Chiropractic Care and Pregnancy

The following article compiled research  that includes a search of the PubMed database using the terms "pregnancy" and "chiropractic." After reviewing the initial articles obtained through the search, additional information was gathered by cross-referencing the sources, providing a comprehensive examination of the relationship between pregnancy and chiropractic care.

The practice of chiropractic care has traditionally included the provision of care to pregnant patients, with the aim of ensuring their comfort during pregnancy and facilitating an uncomplicated delivery. Despite this, there is limited literature available on the rationale and characteristics of chiropractic care for pregnant patients. While some studies have supported the use of chiropractic care in pregnancy, the lack of definitive evidence has led to a lack of consensus within the profession on the appropriate approach to care This article provides a comprehensive overview of the role of chiropractic care for pregnant women during pregnancy and labor. The author conducted a narrative review by searching for relevant articles published in English language using PubMed (1987-2006) with the medical subject headings "pregnancy" and "chiropractic," as well as key phrases "low back pain in pregnancy" and "Webster Technique." The search yielded a number of pertinent articles, and the bibliographies of these articles were then searched for additional references. The author also consulted standard chiropractic textbooks. In total, 33 references were used for this review.

Back Pain During Pregnancy

Back pain is a common issue for pregnant women, with up to 50% experiencing it during pregnancy and labor. However, only a small percentage of women seek consultation with medical physicians. According to a 2005 Job Analysis of Chiropractic, surveyed chiropractors reported that they rarely treat pregnant women, but of the pregnant population that they did encounter in their practices, 72% were likely to have benefited from chiropractic care and were thus co-managed. A 2-part survey of 950 pregnant women and 87 allopathic providers of prenatal health care reported that 31% of respondents used alternative therapies during pregnancy, and chiropractic was the third most common form of treatment sought (6%), behind massage (32%) and yoga (18%).

Low back pain during pregnancy can be caused by structural adaptations in the pregnant body, changes in load distribution within the lumbar spine and sacroiliac joints, and pressure or stretching of various pelvic structures. The increased weight gain during pregnancy places extra stress on the sacroiliac joints, and as the fetus develops, this weight is projected forward, increasing the stress on the intervertebral discs and facet joints.

Hormonal changes during pregnancy, such as an increase in progesterone, estrogen, and relaxin, can also lead to pelvic hypermobility and decreased spinal stabilization.

During pregnancy, the pressure exerted by the fetus on the lumbosacral nerve roots may result in discomfort and pain. Furthermore, engaging in physically demanding work or having a prior history of low back pain can elevate the likelihood of developing sacroiliac dysfunction and low back pain. Therefore, it is essential for pregnant women to monitor their physical activity and seek medical attention promptly if they experience any discomfort or pain.

Due to all of these factors, some pregnant patients may seek chiropractic care for relief of their low back pain.

Numerous clinical studies have explored the efficacy of chiropractic care for pregnant women. For instance, Shaw's study revealed that 75% of expectant patients who received chiropractic care reported pain relief. In addition, a retrospective chart review of 400 pregnancies and deliveries demonstrated that 84% of patients experienced relief from back pain during pregnancy, and chiropractic manipulation could potentially reduce the incidence of "back labor." Furthermore, other research suggests that a correlation may exist between back pain throughout pregnancy and longer labor and delivery durations, and that pregnant women who receive chiropractic care throughout pregnancy may experience shorter labor times.

Improved Labor and Delivery

In addition to chiropractic, there is also evidence from the osteopathic profession that prenatal osteopathic manipulative treatment can improve outcomes in labor and delivery. A case-control study conducted retrospectively discovered a significant correlation between prenatal osteopathic manipulative treatment for women and a decrease in adverse outcomes such as meconium-stained amniotic fluid, preterm delivery, use of forceps, and cesarean delivery. Practitioners and obstetricians are increasingly recognizing the advantages of manual therapy for expectant mothers, and the inclusion of chiropractic or osteopathic care during pregnancy and labor is gaining more widespread acceptance. Although low back pain during pregnancy is often considered an unavoidable complication, it can be caused by various factors such as fascial constraint and spinal pelvic subluxation. As the uterus expands during pregnancy, it pulls the sacral base forward, resulting in an anterior tilt of the pelvis, an increase in lumbar lordosis, and increased activity in the iliopsoas muscles, which can cause pain and tension. Gentle myofascial relaxation of the piriformis and iliopsoas muscles, as well as the improvement of transversus abdominis muscle strength, can aid in pain reduction and prevent postural changes. Additionally, the anterior translation of the cervical spine and extension of the occiput on the atlas can cause muscle spasms and suboccipital headaches. The release of these spasms can be beneficial in alleviating these headaches. Moreover, an exaggerated thoracic kyphosis, anterior translation of the head, and increased weight of the breast tissue may result in cervicothoracic pain, thoracic outlet syndrome symptoms, or myofascial pain syndromes. The hormone relaxin, which is found in greater quantities in a woman during her third trimester, can also contribute to the body's laxity, which may lead to pain.

Overall, the mechanisms of relief of low back pain during pregnancy involve addressing the structural and postural changes that occur during pregnancy, as well as the hormonal changes that affect the body's ability to cope with the added weight and stress of pregnancy

The Webster Technique

During pregnancy, structural and postural changes can occur, and a specific chiropractic adjustment known as the Webster Technique can help to address potential musculoskeletal causes of intrauterine constraint. Intrauterine constraint refers to any external force that obstructs the normal movement of the fetus, and the Webster Technique has shown promising results in relieving constraints that may contribute to malposition of the fetus, particularly in the eighth month of pregnancy with breech presentation. A survey of chiropractors belonging to the International Chiropractic Pediatric Association, an organization that provides training in this specialized technique, found that 82% of responding doctors reported using the Webster Technique, with 92% of cases resulting in resolution of the breech position. This is significant, given that 3% to 4.6% of all pregnancies result in a breech position, often requiring cesarean delivery. The increasing rate of cesarean delivery, which was 22% of all deliveries in 1999, with 13% due to breech presentation, should be a concern for those caring for pregnant patients. However, chiropractic care has been associated with a reduction in the number of cesarean deliveries. While some fetuses in the breech position may spontaneously convert before 34 weeks of gestation, data indicate that only about 9% will do so. The role of a chiropractor in addressing breech presentation is to balance the pelvis and corresponding muscles and ligaments to remove any constraint on the uterus, allowing the fetus to assume the correct position. Unlike external cephalic version, the chiropractor does not physically attempt to change the position of the fetus but aims to correct potential causes of intrauterine constraint. The authors of the International Chiropractic Pediatric Association survey have suggested that the Webster Technique should be further investigated for its role in the care of pregnant women with breech presentation.

In addition to addressing breech presentation, chiropractors can also help pregnant patients manage an exercise routine that is compatible with their changing bodies. Studies have shown that pregnant women who exercise have more energy, fewer mood swings, better stress management, and better sleep compared to sedentary women. They also gain less weight, have shorter and easier labors, experience fewer medical interventions, less fetal distress, and faster recovery. With their training and knowledge, chiropractors can help pregnant women safely and effectively maintain an exercise routine throughout pregnancy

The safety of chiropractic care during pregnancy has been studied in several research. A case series conducted retrospectively discovered that 16 out of 17 pregnant patients displayed clinically significant improvement in low back pain with an average of 1.8 treatments and relief achieved after an average of 4.5 days. No adverse reactions were reported following chiropractic treatment, suggesting its effectiveness in reducing low back pain intensity during pregnancy.

It is important to note that while chiropractic care is generally safe for pregnant patients, precautions must be taken in certain cases, such as vaginal bleeding, ruptured amniotic membranes, cramping, sudden onset of pelvic pain, premature labor, placenta previa, placenta abruption, ectopic pregnancy, and moderate to severe toxemia. Additionally, the use of electrical modalities and radiodiagnostic imaging should be avoided during pregnancy.

Therefore, it is important for the chiropractor to evaluate each patient individually and in cases of any uncertainty or contraindication to refer the patient to the appropriate healthcare provider.

During pregnancy, ligamentous laxity makes adjustments easier and less forceful. The pregnant patient's comfort should be considered and a gentler approach may be necessary. As it becomes uncomfortable for the pregnant patient to lie prone after about the fifth month of pregnancy, tables with abdominal drops can be used for prone adjusting, especially for targeting the pelvic area. Also, to accommodate the enlargement of breast tissue during pregnancy, using commercially made pillows may provide proper positioning and comfort for the patient.

There are still viable techniques for performing side posture adjustments during pregnancy, but with the leg bent and positioned slightly lower. One author recommends left lateral decubitus adjustments, while supine adjustments require elevating the head and shoulders to avoid cardiovascular strain and supporting the knees in a flexed position. By positioning the patient for relaxation and comfort, minimal force can be applied to effectively correct spinal and pelvic misalignment and fixation during pregnancy.

Previous studies have demonstrated that sacroiliac joint asymmetry and laxity can predict persistent pelvic pain postpartum in 77% of women with moderate to severe pregnancy-related pelvic pain. Incorporating chiropractic care into the treatment protocol during pregnancy may reduce the likelihood of in utero constraint and associated risks after childbirth. It may also help prevent or decrease the incidence of common prenatal conditions with neurological and physiological involvement after childbirth. As the body returns to its pre-pregnancy state, the postpartum patient undergoes physiological changes.

Rehabilitative exercises can be used to strengthen weakened spinal and abdominal muscles. Continuing chiropractic care may also be beneficial in restoring normal spinal biomechanics.

Final Thoughts

Chiropractic care is known to include the care of pregnant patients, but there is limited research available. The changes and stress on the neuromusculoskeletal system during and after pregnancy, may warrant chiropractic evaluation and treatment as a safe and effective way to treat common musculoskeletal symptoms. Studies suggest that regular chiropractic care may even improve the chances of a successful natural birth.