CASE STUDY – Posterior Occiput Presentation and low back pain at 38 weeks

Case History  : 37 year old woman presents with a posterior presentation at 38 weeks gestation on August 9, 2009.  She is a previous patient.


The patient is pregnant for the 7th time.  She had suffered a miscarriage during the 12th week of a previous pregnancy in July of 2004.  She was referred to our office for care by her midwife. Her previous 5 births were vaginal and reportedly without interventions.  


She is currently complaining of a posterior presentation of her baby and backache of pregnancy.  She also is complaining of water retention which she admits has occurred during all of her previous pregnancies as well.  Her midwife reports this patient’s uterus is normal and is free from uterine myomas and free from any anomalies, such as a bicornuate, septate, or unicornuate uterus.  


Consultation:

She denies having any automobile accident history.


She communicated the following accident history:
This patient has played soccer throughout high school and college.  She sustained many impacts to her knees and suffered from “water on the knee” in her left knee.  She did not have any surgery, fractures or stitches directly related to her involvement in this sport.   


She is a labor and delivery nurse and denies any on the job injuries.


This patient denies smoking.  She reportedly does not drink coffee or tea.  She reports that she eats a well-balanced diet.  She exercises on a regular basis; at least four to five times per week by way of walking on a treadmill.  She claims that she does not 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 lumbosacral spine was conducted due to her advanced stage of pregnancy and due to her chief complaints of low back pain and posterior presentation of her baby.  Postural evaluation revealed a lumbar hyperlordosis most likely due to her advanced pregnancy.   


Lumbar active range of motion was within normal limits with no noted pain or discomfort except for lumbar extension which caused pain at the lumbosacral area.   

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:
Sacrum was posterior on the left (P-L), Right superior pubic arch, Right anterior trochanter, T4-T7 Posterior, C7 body right, and C2 body left.  


Prone leg checks uncovered a right short leg of ¼. George’s test was found to be negative.    


Using Basic Sacral Occipital analysis, the patient was not found to be a 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 thermal asymmetries in the cervical spine (specifically C2 through C4) and in the lumbosacral spine (L5-S1) 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:


Due to the acute level of this patient’s presenting symptom and limited time before the birth of the baby, Specific Prenatal Chiropractic spinal adjustments are recommended two to three times weekly 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 has been a long time patient of this office and regularly receives care when pregnant.  She received her first chiropractic adjustment for this complaint on August 5, 2009.


C2 (BL) was adjusted on the left, manually, in the prone position as was C7 (BR) and T4 (PL).  .  L5 (PR) was also adjusted on the prone position using an instrument.  A right anterior trochanter was adjusted using an instrument in the prone position.  A right superior pubic bone was adjusted in the supine position using an  instrument.  Because of the urgent nature of her condition and the time constraint to make significant changes prior to the start of labor, this patient was also advised to start taking Homeopathic Pulsatilla at 30C potency.


This patient received her second chiropractic adjustment one week later on August 12, 2009.     She reported marked improvement of her primary complaint after the first adjustment. The low back pain that accompanies a posterior presentation was much better.  C4 (BL) was adjusted on the left, manually, in the prone position as was T5 and T12. Her sacrum was adjusted on the left (PL) in the prone position using an instrument.  A right superior pubic bone was adjusted in the supine position using an instrument.   


This patient only received two adjustments as she delivered her baby the following week and wasn’t able to maintain her scheduled care plan at that time.  


Discussion


Because of this patient’s primary complaint of a posterior presentation and concomitant low back pain, it was vital that her pelvis be evaluated thoroughly.  


Left Occiput Anterior LOA is the most common position at the start of labor.  In this position the baby is lined up so as to fit through the pelvis as easily as possible.  
The baby is head down; facing the mother’s back – specifically, the sacrum.  Its left occiput is resting on the left anterior portion of the mother’s pelvis.


In an occiput anterior position, the baby’s head is easily ‘flexed’, so that the smallest part of its head will be applied to the cervix first. The diameter of its head (suboccipitobregmatic diameter) which has to fit through the pelvis is approximately 9.5 cm.
In a Vertex, Occiput Posterior, the baby’s occiput is resting on the posterior portion of the mother’s pelvis.


  • This makes for a more difficult vaginal delivery.  
  • It almost always causes a great deal of back labor.  
  • The baby cannot fully flex its head in this position
  • The diameter of its head (occipitofrontal diameter) which has to enter the pelvis is approximately 11.5cm and can reach up to 12.5 cm.
  • If the baby is in the occiput posterior position (right or left) during late pregnancy, it’s possible that it won’t engage (descend into the pelvis) before labor starts.   
  • By not engaging, it is harder for labor to start naturally and usually leads to induction of labor with Pitocin.  
Furthermore, in the occiput posterior position

  • Braxton-Hicks contractions especially painful
  • The baby will put a great deal of pressure on the bladder.  
  • By not engaging it is likely that the mother may go past her due date and therefore more likely to be induced.   
  • Posterior presentation is more of a problem for a first time mother (Primigravid) than it is for subsequent births (Multiparous) because when a mother has given birth before, there is generally more room for the baby to maneuver and rotate during labor.


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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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