CASE STUDY - Breech Baby at 36 weeks

Case History:

39 year old woman presents with breech baby at 36 weeks gestation.

The patient is pregnant for the 2nd time.  She had suffered a miscarriage during the 5th week of her first pregnancy.  She was referred to our office for care by her midwife.

She is currently complaining of low back pain, water retention, carpal tunnel syndrome and sinus congestion during this pregnancy.  She also reported suffering from low back pain and neck pain prior to this pregnancy.   None of her current symptoms are interfering with her activities of daily living.  

She is currently under the care of a midwife for this pregnancy.   She does have a history of a uterine myoma measuring approximately 5 cm. in the lower right quadrant of her uterus.  The fibroid has not been removed surgically and she denies having any other abdominal surgeries.  Except for the myoma, her midwife reports this patient’s uterus is otherwise normal and is free from 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:

In 1984, she was a passenger in the back seat of a car when it was impacted at a high rate of speed on that same side.  She suffered head trauma and was hospitalized over night.  The head trauma included a concussion, broken front teeth and a fractured skull.  She could not describe which bones of her skull sustained the fracture(s).  

In 1989 she was involved in a minor fender bender as a passenger.  The driver side of the car she was traveling in was struck at approximately 30 mph.  Her right knee hit the dash board and she suffered pain and bruising as a result.  No other injuries were reported and she received no medical care for her injuries.

In 2000, she was involved in another minor fender bender as a passenger.  The driver side of the car she was traveling in was struck at approximately 30 mph.  She reported no injuries other than general aches and pains.  She did not receive any medical care for this accident.  

She communicated the following accident history:

In 1991, she reported a bicycle accident where the front tire of her bicycle slipped into a trolley track.  She then flipped over the handle bars of her bike and was then struck by the trolley car.  As a result she suffered upper back pain.  She sought medical care for this trauma and was prescribed muscle relaxers and massage therapy.  She reported some symptomatic relief using these treatments.  

She had two notable impacts to her coccyx.  Both impacts involved falling down a spiral staircase.  The first fall occurred in 1994 and the second fall occurred in 1995.  Both falls left visible bruising in the coccyx area.

Her current complaint of low back pain started gradually and can be traced back as far back as 1998.  She describes that it can be sharp at times at her right sacroiliac joint and that it does not radiate.  Standing for long periods exacerbates her symptoms.  Deep breathing and Yoga tend to relieve some of this discomfort.  This patient denies smoking.  She reportedly drinks one cup of coffee as well as one cup of tea 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 as directed by her midwife.  This supplement is 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.  

Physical Examination –

A thorough examination of her lumbar and cervical spine was conducted due to her complaints of neck pain and lower back pain.   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 within normal limits however pain was present at the L5-S1 level during lumbar flexion, lumbar extension and lumbar right lateral flexion.  

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.  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 coccyx on the right, Posterior Sacrum on the right, superior pubic bone on the right, posterior T-4 on the left, C2 body right and a left posterior occiput.

Prone leg checks uncovered a right short leg of ¼ inch and a negative Derefield.  Therapy localization indicated a left C2.  Supine leg checks also uncovered a left short leg of ¼ inch.  

Using Basic Sacral Occipital analysis, the patient was not found to be a Category II.    

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 with the exception of a positive Minor’s sign on the right and a bilaterally positive supported Adam’s test.

A thermal spinal scan showed areas of severe thermal asymmetries in the cervical (specifically C2 through C3) and lower lumbar (specifically lumbo-sacral) 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 Prenatal Chiropractic spinal adjustments three to four times weekly until baby turns itself into the vertex 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 February 2, 2006.

A left posterior occiput was adjusted using an occipital lift; C2 (BL) was adjusted on the left, manually, in the prone position as was T9 and T3.  A Sacral Apex Right was adjusted using an instrument.  A posterior right coccyx was adjusted with an instrument as was a right superior pubic bone.  Light contact was held on the right round ligament until the residual spasm subsided.  

This patient received her second chiropractic adjustment on February 6, 2006.   Atlas (ASLP) was adjusted using toggle recoil technique.  T1 and T3 were adjusted in the prone position, manually.  A P-R sacrum was adjusted in the prone position using an instrument.  A superior right pubic bone was adjusted in the supine position using an instrument.  There was no residual spasm in the round ligament; therefore contacting the ligament was not necessary on this visit.  The day after this visit, the patient visited her midwife who confirmed the baby was in the vertex position by way of the Leopold maneuver.

Three more weekly adjustments were performed on this patient after the baby had turned to a vertex position to maintain correction and prevent reverting back to a breech position which has happened in other cases where continued care was terminated pre-maturely.   

Re-evaluation and follow up

The baby turned to a vertex position after the 2nd adjustment.  Therefore this patient returned once per week for the next 3 weeks for follow up chiropractic evaluation.  On each of these visits and right superior pubic bone was detected and corrected using an instrument.  After confirmation of the vertex baby, a recommendation of a pregnancy support belt was made to help alleviate the backache of pregnancy and to help maintain the pubic bone correction.  It’s very important to refrain from using a support belt while the baby is still in a breech position.  It is possible that the belt could further restrain the baby in utero and inhibit its ability to turn to a vertex position.  

A follow up thermal scan was performed on March 8, 2006 and showed that the previous severe thermal asymmetries in the cervical and lumbo sacral regions have improved and were described as normal to mild in nature.  

Discussion

Prior to her first visit in our office, this patient was performing what she called a “breech tilt” exercise.  She further describes this exercise as “being on my back and elevating my pelvis approximately 20 inches for 10-15 minutes 2 or 3 times per day.  I use pillows and a deflated birthing ball to accomplish the position (I don’t have the recommended ironing board) but I find that this puts a lot of strain on the back of my neck.”  She was discouraged from continuing this exercise after her initial consultation as it was causing her pain.  

She reportedly slept on her right side which may or may not be contraindicated during pregnancy.  Since two of her major complaints involved water retention and carpal tunnel syndrome (also closely related to water retention issues) she was advised to only sleep on her left side.  By sleeping on the left side, the weight of the pregnant uterus is put on the rigid abdominal aorta.  When lying in the right lateral recumbent position,   pressure is exerted on the inferior vena cava.  The inferior vena cava is the route by which de-oxygenated blood from the lower half of the body returns to the heart. When the inferior vena cava is compressed it reduces the amount of blood that returns to the heart and reduces cardiac output .  Reduced cardiac output is dangerous to both the mother and the baby.  

Trauma to the coccyx almost always impacts a woman’s reproductive system in some way.  Many women with Dysmenorrhea or Menorrhagia are found to have a history of coccygeal trauma.  In many cases of breech or transverse presentation, a coccyx misalignment is very often present.  It is essential to take a thorough history of coccyx trauma in these cases.

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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