Case History of Occiput Posterior Presentation at 31 weeks gestation

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.  

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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:

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:

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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