Case History: 32 year old pregnant female presents with low back pain and a breech baby at 37 weeks gestation.
The patient is pregnant with her third child and denies ever experiencing a breech presentation with her previous pregnancies.
Her main reason for coming to our office for care to is have her pelvis evaluated for its possible contribution to the current breech presentation of her baby and for palliative relief of her low back pain.
In the past, she has had headaches prior to this pregnancy and is currently complaining of low back pain and water retention; neither of which interfere with her activities of daily living. She admits to having headaches during her first trimester with this pregnancy and she has an occasional occipital headache. 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 breech presentation of the baby. She does mention that during her last pregnancy she experienced high blood pressure during the last few weeks before birth. Currently, her blood pressure is within normal limits.
Consultation:
She communicated the following accident history:
She communicated the following accident history:
During her senior year in high school, this patient was involved in an auto accident where she was the driver. She was struck by another vehicle on the driver’s side of her vehicle. As a result of this accident she admits to “blacking out”. She was treated for lacerations to the left side of her face and required stitches for her injuries. She was released and no further treatment was obtained. She admitted to another minor automobile accident prior to this one but was unable to give any specific details in its regards.
This patient also experienced a fairly serious fall down a flight of 14 stairs during her last pregnancy. She reports that the fall involved her landing on her tailbone; and that it took place during her third trimester of pregnancy. She denies having any adverse effects due to this fall and maintains that her pregnancy progressed normally. She did not receive any medical treatment for this injury.
Although this is her third pregnancy, this is the first time she is carrying a breech baby. Her previous two pregnancies were delivered vaginally with the aid of the same midwife who is currently caring for her.
This patient denies smoking. She reportedly drinks an occasional cup of tea as well as one cup of coffee per day. She is taking pre-natal vitamins and a B-complex vitamin as directed by her midwife. Neither supplement is causing digestive distress that is sometimes common with these particular supplements. She reported being unaware if her amniotic fluid levels were within normal limits or not.
Physical Examination –
Physical Examination –
A thorough examination of her lumbar and cervical spine was conducted due to her complaints of occasional headache, constant lower back pain, and breech baby. Postural evaluation revealed a lumbar hyperlordosis most likely due to her advanced stage of pregnancy.
Cervical active range of motion was within normal limits except for left rotation which was decreased to 70 degrees. There was no pain or discomfort present in all cervical ranges of motion. She did, however, present with functional weaknesses in left and right cervical rotation. Lumbar active range of motion was within normal with no pain, discomfort or functional weakness.
Palpation revealed taut and tender fibers and palpable nodules in the lumbo sacral region bilaterally from L-3 through Coccyx. Edema was also noted at the same levels previously mentioned.
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:
Sacral Apex left, anterior right trochanter, superior pubic bone on the left, posterior L5 on the left, Posterior L3, Posterior T1, T2, T5, T6, C2 body left, and a superior right 1st rib.
Prone leg checks uncovered a right short leg of ¼ inch and a negative Derefield. Supine leg checks also uncovered a left short leg of ¼ inch.
Using Basic Sacral Occipital analysis, the patient was not found to be in 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 mild to moderate thermal asymmetries in the lower cervical and upper thoracic regions as well as severe thermal asymmetries in the 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, presenting symptoms and breech presentation of her baby, the following care plan has be recommended:
Specific Prenatal Chiropractic spinal adjustments two to four times weekly until baby turns to the vertex position. Once the baby turns, one to two weekly adjustments are 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 April 26, 2007. C2 body left was adjusted manually as was a posterior C5; both in the prone position.. The T1-T2 motor unit and the T5-T6 motor unit were adjusted manually, also in the prone position. L3(P) and L5 (PL)were adjusted in the prone position using an instrument. Left sacral apex rotation was corrected in the prone position using an extremely light drop table. An anterior right trochanter was adjusted in the prone position with an instrument. A left superior pubic bone was corrected in the supine position, also using an instrument with a slight anterior to posterior and superior to inferior line of drive. Light contact was held on the left round ligament until the residual spasm subsided.
Re-evaluation and follow up
The baby turned to a vertex position after the first adjustment. This patient returned in four days for a follow up chiropractic evaluation. A brief kinesiological exam revealed a posterior C5, T4, T6 and L3. All segments were adjusted with an instrument in the prone position. A posterior Left Sacrum was also corrected in the prone position using an instrument. The pubic bone misalignment that was corrected during the first adjustment did not present, nor did any round ligament spasm. The right anterior trochanter, however, was still present and was corrected in the prone position using an instrument.
Discussion
Since this patient had two non-breech pregnancies prior to this one, it is logical to inquire about any injuries or traumas that may have occurred during or prior to this breech pregnancy. During her consultation, it was discovered that she indeed had a serious fall during the late third trimester of her last pregnancy. Luckily, the fall did not cause any complications to that pregnancy. It is easy to surmise that the trauma she endured to her pelvis at that time may have affected this current pregnancy and the position of this baby. After a complete physical exam, it was discovered she did experience misalignment to her pelvis, specifically her sacrum and symphysis pubis. These two areas, when misaligned, often present with a breech presentation. When these areas of misalignment are corrected, the baby normally turns into the vertex position. It is easy to conclude there may very well be a connection with these misalignments and the positioning of the baby in utero.
The evening after her first adjustment, the patient revealed experiencing a tremendous amount of fetal movement. On April 30, 2007 – four days following her initial chiropractic treatment, the patient visited her midwife where, through the Leopold maneuver, it was determined that the baby had turned into a vertex position. The vertex positioning of the baby was later confirmed by ultrasound.
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