CASE STUDY - 35 weeks gestation with low back pain and a breech baby

Case History: 30 year old woman who is at 35 weeks gestation presents on 12/31/2008 with low back pain and a breech baby.  

The patient is pregnant for the 1st time.  She was referred to our office for care by her midwife.

In addition to the low back pain and breech presentation of her baby, described above, she is also complaining of recurring ear infections, sinus trouble and stomach trouble during this pregnancy.  With the exception of sinus trouble, her symptoms were not present prior to this pregnancy.   None of her current symptoms are interfering significantly with her activities of daily living.  

She is currently under the care of a midwife for this pregnancy.   She does not have any history of abdominal surgeries, uterine myomas or any other abnormalities, such as a bicornuate, septate, or unicornuate uterus,  that may be contributing to the breech presentation of the baby.  

Consultation:
She communicated the following automobile accident history:

At 21 years of age she was the driver involved in what she calls a minor fender bender that involved a front impact with another car.  She reported no symptoms and therefore received no medical attention for this accident.  

In 2003 she was involved in a rear-end collision on an interstate highway.  She was a passenger and was wearing a seatbelt at the time of impact.  She reported that she experienced mild stiffness that evening but again, did not seek any form of medical treatment for her symptoms.  

In 2007, she was involved in another minor fender bender as the driver.  The front impact collision again left her with residual soreness later in the day.  She reported no other injuries.  She did not receive any medical care for this accident.  

She communicated the following accident history:

In 2004, she reported a slip and fall at her place of employment.  She slipped on the wet floor and landed on the right side of her pelvis.  She was taken to the hospital for x-rays to rule out a possible fracture to her pelvis.  While in the hospital she was given pain killer s and muscle relaxers for her symptoms.  She does not recall the specific medications

I addition to her accidents, she reported having a long standing childhood history of ear infections.  She still suffers with them to this day and they have gotten worse during pregnancy.  

Her primary complaint of low back pain has been intermittent for year and had gradually progressed with her pregnancy.  It is reportedly worse in the afternoon.  She also reports soreness around her abdomen in the area of the round ligament attachment that is worse after walking her dog.  The stomach trouble or indigestion she is experiencing started during the second trimester and is getting worse as the bay gets bigger.  She mentions that it is now waking her up at night and describes it as heartburn.

This patient denies smoking.  She reportedly drinks one cup of tea and three diet soft drinks per day.  She reports that she eats a well-balanced diet.  She exercises on a regular basis; at least four to five times per week.  She claims to get at least eight hours of quality sleep per night.  

She is taking pre-natal vitamins and DHA as directed by her midwife.  The pre-natal supplements are not causing digestive distress that is sometimes common with this particular supplement.  She reported being unaware if her amniotic fluid levels were within normal limits.  

DHA stands for Docosahexaenoic acid. DHA is an omega-3 long chain polyunsaturated fatty acid that is a crucial building block for proper development of the nervous system, eyes, and brain.  Foods containing a significant amount of DHA, such as fatty fish, organ meats, and marine plants are not usually eaten with frequency.  Therefore, supplementation is the usual means of ingestion.  

Babies are dependent upon their mother's diet for DHA and other nutrients. Particularly in the third trimester of pregnancy, when baby's brain develops rapidly.  

Pre-natal DHA supplementation is a rather new development.  

Physical Examination –

A thorough examination of her lumbar and cervical spine was conducted due to her complaints of lower back pain, breech baby and ear infections.  Postural evaluation revealed a lumbar hyperlordosis most likely due to her advanced pregnancy.  

Cervical active range of motion was within normal limits with no noted pain or discomfort.  

Lumbar active range of motion was also within normal with no noted pain or discomfort.  

Palpation revealed taut and tender fibers in the lumbo sacral region bilaterally from L-3 through Sacrum and in the cervical region from Occiput to C7.  There was marked myospasm noted in the mid dorsal region from T4 through T9.  Palpatory tenderness was noted at the right sacroiliac joint.    

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 Sacrum on the right, superior pubic bone on the right, posterior T2, T-5 and T-6, and a C2 body right.  An anterior right trochanter was also found to be present.   

Prone leg checks uncovered a right short leg of ½ inch and a positive Derefield.  A left cervical syndrome was also noted.  Supine leg checks also uncovered a right short leg of ¼ inch.  

Using Basic Sacral Occipital analysis, the patient was found to be a Category II, right major.

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 mild to moderate thermal asymmetries in the cervical region from Atlas to C7.  Areas of severe thermal asymmetries were noted at L1.  Moderate thermal asymmetries were noted at L2, L4 and L5 which all correlate and support the initial exam findings.  

Care Plan
Based upon the patient’s history of traumas, weeks gestation of current pregnancy and presenting symptoms, the following care plan has be recommended:

Specific Prenatal Chiropractic spinal adjustments three to four times weekly until baby turns to the vertex position.  Once the baby turns one to two weekly adjustments is recommended until the birth of the baby to maintain the correction to the patient’s pelvis and to continue correction to the other areas involved.  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 December 31, 2008

C2 (BR) was adjusted on the right, manually, in the prone position as was T2, T5, T6.  A posterior right sacrum was adjusted in the prone position using an instrument.  A right superior pubic bone was adjusted with an instrument in the supine position.  There was no residual spasm noted in the round ligament after the adjustment therefore there was no need for correction.  

This patient received her second chiropractic adjustment on January 5, 2009.   Atlas (ASLP) was adjusted using toggle recoil technique.  T2 and T3 were adjusted in the prone position, manually.  A P-R sacrum was adjusted in the prone position using an instrument.  Left coccyx was adjusted in the prone position using an instrument.  After this adjustment, the patient reported experiencing a lot of fetal movement.  Increased fetal movement often indicates that the baby is trying to move into the vertex position.  

This patient received 3 adjustments each week for 3 additional weeks.  After her third visit, the patient visited her midwife.  By way of the Leopold maneuver, the midwife confirmed that the baby had turned from a breech position tot a transverse position by way of the Leopold maneuver.  On all of her subsequent visits she presented with virtually the same subluxation patterns.  Sacrum, superior pubic bone, anterior trochanter and residual round ligament spasm had to be adjusted on every visit.  After her first adjustment her complaint of heartburn was resolved.  

Re-evaluation and follow up

Two follow up thermal scans were performed on January 5, 2009 and January 7, 2009.  Each scan showed no marked improvement in any of the thermal asymmetries in the cervical and lumbo sacral regions.    The patient’s last adjustment before the birth of her baby was on January 19, 2009.  She was advised to take the homeopathic remedy, Aconite on that same visit.  Later that same day, the patient reported a marked increase in fetal movement.  After the Aconite on 1/19/09 she was scheduled to have an external cephalic version performed by her midwife on 1/20/09 which proved to be unsuccessful.  On January 26, 2009 the patient delivered her baby via c-section.

Discussion

Aconite has been used successfully in women carrying a breech baby.  In addition to having a breech baby, many women who are good candidates for Aconite also exhibit a tight and firm abdomen.  Unrelenting round ligament spasm (not necessarily round ligament pain) is also common with these cases.  This was a very interesting case because the baby never moved past a transverse position.  The midwife noted while performing the version that it was almost as if the baby was getting stuck as it tried to move.  The fact that this patient’s thermal scans and patterns of subluxations did not change during the course of her care also indicated that there was may be other underlying causes of this breech presentation.  The patient reported during her follow up care in our office, that she was told her uterus was abnormally shaped and the baby was in fact “stuck in one spot” and couldn’t move.  When asked, she couldn’t elaborate any further on what exactly was meant by an abnormally shaped uterus.  She was told this could affect subsequent pregnancies.  

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