore, Williams & Wilkins, 1996, p 169.

Iliac Spine Anatomy

Figure 16-3. Anteroposterior radiograph of the female pelvis. 1 = iliac crest; 2 = posterior superior iliac spine; 3 = wing of the ilium; 4 = posterior inferior iliac spine; 5 = anterior superior iliac spine; 6= arcuate line of the ilium; 7 = acetabular rim; 8= acetabular fossa; 9= ischial spine; 10 = ischial tuberosity; 11 = superior ramus of the pubis; 12 = inferior ramus of the pubis; 13 = ala of the sacrum; 14 = pelvic sacral foramina; 15 = sacroiliac joint; 16 = intrauterine device; 77 = lunate surface of the acetabulum; 18 = coccyx; 19 = obturator foramen; 20 = body of the pubis; 21 = pubic symphysis. (Reprinted with permission from Fleckenstein P, Tranum-Jensen J: Anatomy in Diagnostic Imaging. Philadelphia, WB Saunders, 1993, p 80.)

Figure 16-3. Anteroposterior radiograph of the female pelvis. 1 = iliac crest; 2 = posterior superior iliac spine; 3 = wing of the ilium; 4 = posterior inferior iliac spine; 5 = anterior superior iliac spine; 6= arcuate line of the ilium; 7 = acetabular rim; 8= acetabular fossa; 9= ischial spine; 10 = ischial tuberosity; 11 = superior ramus of the pubis; 12 = inferior ramus of the pubis; 13 = ala of the sacrum; 14 = pelvic sacral foramina; 15 = sacroiliac joint; 16 = intrauterine device; 77 = lunate surface of the acetabulum; 18 = coccyx; 19 = obturator foramen; 20 = body of the pubis; 21 = pubic symphysis. (Reprinted with permission from Fleckenstein P, Tranum-Jensen J: Anatomy in Diagnostic Imaging. Philadelphia, WB Saunders, 1993, p 80.)

way: a 1% lidocaine solution is injected transvaginal^ or just lateral to the labia majora around the tip of the ischial spine and through the sacrospinous ligament. The pain of childbirth is transmitted by the pudendal nerve through the sensory fibers of spinal nerves S2—5. The pudendal nerve exits the pelvic cavity through the greater sciatic foramen, travels around the posterior surface of the ischial spine, and reenters the pelvic cavity through the lesser sciatic foramen. It travels within the fascia of the obturator internus muscle (pudendal canal of Alcock) and divides into the perineal nerve, posterior labial nerves, inferior rectal nerve, and dorsal nerve of the clitoris. To obtain complete anesthesia of the perineal region, the ilioinguinal nerve (which branches into the anterior labial nerves), the genitofemoral nerve, and the perineal branch of the posterior femoral cutaneous nerve also must be anesthes-tized by cutaneous injection of 1% lidocaine.

VII. RADIOLOGY. Anteroposterior radiograph of the female pelvis (Figure 16-3)

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Pregnancy And Childbirth

Pregnancy And Childbirth

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