When I wrote “Urgent Updates to Prenatal Care,”1 it was my intent to share with the profession some specific information about treating pregnant women. I received several e-mails thanking me for the information I had shared, including a few with specific questions. I also received a few e-mails that greatly disagreed with my comment about not performing a side-posture adjustment on a pregnant woman. I usually keep my articles fairly short and to the point; however, clearly more detail was needed in my last article.

As I have stated before, what I write is in my opinion.2 In this instance, “Urgent Updates to Prenatal Care” was based upon a review of courses I had taken, the materials I had seen and OBs with whom I had discussed care. I believe what I wrote is reasonable. Let me also add that I have taken the class for hospital chiropractic, I have worked in a hospital, and I work now with two OB/GYNs. I am proudly a chiropractor, but I work with and understand the mindset of MDs. I know medical doctors are very careful about anything that could be contraindicated, and that to ignore any pertinent information is negligence. 1 did discuss rotational moves with the OBs I work with. They thought it made perfect sense not to do a rotational-type adjustment, as there is a potential risk. Shouldn’t midwives and OBs be the ones to advise us of the risks during pregnancy, since this is their entire patient base? If OBs and midwives suggest there is a potential risk, why isn’t that good enough? Why take the chance?

I do believe pregnant women need chiropractic. Facilitating a healthy pregnancy and restoring a normal physiological environment for natural birth is well within the chiropractic scope of practice.3 Pregnancy is perhaps the most traumatic experience a woman’s body will ever undergo.4 The body begins to change from the moment of conception. Given the progressive postural stresses and ligamentous laxity, pregnancy creates a myriad of distinct aches and pains. The most common of these is lower back pain, especially in the second and third trimester.5

“Because of these physiological and biomechanical compensations, practitioner care must be taken to select the specific analysis and adjustment most appropriate for the complex changes during the various stages of pregnancy. The increased potential for spinal instability in the mother and the resulting subluxations in the woman’s spine throughout pregnancy affect the health and well-being of both her and her baby.”6

Pregnant women are probably some of the best candidates for chiropractic. However, the normal battery of techniques is not always appropriate for care. “The obstetrician [physician in general includes chiropractor] must be aware of the normal physiology of pregnancy and the unique response of the pregnant patient to stress and trauma.”7

I did not state that side posture itself causes placental abruption. I said that rotational motion brings an increased risk for placental abruption. Since one or both of these can occur during an “aggressive” side-posture adjustment, I advise to adjust in a different way. To quote what I did say, “Using a higher-force technique can cause more problems than relief, so less force is the standard. Also, straightline-of-correction techniques should be used - Thompson, Activator or Nimmo. If you are in the habit of performing a diversified side-posture roll, it is time to learn a new technique. Remember, a pregnant body is chemically and biomechanically different from a nonpregnant body, and the usual battery of techniques is not always appropriate.”

I am aware that the Gonstead technique uses a straight line of correction when performing a side-posture adjustment. However, there are cautions about very careful patient positioning, as anything less would lead to insufficient correction or a negative response from the patient.” A chiropractor who practices nonforce technique said it like this: “DNFT achieves the goals of traditional chiropractic to relieve pain and discomfort created by structural misalignments without all the rack ‘em, stack ‘em and cracking force on the spine.”91 can recall a comment made in my technique classes at Palmer: “Anyone can make a back crack. Monkeys can be taught to do that. The art of chiropractic is knowing how to adjust, knowing when to adjust, and knowing when not to adjust.” A patient information brochure on pregnancy notes, “Modifications to the table or adjusting technique are made during each stage of pregnancy.”‘” Clearly, I am not alone in my belief that some degree of caution is reasonable and responsible.

Of course, I know that not all doctors adjust aggressively. I have no way of determining another doctor’s individual skill or level of aggressiveness. Again, I prefer to play it safe. There are enough other techniques available to the practitioner - why take the chance? The caution raised is not a question of force, it is a question of rotation of the pelvis during pregnancy. As I stated in my previous article, even prenatal exercise and yoga classes are now cautioning against rotational-type motions, as there is a risk of abruption.” “There are obvious concerns for uterine injuries in the pregnant woman. Particularly worrisome is the specter of placental abruption, which complicates 1 to 6 percent of minor injuries and up to 50 percent of major injuries. It is hypothesized that the abruption is likely caused by deformation of the elastic myometrium around the relatively inelastic placenta.”12