Adjusting… Pregnancy Modifications for the Pregnant Patient
What causes subluxation? • 3T’s • Thoughts • Trauma • Toxins • Also consider hormonal and biomechanical factors
Hormonal Factors – Alteration of supporting structures • Progesterone – decreases smooth muscle tone • This alters the vascular supply to the motor unit as well as the surrounding structures and all of the joints of the body • Estrogen – relaxes the joint capsule • Allows for more “play” in the joints • Relaxin – contributes to the “relaxation effect” allowing the pelvis to open (Fallon, 1994)
Biomechanical Changes Increased kyphosis Increased lordosis
What modifications should we make? • Alteration of supporting structures; joint laxity • ? • Changes in kyphosis/lordosis • ?
Cervical Spine • Adjusting is handled in the same manner as non-pregnant women Remember to consider: • laxity of ligamentous structure • decrease in cervical lordosis (kypholordosis) • anterior head carriage, etc.
Thoracic Spine • Stress on the thoracic kyphosis • breast enlargement • compensatory curve changes • Flaring of the ribcage • Adjust the thoracic spine as well as ribs NOTE: intercostal neuralgia is common
Clinical Note Thoracic and abdominal compression will become more and more uncomfortable as the baby grows… • Some DC’s like to use anterior adjusting • patient doesn’t have to be prone
Other Solutions • Swing-away abdominal piece • Crank pelvic piece • Pregnancy pillow • gap for baby • protects the breasts • softens the table
Lumbar Spine • Hyperlordosis ~> stress on facets • Spinous imbrication - facet “jams”
Pelvis • Subluxations can occur in 3 separate places • R and L SI joints, symphysis pubis • Most common area of involvement • Hormonal influences • Weight gain • Altered support structures • Joint capsules constantly stretched by pressure from the fetus
Chiropractic Assessment • Observation • Static Palpation • Motion Palpation • Instrumentation • Radiography • Adjustments
Observation – Pregnancy Normal postural changes of pregnancy must be differentiated from postural abnormalities that are clinically relevant. Lateral view • Increased lumbar lordosis & sacral base angle • usually present by the 2nd tri • Exaggerated thoracic kyphosis • Anterior translation of the head and cervical spine
Observation – Pregnancy • The innominates may flare outward to compensate for the developing fetus • May cause a compensatory gait alteration • “waddle” • This does not indicate a bilateral “In” ilium fixation or a bilateral ilium adjustment
Clinical Note Pregnant patients may present the doctor with a more complex and difficult palpation assessment - constantly changing posture and biomechanical adaptation • Subluxation vs. compensation? • Compensation – may manifest as more symptomatic that the site of joint fixation
For example… • SI joints may be • symptomatic • reveal tenderness upon static palpation • movement is normal Does not warrant adjustment! • Similar findings may present in transitional regions (CO-C1, C7-T1, T12-L1)
Static Palpation – Pregnancy • Digital palpation for tenderness and edema • Detected at both hypo and hypermobile* segments • Also note suderiferous changes, tissue prominency, etc. *It is contraindicated to adjust a hypermobile articulation!
Motion Palpation – Pregnancy • Intersegmental range of motion palpation • Passive • Patient assisted • May be best done seated • Spine in a neutral position • Modify your technique as the abdomen grows
Instrumentation – Pregnancy • Dual Probe – break analysis • temperature patterns may vary more than the non-pregnant patient • Compensations – may manifest as increased temperature differentials • Subluxations – demonstrate a constant “break” Findings should be correlated with other exam findings.
Radiography – Pregnancy Usually not obtained on the pregnant female • Increased risk associated with fetal exposure Ursprung et al. Plain Film Radiography, Pregnancy, and Therapeutic Abortion Revisited. JMPT 2006; 29(1):83-87 In the case of trauma (cervical spine)… • may consider limited views • Must discuss possible risks • Use all safety precautions
Adustments – Pregnancy As stated before… Hormonal changes increase mobility • If a motion segment is compensating for a lack of mobility at any level, then it may become more hypermobile Forces should not be introduced into joints that exhibit hypermobility!
– GONSTEAD – ACTIVATOR – LOGAN – THOMPSON – SOT – DIVERSIFIED – Any technique can be modified! Limitations: • Patient comfort • Patient size & mobility/flexibility • Your creativity…
Remember... • Make sure she‘s comfortable • Keep her spine in a neutral position • Light thrusts! “...a rebound effect can occur if adjustments are too forceful during pregnancy.“ Larry Webster
Positioning her comfortably • Give baby room but still support the abdomen • slight pressure on the abdomen will not harm the baby • Work with your patient • her needs will change as the pregnancy progresses • let her tell you what feels best
Clinical Note • In the last trimester, minimize time spent flat on her back • puts unnecesary pressure on abdominal aorta
Treatment Protocol (Fallon, 1994) How often should a pregnant woman be adjusted? Varies from patient to patient. 1x/month 1st trimester 2x/month 2nd trimester 1x/week leading up to & following birth 2x/month 1x/month (stabilizes)
References • Anrig & Plaugher. Pediatric Chiropractic. Baltimore, MD: Lippincott Williams & Wilkins, 1998. • Anrig-Howe C. Scientific Ramifications for Providing Pre-natal and Neonate Chiropractic Care. The American Chiropractor, 1993; May/June: 20-26. • Fallon. Textbook on Chiropractic and Pregnancy. Arlington, VA: International Chiropractors Association, 1994. • Forrester J. Chiropractic Management of Third Trimester In-utero Constraint. Canadian Chiropractor, 1997; 2(3): 8-13. • Fysh. Chiropractic Care for the Pediatric Patient. Arlington VA: ICACCP, 2002. • Kunau P. Application of the Webster In-utero Constraint Technique: A Case Series. Journal of Clinical Chiropractic Pediatrics, 1998; 3(1): 211-6. • McMullen M. Assessing upper Cervical Subluxations in Infants Under Six Months. ICA International Review of Chiropractic, 1990; March/April: 39-41 • Pistoles R. The Webster Technique: A Chiropractic Technique with Obstetric Implications. JMPT, 2002; 25(6). • Webster L. Chiropractic Care During Pregnancy. Today’s Chiropractic, 1982; Sept/Oct: 20-22.