Urgent Updates to Prenatal Care: A Follow-Up

When I wrote "Urgent Updates to Prenatal Care,"¹ it was my intent to share with the profession some specific information about treating pregnant women. I received several e-mails thanking me for the information I had shared, including a few with specific questions. I also received a few e-mails that greatly disagreed with my comment about not performing a side-posture adjustment on a pregnant woman. I usually keep my articles fairly short and to the point; however, clearly more detail was needed in my last article.

As I have stated before, what I write is in my opinion.² In this instance, "Urgent Updates to Prenatal Care" was based upon a review of courses I had taken, the materials I had seen and OBs with whom I had discussed care. I believe what I wrote is reasonable. Let me also add that I have taken the class for hospital chiropractic, I have worked in a hospital, and I work now with two OB/GYNs. I am proudly a chiropractor, but I work with and understand the mindset of MDs. I know medical doctors are very careful about anything that could be contraindicated, and that to ignore any pertinent information is negligence. I did discuss rotational moves with the OBs I work with. They thought it made perfect sense not to do a rotational-type adjustment, as there is a potential risk. Shouldn't midwives and OBs be the ones to advise us of the risks during pregnancy, since this is their entire patient base? If OBs and midwives suggest there is a potential risk, why isn't that good enough? Why take the chance?

I do believe pregnant women need chiropractic. Facilitating a healthy pregnancy and restoring a normal physiological environment for natural birth is well within the chiropractic scope of practice.³ Pregnancy is perhaps the most traumatic experience a woman's body will ever undergo.⁴ The body begins to change from the moment of conception. Given the progressive postural stresses and ligamentous laxity, pregnancy creates a myriad of distinct aches and pains. The most common of these is lower back pain, especially in the second and third trimester.⁵

"Because of these physiological and biomechanical compensations, practitioner care must be taken to select the specific analysis and adjustment most appropriate for the complex changes during the various stages of pregnancy. The increased potential for spinal instability in the mother and the resulting subluxations in the woman's spine throughout pregnancy affect the health and well-being of both her and her baby."⁶

Pregnant women are probably some of the best candidates for chiropractic. However, the normal battery of techniques is not always appropriate for care. "The obstetrician [physician in general includes chiropractor] must be aware of the normal physiology of pregnancy and the unique response of the pregnant patient to stress and trauma."⁷

I did not state that side posture itself causes placental abruption. I said that rotational motion brings an increased risk for placental abruption. Since one or both of these can occur during an "aggressive" side-posture adjustment, I advise to adjust in a different way. To quote what I did say, "Using a higher-force technique can cause more problems than relief, so less force is the standard. Also, straight-line-of-correction techniques should be used - Thompson, Activator or Nimmo. If you are in the habit of performing a diversified side-posture roll, it is time to learn a new technique. Remember, a pregnant body is chemically and biomechanically different from a nonpregnant body, and the usual battery of techniques is not always appropriate."

I am aware that the Gonstead technique uses a straight line of correction when performing a side-posture adjustment. However, there are cautions about very careful patient positioning, as anything less would lead to insufficient correction or a negative response from the patient.⁸ A chiropractor who practices nonforce technique said it like this: "DNFT achieves the goals of traditional chiropractic - to relieve pain and discomfort created by structural misalignments without all the rack 'em, stack 'em and cracking force on the spine."⁹ I can recall a comment made in my technique classes at Palmer: "Anyone can make a back crack. Monkeys can be taught to do that. The art of chiropractic is knowing how to adjust, knowing when to adjust, and knowing when not to adjust." A patient information brochure on pregnancy notes, "Modifications to the table or adjusting technique are made during each stage of pregnancy."¹⁰ Clearly, I am not alone in my belief that some degree of caution is reasonable and responsible.

Of course, I know that not all doctors adjust aggressively. I have no way of determining another doctor's individual skill or level of aggressiveness. Again, I prefer to play it safe. There are enough other techniques available to the practitioner - why take the chance? The caution raised is not a question of force, it is a question of rotation of the pelvis during pregnancy. As I stated in my previous article, even prenatal exercise and yoga classes are now cautioning against rotational-type motions, as there is a risk of abruption.¹¹ "There are obvious concerns for uterine injuries in the pregnant woman. Particularly worrisome is the specter of placental abruption, which complicates 1 to 6 percent of minor injuries and up to 50 percent of major injuries. It is hypothesized that the abruption is likely caused by deformation of the elastic myometrium around the relatively inelastic placenta."¹²

In the interest of covering bases, I will note that the condition of uterine torsion occurs mainly in the third trimester.¹³ Uterine torsion is defined as a rotation of more than 45 degrees around the long axis of the uterus.¹⁴ Uterine torsion may be facilitated by many factors, including scar tissue or trauma. Other clinical predisposing factors include the mother's age, race, lifestyle, previous health and pregnancy history, along with comorbid health conditions. From a medical perspective, the nonspecific clinical course and rarity of this condition make the (preoperative) diagnosis difficult and raise critical management considerations.¹⁵

Having said all that, allow me to present some other data that I believe support my conclusion:

• Circulatory disturbances are considered one of the most common placental lesions.¹⁶
• As pregnancy progresses, the placenta begins to "age." There is a dense, yellowish-white, fibrous ring, representing a zone of degeneration and necrosis, (termed a marginal infarct).¹⁷ Basically, the placenta is more susceptible to separation as the pregnancy progresses.
• As pregnancy advances, the placental membrane becomes progressively thinner, with the capillaries lying closer to the surface. The welfare of the fetus depends more on the adequate bathing of the chorionic villi by maternal blood than any other factor. Acute reductions of uteroplacental circulation result in fetal hypoxia.¹⁸
• Uterine torsion signs, when present, are not specific. Pain, nausea and vomiting may present without any sign of shock.¹⁹ The most common symptom is abdominal pain. However, this may vary from nonspecific, mild abdominal discomfort to symptoms of an acute abdomen with shock, thus making diagnosis difficult.²⁰ One of the early signs of abruption is low back pain. Since many women come to a chiropractor during pregnancy with low back pain, this alone may increase the doctor's chances of encountering a case of early abruption.

The concept of a secondary abruption must also be considered. Many patients see a chiropractor after a trauma, such as a motor vehicle accident (MVA). It has been referenced that MVAs are a source of trauma to the gravid uterus.²¹ However, not all abruptions are immediate or complete.²² For the sake of argument, suppose a pregnant patient presents following an MVA - with an occult, clinically undetected abruption - and the chiropractor performs their treatment. If the patient starts to hemorrhage later that day, where will the blame be placed? The answer should be as obvious as it is sobering.

The medical care provided to a pregnant trauma patient by a trauma specialist should be supplemented by a careful evaluation of the pregnant woman by an obstetrician.²³ MVAs account for two-thirds of all trauma events during pregnancy. Both blunt abdominal trauma and trauma to the skull are associated with high mortality of the fetus. The severity of the trauma is an important prognostic factor for survival of both mother and fetus. Fetal injury can be caused even by apparently mild forms of maternal trauma.²⁴ As I said in my original article, a pregnant body is different, both chemically and biomechanically, from a nonpregnant body. The various anatomic and physiologic changes of pregnancy may alter the type of injury experienced by pregnant women. These changes also may alter the manifestations of given injuries and the treatment required to re-establish maternal-fetal hemostasis.²⁵

With all of that being said, it should be logical that a side-posture roll could be potentially dangerous. Again, why take the chance? If a person presented in my office with a positive George's test, I wouldn't do a rotary-break adjustment on their cervical spine. Does that mean if I did, they would have a stroke? Of course not. But the risk is there, so choose another way to treat. That's all I ever said about side posture during pregnancy. (By the way, there is also dispute over the use of George's test.²⁶)

Consider the recently resurrected issue of chiropractic manipulation causing a stroke²⁷ - only one doctor, only one adjustment - but look at the fallout. Can you imagine the negative consequences of a chiropractor being accused of causing the termination of a pregnancy? And I can think of no greater loss than the loss of a child. It is too easy to modify the technique and remove the risk. Why take the chance? Choose another way to adjust and err on the side of caution. As I stated in my article, I, too, had performed a side-posture adjustment for many years without incident, prior to coming across the information I shared. However, there is a potential for risk to the mother and child with rotational motion of the lumbopelvic spine.²⁸ This is the message I was trying to convey.

It is impossible to write on any one topic and cover the myriad variations in scope of practice, practitioner skill and personal opinion. Pregnant women need chiropractic care, but that care must be tailored to the specific needs of the pregnancy. Clearly, in my original article, I was very broad in my definition of a side-posture adjustment. But I do believe there is sufficient information to warrant caution with that technique. I imagine if I told people it was OK to do side posture and something happened, I would be held responsible for that, as well. So, to err on the side of caution, I say to people who ask, "I adjust pregnant women by means other than side posture."

Can you do a side-posture adjustment during pregnancy? Arguably, you can do anything you want. Whether you should is a clinical decision you must make. As a health care professional, you are responsible for the care you provide to your patient. I have provided you with the information I used to establish my prenatal treatment protocols. I hope this information will help you decide what techniques to use when caring for the pregnant patient.

References

1. Briggs DR. "Things I Have Learned: Urgent Updates to Prenatal Care." Dynamic Chiropractic, March 2007;25(7). Available at www.chiroweb.com/archives/25/07/19.html.
2. Briggs DR. "Things I Have Learned: Welcome to the Big Show." Dynamic Chiropractic, Sept. 2006;24(20). Available at www.chiroweb.com/archives/24/20/09.html.
3. Clinical Practice Guideline: Vertebral Subluxation in Chiropractic Practice. Council on Chiropractic Practice, 2003. Available at www.ccp-guidelines.org/guideline-2003.pdf.
4. "Gonstead Chiropractic." Available at www.gonsteadclinicpc.com/Page.html#Q5.
5. Ibid.
6. Clinical Practice Guideline, op. cit.
7. Trauma and pregnancy. Clin Obstet Gynecol, March 1984;27(1):32-8.
8. Hervst RW. Gonstead Chiropractic Science & Art. Schi-Chi Publications.
9. "Gonstead Chiropractic," op. cit.
10. Pregnancy and the Chiropractic Lifestyle. Back Talk Systems. 1995.
11. Lai B. "Ashtanga Yoga Practice During Pregnancy." Available at www.ashtanga.com/html/pregnancy.html.
12. Cunningham, et al. Williams Obstetrics. 20^th ed. Appleton and Lange: 1997.
13. Third trimester uterine torsion: case report. J Obstet Gynaecol Can, June 2006;28(6):531-5.
14. Uterine torsion in pregnancy: a review. Int J Gynaecol Obstet, 2006;6(1).
15. Ibid.
16. Cunningham, et al. Williams Obstetrics. 20^th ed. Appleton and Lange 1997.
17. Ibid.
18. Moore KL. Before We Are Born, 3^rd ed. WB Saunders Co: 1989.
19. Uterine torsion with maternal death: our experience and literature review. Clinical Exp Obstetrics & Gynecology, 2005;32(4):245-6.
20. Uterine Torsion in Pregnancy: A Review, op. cit.
21. Torsion of a gravid uterus associated with maternal trauma: a case report. J Reprod Med, Aug 2002;47(8):683-5.
22. Gabbe SG. Obstetrics - Normal and Problem Pregnancies. Churchill Livingstone: 1986.
23. Ibid.
24. Trauma and pregnancy. Arch Gynecol Obstet, 1993;253 Suppl:S4-14.
25. Abdominal trauma during pregnancy. Clin Perinatol, June 1983;10(2):423-38.
26. "We Get Letters." Dynamic Chiropractic, Sept. 2006:24(18). Available at www.chiroweb.com/archives/24/18/19.html.
27. "Chiropractic Adjustment Contributed to Woman's Death, Quebec Coroner Concludes." CBC News. Available at www.cbc.ca/canada/montreal/story/2007/04/12/qc-
    chiropracticreport20071012.html.
28. "Things I Have Learned: Urgent Updates to Prenatal Care," op. cit.