Over the years I have penned many case histories for various publications and continuing education courses I have taught. Since so many doctors ask for advice in caring for pregnant women, I've decided to post some of my more interesting case histories (well, I think they're interesting. My hope is that you will, too!) so that more doctors can read about various methods I have found in caring for moms to be. As always, feel free to forward this info to your friends and colleagues and if you have any questions or comments about this or other cases, please fell free to post it here.
This patient denies smoking. She reportedly drinks one cup of coffee as well as one cup of tea per day. She is taking pre-natal vitamins; iron (Flourodix) and Calcium (Citracel) as directed by her midwife. Even though she is experiencing acid reflux and indigestion, none of these supplements appear to be causing digestive distress that is sometimes common with these particular supplements. She reported being unaware if her amniotic fluid levels were within normal limits. She admits to exercising regularly as well as eating a balanced diet. She does not get at least eight hours of sleep per night due to her chronic insomnia.
Physical Examination –
Palpation revealed taut and tender fibers in the lumbo sacral region bilaterally from L3 through Coccyx. Palpatory tenderness was noted at the Coccyx and Sacrum, also bilaterally. Trigger points were noted in the upper trapezius muscles from C7 to T-5
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Case History: 33 year old woman
presents with headaches, low back pain and a posterior baby at 31 weeks
gestation.
The patient is pregnant
with her first child.
Her
main reason for coming to our office for care to is have her pelvis evaluated
for its possible contribution to the current occiput posterior presentation of
her baby.
In the past, she has had headaches, low back pain, stomach
trouble and neck pain prior to this pregnancy and is also currently complaining
of the same. None of her current complaints, however, are interfering
with her activities of daily living. She is currently
under the care of a midwife for this pregnancy. She does not have a history of any hernias,
uterine fibroids, or ovarian cysts. She
had never had any abdominal surgeries.
Her midwife reports this patient’s uterus is normal and is free from any
abnormalities that may be contributing to the posterior presentation of the
baby.
She did report that in the seventh grade she was fitted for
a back brace to treat her severe scoliosis.
She wore the brace for 18 hours each day for three years. She was unable to describe her degree of
scoliosis or any details about the brace, however. She was not able to obtain patient records
from her physician who ordered the braced and cared for her during this three
year period.
Consultation:
She communicated the following accident history:
She communicated the following accident history:
As a teenager (she did not give a specific age when asked)
this patient was thrown from a horse, hit the ground and landed on her coccyx. Again, no medical treatment was obtained for
this injury. At approximately 8 years of
age she was involved in a “fender bender” type auto accident as a back seat
passenger. She was not wearing a
seatbelt and reports that she did not experience any symptoms after the
accident and therefore did not receive any medical care. This patient also experienced a fairly
serious fall down a flight of stairs at age as a young child at camp. She could not remember how old she was at the
time of the accident. She reports that she
fell on her tailbone repeatedly and describes it as the absolute worst pain of
her life.
This patient denies smoking. She reportedly drinks one cup of coffee as well as one cup of tea per day. She is taking pre-natal vitamins; iron (Flourodix) and Calcium (Citracel) as directed by her midwife. Even though she is experiencing acid reflux and indigestion, none of these supplements appear to be causing digestive distress that is sometimes common with these particular supplements. She reported being unaware if her amniotic fluid levels were within normal limits. She admits to exercising regularly as well as eating a balanced diet. She does not get at least eight hours of sleep per night due to her chronic insomnia.
Physical Examination –
A thorough examination of her
lumbar and cervical spine was conducted due to her complaints of headache,
lower back pain, and posterior baby. Postural evaluation
revealed a lumbar hyperlordosis most likely due to her advanced stage of pregnancy. She also presented with anterior weight
bearing. Despite her history of
scoliosis, the remainder of her postural evaluation appeared to be within
normal limits.
Cervical active range of motion was within normal limits
with no noted pain or discomfort. Lumbar
active range of motion was also within normal limits.
Palpation revealed taut and tender fibers in the lumbo sacral region bilaterally from L3 through Coccyx. Palpatory tenderness was noted at the Coccyx and Sacrum, also bilaterally. Trigger points were noted in the upper trapezius muscles from C7 to T-5
Deep Tendon Reflexes: Biceps (C5\C6): left: normal;
right: normal. Brachioradialis (C5\C6):
left: normal; right: normal.
Triceps (C7\C8): left: normal; right: normal. Patellar (L2\L4): left: normal;
right: normal. Hamstrings (L4\L5):
left: normal; right: normal.
Achilles (S1\S2): left: normal; right: normal. Cranial Nerve Exam: Myotome evaluation revealed no weakness in
the upper and lower extremity. Dermatome
evaluation revealed no altered sensation to pin prick in the upper and lower extremity.
Spinal analysis using
muscle testing uncovered the following misalignments:
Posterior coccyx on the
right, superior pubic bone on the left, posterior L3 on the left, posterior T6
and T4, and C3 Body left.
Prone leg checks uncovered
a left short leg of ¼ inch with a left cervical syndrome. Therapy localization indicated a left
posterior Atlas on the right. Supine leg
checks uncovered a right short leg of ¼ inch.
Using Basic Sacral
Occipital analysis, the patient was not found to be any Category.
All cervical orthopedic
tests were found to be within normal limits.
The lumbar orthopedic tests that are not contraindicated during
pregnancy were also found to be within normal limits.
A thermal spinal scan
showed areas of severe thermal asymmetries in the upper cervical (specifically
atlanto-occipital) and upper lumbar (specifically thoraco-lumbar) regions which
correlates and supports the initial exam findings.
Care Plan
Based upon the patient’s history of traumas, previous pregnancies, weeks gestation of current pregnancy and presenting symptoms, the following care plan has be recommended:
Based upon the patient’s history of traumas, previous pregnancies, weeks gestation of current pregnancy and presenting symptoms, the following care plan has be recommended:
Specific
Chiropractic spinal adjustments following the
Bagnell Technique protocol three to four times weekly until baby turns to the anterior
position. Once the baby turns, one to
two weekly adjustments is recommended until the birth of the baby. A 6 week post-partum check up is also
recommended to evaluate a continued need for care.
Treatments
This patient received her
first chiropractic adjustment on May 26, 2009.
C3 was adjusted, manually, in the prone position as was T4 and T6. L3 was adjusted using an instrument in the
prone position as was a posterior right coccyx.
A superior right pubic bone was corrected in the supine position using a
very light setting (2 rings) on the activator instrument.
Re-evaluation and follow up
On June 3, 2009, the
patient returned for her second adjustment and reported that the baby was in a
breech presentation. A brief kinesiological exam revealed a C2 body left and a
posterior right coccyx. Both were
adjusted in the prone position using an instrument. A superior right pubic bone was corrected in
the supine position using a very light setting (2 rings) on the activator
instrument. A follow up thermal scan
showed the previous severe thermal asymmetries in the cervical area have
improved and were described as mild to moderate in nature. The thoraco-lumbar area still showed severe
asymmetries however they were on the opposite side from the first scan.
On June 11, 2009 she
returned for her third adjustment, even though it was recommended that she be
seen more frequently until the baby turns.
C7 and T1 were adjusted in the prone position. Her sacrum and not her coccyx needed to be
adjusted on this visit. A P-L listing
was adjusted in the prone position using an instrument. In addition, an anteriorly rotated trochanter
was found and adjusted on the right in the prone position using an
instrument. The patient reported that an
ultrasound examination revealed that the baby had turned to the vertex position
and that the baby was also in an occiput anterior position.
Discussion
Prior to her third visit in our office, this patient was
taking Homeopathic Pulsatilla (a dilution 6C) as recommended by her
midwife. Pulsatilla is a widely used
homeopathic remedy derived from the vegetable kingdom, from the wind
flower. It is often referred to as “the”
pregnancy remedy as is addresses many common complaints of pregnancy. It also has some notable success in getting
babies to turn head down. The 6C
dilution is an extremely mild dilution and in most, if not all, states in the U.S. it is
available without a prescription. The
midwives we work with on a regular basis will often suggest Pulsatilla to their
breech patients as they did the case discussed above.
Initially this patient came to our office because the baby
was in an occiput posterior position.
This baby later turned from vertex to Breech as it will sometimes
happen. As expected, her pubic bone and
coccyx were misaligned and needed to be adjusted regularly; even after the baby
turned to the vertex position. In fact,
on every visit prior to delivery (eleven office visits in total) she needed her
coccyx adjusted. This misalignment was
of no surprise given her history of trauma to this area of her pelvis.
On August 2, 2009 – just three days after her last
adjustment in this office, this patient was able to deliver her baby vaginally
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Dr. Karen, just wanted to say wow...I've learned so much and I'm only into the 2nd module. This is the stuff we need to know in everyday practice! I could listen to you all day long! ~ Dr. Katie Gelesko Stull
