CASE STUDY – Breech presentation, backache of pregnancy, dizziness and indigestion at 37 weeks gestation.

Case History: 39 year old woman presents on June 16, 2009 with a breech presentation, backache of pregnancy, dizziness and indigestion.  She is 37 weeks gestation.


The patient is currently pregnant with her third child.  


She is currently complaining of dizziness, low back pain, and indigestion with this pregnancy.  She also reported suffering from dizziness, and back pain prior to this pregnancy.   None of her current symptoms are interfering with her activities of daily living except for an occasional restless night of sleep due primarily to her lower back pain.    


She is currently under the care of a midwife for this pregnancy.  Her first two children were delivered vaginally.  She is hoping for a home birth which she cannot do if the  baby remains in the breech position.


Consultation:
She communicated no automobile accident history:


This patient communicated the following accident history:
She has previously been an avid field hockey and basketball player.  She had arthroscopic surgery performed on her right knee in 1985 and does not have any further complaints or symptomotology worth noting on that knee.  


This patient admits to falling on her left hip a few years ago but offers no real details regarding that incident and claims it was minor.  There were no other remarkable traumas disclosed during the initial consultation.  


Her current complaint of low back pain started last week She describes the pain as being intermittent and dull in nature.  She explains that the low back pain is primarily at the L5-S1 level and that it radiates into her left hip and sometimes into the right groin area.


This patient denies smoking and drinking tea.  She reportedly drinks one cup of organic coffee per day.  She reports that she eats a well-balanced diet.  She does not exercise 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 when her back pain isn’t interfering with that.  She is taking pre-natal vitamins, Calcium and Magnesium supplements and Omega 3 Fatty Acids as directed by her midwife.  
Physical Examination :


A thorough examination of her lumbar and cervical spines was conducted due to her chief complaint lower back pain and breech baby and secondary complaints of dizziness and indigestion.  Postural evaluation was within normal limits with the exception of a mild 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 limits with no noted pain or discomfort.  
Palpation revealed taut and tender fibers in the trapezius at the  lower cervical and lower lumbar  regions.  Trigger points and muscle spasms were noted upon palpation of the paraspinal musculature of the lumbar area.  Palpatory tenderness and spasm were also noted bilaterally at the L5-S1 region.      
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 or 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 L5 on the left (P-L), Left Sacral Apex Rotation (SAL),  Right anterior trochanter, posterior T5 and T6, T1 posterior on the right (PR), C7 (BL), and C2 (BR).


Prone leg checks uncovered a left short leg of ½ inch and a negative Derefield.  Supine leg checks also uncovered a right short leg of ½ inch.  This patient also had a left cervical syndrome and therapy localization at C2.


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


All cervical orthopedic tests were found to be within normal limits. All lumbar orthopedic tests that are not contraindicated during pregnancy were found to be within normal limits as well.  


A thermal spinal scan showed areas of moderate thermal asymmetries in the cervical spine (specifically C2)  in the thoracic spine (specifically T1) which correlates and supports the initial exam findings and the patient’s presenting history and chief and secondary complaints.  
NOTE: C2 almost always shows thermal asymmetries with a breech presentation.


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 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 June 16, 2009


C2 (BR) was adjusted using an instrument in the prone position as was C7 (BL) and T1 and T5. L5 (PL) was also adjusted in the prone position using an instrument.  A Sacral Apex Left,  and a right anterior trochanter were also adjusted in the prone position using an instrument.  


She received her second chiropractic adjustment one day later on June 17, 2009.   She reported a tremendous improvement in both of her chief complaints of low back pain and dizziness.  Additionally she admits to having a very restful night’s sleep. She mentioned that there was also a lot of fetal movement in the hours directly following her first adjustment and that she no longer “felt breech”.  On this second visit T5 was adjusted in the prone position as was L5, both with an instrument.  This time it was an anterior Left trochanter that was adjusted in the prone position.  
NOTE:  It is not unusual for the side of trochanter anteriority to switch from left to right from visit to visit.  


Re-evaluation , discussion and follow up


This patient’s next adjustment was one week later on June 24, 2009. C2 and T5 were adjusted in the prone position as was L5.  This time a right superior pubic bone was found and adjusted in the supine position using an instrument.  It was confirmed, on this day, by an ultrasound performed by her midwife that the baby was in a vertex position.  Thermal Scan did not show thermal asymmetries at the C2 level as it did when the baby was breech.    


This patient has one more adjustment before delivering her baby.  The same cervical and lumbar segments were adjusted exactly the same as her previous visits.  Her trochanters required adjustments on every visit; some visits on the left and some on the right.  In either case the trochanter always rotated anteriorly.  Regardless of the misalignment, it was always adjusted using an instrument as before.  


Her pubic bone only showed up once and was only adjusted once.  Although misalignments to the pelvis, especially, the pubic bone and sacrum, are seemingly a causative factor in a breech presentation, it is not entirely impossible for a breech baby to present when the mother doesn’t have major pelvic misalignments; as it was in this case.  She experienced no major trauma or repetitive injuries or stresses to her pelvis.  Therefore, the fact that no major pelvic misalignments were uncovered during examination was not entirely unexpected.   


It bears repeating that low back pain of pregnancy will present many times, with a breech presentation and also with a trochanter rotation.  Most usually it will appear on the same side of symptomatology initially and may change sides once changes to the pelvis occur; as it did in this case.  

Based on the information in this case study, when a pregnant patient presents with a breech baby with no major history of trauma to her pelvis and no major pelvic misalignments, which is mostly likely to be found in need of adjustment?


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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

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