1. Adjusting… Pregnancy Modifications for the Pregnant Patient

2. What causes subluxation? 3T’s – Thoughts – Trauma – Toxins Also consider hormonal and biomechanical factors

3. Hormonal Factors – Alteration of supporting structures Progesterone – decreases smooth muscle tone – This alters the vascular supply to the motor unit as well as the surrounding structures and all of the joints of the body Estrogen – relaxes the joint capsule – Allows for more “play” in the joints Relaxin – contributes to the “relaxation effect” allowing the pelvis to open (Fallon, 1994)

4. Biomechanical Changes Increased kyphosis Increased lordosis

5. What modifications should we make? Alteration of supporting structures; joint laxity – ? Changes in kyphosis/lordosis – ?

6. Cervical Spine Adjusting is handled in the same manner as non-pregnant women Remember to consider: laxity of ligamentous structure decrease in cervical lordosis (kypholordosis) – anterior head carriage, etc.

7. Thoracic Spine Stress on the thoracic kyphosis – breast enlargement – compensatory curve changes Flaring of the ribcage – Adjust the thoracic spine as well as ribs NOTE: intercostal neuralgia is common

8. Clinical Note Thoracic and abdominal compression will become more and more uncomfortable as the baby grows… Some DC’s like to use anterior adjusting – patient doesn’t have to be prone

9. Other Solutions Swing-away abdominal piece Crank pelvic piece Pregnancy pillow – gap for baby – protects the breasts – softens the table

10. Lumbar Spine Hyperlordosis ~> stress on facets – Spinous imbrication - facet “jams”

11. Pelvis Subluxations can occur in 3 separate places – R and L SI joints, symphysis pubis Most common area of involvement – Hormonal influences – Weight gain – Altered support structures – Joint capsules constantly stretched by pressure from the fetus

12. Chiropractic Assessment Observation Static Palpation Motion Palpation Instrumentation Radiography Adjustments

13. Observation – Pregnancy Normal postural changes of pregnancy must be differentiated from postural abnormalities that are clinically relevant. Lateral view Increased lumbar lordosis & sacral base angle – usually present by the 2 nd tri Exaggerated thoracic kyphosis Anterior translation of the head and cervical spine

14. Observation – Pregnancy The innominates may flare outward to compensate for the developing fetus May cause a compensatory gait alteration – “waddle” This does not indicate a bilateral “In” ilium fixation or a bilateral ilium adjustment

15. Clinical Note Pregnant patients may present the doctor with a more complex and difficult palpation assessment - constantly changing posture and biomechanical adaptation Subluxation vs. compensation? Compensation – may manifest as more symptomatic that the site of joint fixation

16. For example… SI joints may be – symptomatic – reveal tenderness upon static palpation – movement is normal Does not warrant adjustment! Similar findings may present in transitional regions (CO-C1, C7-T1, T12-L1)

17. Static Palpation – Pregnancy Digital palpation for tenderness and edema – Detected at both hypo and hypermobile* segments Also note suderiferous changes, tissue prominency, etc. *It is contraindicated to adjust a hypermobile articulation!

18. Motion Palpation – Pregnancy Intersegmental range of motion palpation – Passive – Patient assisted May be best done seated – Spine in a neutral position Modify your technique as the abdomen grows

19. Instrumentation – Pregnancy Dual Probe – break analysis – temperature patterns may vary more than the non- pregnant patient Compensations – may manifest as increased temperature differentials Subluxations – demonstrate a constant “break” Findings should be correlated with other exam findings.

20. Radiography – Pregnancy Usually not obtained on the pregnant female – Increased risk associated with fetal exposure Ursprung et al. Plain Film Radiography, Pregnancy, and Therapeutic Abortion Revisited. JMPT 2006; 29(1):83-87 In the case of trauma (cervical spine)… – may consider limited views Must discuss possible risks Use all safety precautions

21. Adustments – Pregnancy As stated before… Hormonal changes increase mobility If a motion segment is compensating for a lack of mobility at any level, then it may become more hypermobile Forces should not be introduced into joints that exhibit hypermobility!

22. – GONSTEAD – ACTIVATOR – LOGAN – THOMPSON – SOT – DIVERSIFIED – Any technique can be modified! Limitations: Patient comfort Patient size & mobility/flexibility Your creativity…

23. Remember... 1. Make sure she‘s comfortable 2. Keep her spine in a neutral position 3. Light thrusts! “...a rebound effect can occur if adjustments are too forceful during pregnancy.“ Larry Webster

24. Positioning her comfortably Give baby room but still support the abdomen – slight pressure on the abdomen will not harm the baby Work with your patient – her needs will change as the pregnancy progresses – let her tell you what feels best

25. Clinical Note In the last trimester, minimize time spent flat on her back – puts unnecesary pressure on abdominal aorta

26. Treatment Protocol (Fallon, 1994) How often should a pregnant woman be adjusted? Varies from patient to patient. 1x/month1 st trimester 2x/month2 nd trimester 1x/week leading up to & following birth 2x/month 1x/month (stabilizes)

27. References Anrig & Plaugher. Pediatric Chiropractic. Baltimore, MD: Lippincott Williams & Wilkins, 1998. Anrig-Howe C. Scientific Ramifications for Providing Pre-natal and Neonate Chiropractic Care. The American Chiropractor, 1993; May/June: 20-26. Fallon. Textbook on Chiropractic and Pregnancy. Arlington, VA: International Chiropractors Association, 1994. Forrester J. Chiropractic Management of Third Trimester In-utero Constraint. Canadian Chiropractor, 1997; 2(3): 8-13. Fysh. Chiropractic Care for the Pediatric Patient. Arlington VA: ICACCP, 2002. Kunau P. Application of the Webster In-utero Constraint Technique: A Case Series. Journal of Clinical Chiropractic Pediatrics, 1998; 3(1): 211-6. McMullen M. Assessing upper Cervical Subluxations in Infants Under Six Months. ICA International Review of Chiropractic, 1990; March/April: 39-41 Pistoles R. The Webster Technique: A Chiropractic Technique with Obstetric Implications. JMPT, 2002; 25(6). Webster L. Chiropractic Care During Pregnancy. Today’s Chiropractic, 1982; Sept/Oct: 20-22.