CASE STUDY:Back Pain, Breech Baby at 35 weeks Gestation

Case History: 31 year old woman presents with headaches, low back pain and a breech baby at 35 weeks gestation.

The patient is pregnant with her fourth 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. 

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 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.

Consultation:

She communicated the following accident history:

At age 7, she fell off of a horse and injured her coccyx.  No medical treatment was obtained for this injury.  At 10 years of age she was involved in a “fender bender” type auto accident as a back seat passenger.  She was not wearing a seatbelt and reports that she did not experience any symptoms after the accident and therefore did not receive any medical care.  This patient also experienced a fairly serious fall down a flight of stairs at age 17.  She reports that this fall tore a ligament in her right knee but was not able to remember which ligament.  She did not undergo any surgical repair for this tear. 


Although this is her fourth pregnancy, this is the first time she is carrying a breech baby.   Her previous three 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 coffee as well as one cup of tea per day.  She is taking pre-natal vitamins and cod liver oil 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. 

Physical Examination –

A thorough examination of her lumbar and cervical spine was conducted due to her complaints of headache, 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 with no noted pain or discomfort.  Lumbar active range of motion was within normal limits with the exception of extension which was decreased with some mild pain presenting at the L5-S1 level.  


Palpation revealed taut and tender fibers in the lumbo sacral region bilaterally from L-3 through Coccyx.  Palpatory tenderness was noted at the Coccyx and Sacrum, also bilaterally.  The right round ligament was also found to be taut upon palpation. 

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, Sacral Apex left, Posterior Inferior Ilium on the right, posterior right trochanter, superior pubic bone on the right, posterior L4 on the left, and left posterior occiput.

Prone leg checks uncovered a left short leg of ¼ inch and a positive Derefield.  Therapy localization indicated a left posterior occiput.  Supine leg checks also uncovered a left short leg of ¼ inch. 

Using Basic Sacral Occipital analysis, the patient was found to be a Category II with a left short leg. 

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 severe thermal asymmetries in the upper cervical (specifically atlanto-occipital) 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 two to three times weekly until baby turns to 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 Jan 20.  A left posterior occiput was adjusted using an occipital lift, C6 was adjusted, manually, in the prone position as was T6.  L4 (PLS) was adjusted using an instrument.  Left sacral apex rotation was corrected using extremely light drop table.  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. 

Re-evaluation and follow up

The baby turned to a vertex position after the first adjustment.  Therefore this patient returned in one week for a follow up chiropractic evaluation.  A brief kinesiological exam revealed a right Atlas and a left posterior coccyx.  Both were adjusted using an instrument.  A follow up thermal scan showed the previous severe thermal asymmetries have improved and were described as mild to moderate in nature. 

Discussion

Prior to her first visit in our office, this patient was taking Homeopathic Pulsatilla (a dilution 200C) as recommended by her midwife.  Pulsatilla is a widely used homeopathic remedy derived from the vegetable kingdom, from the wind flower.  It is often referred to as “the” pregnancy remedy as is addresses many common complaints of pregnancy.  It also has some notable success in getting babies to turn head down.  The 200C dilution is an extremely potent dilution and in some states in the U.S. it isn’t available without a prescription.  The midwives we work with on a regular basis will often suggest Pulsatilla to their breech patients as they did the case discussed above.

Since the remedy did not work in this case, the patient decided to follow another recommendation made by her midwife and come to our office for evaluation.  As expected, her pubic bone and coccyx were misaligned and needed to be adjusted regularly; even after the baby turned to the vertex position. 

On January 21 – the day 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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