Treating Prenatal Patients Dr Lisa Goodman

5 Don’t-Miss Red Flags when Evaluating and Treating Prenatal Patients

Many women seek out chiropractic care during pregnancy. Often for pain, sometimes for help with baby positioning, or to prepare for an easy labor and delivery. Most chiropractors who are treating pregnant women are not extensively trained in prenatal care outside of their traditional chiropractic education. Thus, many will make some adaptations while adjusting pregnant women, for example, with special cushions or lower force techniques during pregnancy. However there are a few really important exam findings and treatment contraindications to be aware of during the course of treatment.

The first two red flags are found during the exam. If you see these in your pregnant patient, you may very well save a life.

  1. Swelling. If you notice a pregnant patient who has excessive swelling, particularly in the lower extremity, do a quick test for pitting edema. If you press your thumb gently into a swollen foot or ankle and the imprint remains, your patient likely has pitting edema. This can be an indicator of Preeclampsia, a very dangerous hypertensive disorder of pregnancy that can lead to seizure and death if left undetected. This concerning finding should be followed up with a blood pressure reading and is cause for immediate referral to their treating Obstetrician or Midwife.
  2. High Blood Pressure. If you are not taking blood pressure readings on your pregnant patients you may be missing significant information. Incidentally, you may also be violating your state’s practice act if you are not taking vital signs on all new patients. It is a good idea to take a baseline blood pressure on pregnant patients, however, if you notice significant edema, always take blood pressure at follow-up visits. If it is over 140/90 you should recheck or recommend it be rechecked within a few hours. If you find blood pressure much higher than that, you may consider immediate referral to the ER or their primary treating physician. Again, this is a sign of Preeclampsia.

The next three red flags are treatment contraindications or modifications to consider with your prenatal patients that you may not have thought of.

  1. Lumbar adjustments in the first trimester. While there is very little evidence to suggest adjustments may be linked to miscarriage, as a conservative practitioner I suggest avoiding them. The worst thing you can have is a patient calling you a day after an adjustment asking if it was related to a miscarriage. Best to wait until the second trimester for lumbar/pelvis treatment. This is only a relative contraindication, if a patient is having lower back pain, always use your judgment about manipulation and receive informed consent prior to treatment.
  2. Rotational adjustments and flexion-distraction. There should be little to no rotation in the pelvis during a side-posture manipulation. If you cannot take rotation out and do a more p to a adjustment, you may want to stick with the drop table as a patient’s uterus and abdomen expand during the second and third trimester. There are some great options for cushions that allow us to safely do drop adjustments on a prone, pregnant patient. Flexion-distraction is always contraindicated during pregnancy.
  3. Ankle Adjustments. This relates to reflexology and Chinese medicine. Again, as a conservative practitioner, we avoid all points that may initiate uterine contraction, and the ankle is full of them! Incidentally, as a patient approaches 40 weeks, the ankle is a great place to do some trigger point work or manual manipulation as it may naturally induce labor!

A great rule of thumb can be less-is-more with the prenatal population. There are very few major concerns with treating prenatal patients. However, with good communication, careful observation at each visit, and common sense, treating pregnant women will dramatically improve their comfort during pregnancy and aid in a successful labor and delivery. As a sports certified and prenatal certified doc, I find that all of my sports techniques can prove very useful in the pregnant population. There are many successful, manual techniques that make a huge difference for these women. Just be aware of the unusual signs that present and use common sense while treating and your practice will thank you!

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