Saturday, January 12, 2019

Induction: Don't Break The Waters Early

Amnihooks, which are used to artificially break a woman's waters

New research (Pasko 2018) suggests that when care providers induce high BMI women, they should NOT break the waters in early labor (early amniotomy), especially in first-time mothers.

Breaking the waters early is commonly done to speed up labor. Sometimes it is done to place an internal monitor to monitor the baby more easily, but usually it is used to intensify contractions and shorten labor. Caregivers assume that this will help obese women avoid a cesarean.

However, the results from this new study suggest that early amniotomy actually increases the risk for a cesarean instead.

Study Details

In this retrospective cohort study, women with Class III "obesity" (body mass index ≥40 kg/m2) who were being induced  (n=285) were placed into two groups.

The first group (n=107) received early amniotomy before 4 cm dilation, and the other group (n=178) received late amniotomy.

The group who received early amniotomy had double the cesarean risk of those who did received later amniotomy.

In first-time (nulliparous) mothers, the risk for cesarean was tripled with early amniotomy. 

The length of labor was not shortened in either group. So the whole justification for using early amniotomy (shorter labor, fewer cesareans) for obese women was irrelevant.

An older study (Sheiner 2000) which examined induction by early amniotomy concluded:
In order to decrease the CS rates, induction should probably start with cervical ripening techniques in order to improve the Bishop scores.
Bishop Scores are a measure of how ripe and ready for labor the cervix is. Inductions on an unripe cervix are more likely to fail and result in cesarean, especially in first-time moms. Bishop scores tend to be lower at the start of inductions in women of size, which is probably an important factor in higher weight women's induction failures. 

Women of size also tend to have longer labors and generally take longer in latent (early) labor before reaching active labor. Yet despite this, research shows that early amniotomy is used more often in higher weight women. This needs to change.

How can early amniotomy (also known as Artificial Rupture of Membranes or early AROM) affect labor? When the water is broken, the cushioning around the baby is removed. Labor becomes much more painful, and there is risk for infection. The baby may be more likely to experience an abnormal heart rate (distress). If the baby is not well-positioned when AROM occurs, then the baby can become stuck in that position and have difficult getting out (labor dystocia). These factors can add up and result in a cesarean.

The take-home message from this study on high BMI women is obvious: Avoid having your waters broken before active labor begins (now defined as at least 6 cm dilation). This is especially important if you are a first-time mother. 

Of course, parents have to remain flexible in labor; plans may need to change. For example, if baby may be in trouble and external monitoring is not working well, then breaking the water sooner to place an internal monitor may make sense. But most of the time, amniotomy should not be done early in labor, especially in obese first-time mothers.

Induction Hints

It is best to await spontaneous labor whenever possible, so always question whether an induction is truly necessary. However, it's a hard truth that sometimes induction of labor does become medically necessary. If so, there are some lessons from research that may lessen your risk for cesarean. Most apply to women of all sizes but may be particularly relevant for higher weight women.

Ask your provider about your Bishop Score; if your cervix isn't ripe (Bishop score <5), ask if the induction can be delayed. If it cannot be delayed, ask for techniques to help ripen the cervix before pitocin is started and realize that you may need more time to reach active labor. Some research suggests that Foley catheter or prostaglandin (PGE2) inductions may be more effective in women of size than misoprostol (Cytotec).

Women of size may also need a larger dose of pitocin to keep an induced labor going strong, but this must be done cautiously because too much pitocin can send the baby into fetal distress. Wait and see how you and baby respond before increasing the dosage and go slowly with any adjustments.

Be sure you have a care provider who understands that latent labor tends to take longer in higher weight women and will give you plenty of time. Many cesareans in women of size are done before active labor, and many could probably be prevented if caregivers were more patient and waited longer before moving to a cesarean.

Be sure your baby is in an optimal position for birth before the induction if possible. Chiropractic care may help align the pelvis and maximize the space for an easier birth. If the baby is posterior (facing your front) in labor, ask your caregiver for manual rotation, which clearly reduces the risk for cesarean in several studies.

Maintain your mobility as much as possible and don't get stuck in bed on your back. Make gravity work for you. Upright positions reduce the length of labor and the risk for cesarean. Special positions like hands and knees or an exaggerated Sims position may help malpositioned babies turn more easily. You can read more aboutvarious labor and birth positions here.

As discussed, don't let the caregivers break the waters until you are well into active labor. If possible, let the waters break on their own. Keeping the waters intact as long as possible can help a malpositioned baby turn more easily.

Hire a doula to give professional labor support. One study found a cesarean rate of 13.4% in a group of first-time mothers with doulas, whereas the cesarean rate in the group without doulas was 25%. The difference was even more marked in those whose labors were induced; the group with doulas had a cesarean rate of 12.5%, vs. a 58.8% rate in those without doulas.

These ideas should improve your chances of a normal vaginal birth with an induction. Of course there are no guarantees, but rest assured that with enough time and patience, a reasonably ripe cervix, a well-positioned baby, and good support, many inductions in women of size can result in vaginal births.



Reference

Am J Perinatol. 2018 Nov 5. doi: 10.1055/s-0038-1675331. [Epub ahead of print] Pregnancy Outcomes after Early Amniotomy among Class III Obese Gravidas Undergoing Induction of Labor. Pasko DN, Miller KM, Jauk VC, Subramaniam A.  PMID: 30396229 
OBJECTIVE: We sought to evaluate differences in pregnancy outcomes following early amniotomy in women with class III obesity (body mass index ≥40 kg/m2) undergoing induction of labor. STUDY DESIGN: This is a retrospective cohort study of women with class III obesity undergoing term induction of labor from January 2007 to February 2013. Early amniotomy was defined as artificial membrane rupture at less than 4 cm cervical dilation. The primary outcome was cesarean delivery. Secondary outcomes included length of labor, a maternal morbidity composite, and a neonatal morbidity composite. A subgroup analysis examined the effect of parity. Multivariable logistic regression was used to adjust for covariates. RESULTS: Of 285 women meeting inclusion criteria, 107 (37.5%) underwent early amniotomy and 178 (62.5%) underwent late amniotomy. Early amniotomy was associated with cesarean delivery after multivariable adjustments (adjusted odds ratio [aOR], 2.05; 95% confidence interval [CI], 1.21-3.47). There were no significant differences in length of labor or maternal and neonatal morbidity between groups. When stratified by parity, early amniotomy was associated with increased cesarean delivery (aOR, 3.10; 95% CI, 1.47-6.58) only in nulliparous women. CONCLUSION: Early amniotomy among class III obese women, especially nulliparous women, undergoing labor induction may be associated with an increased risk of cesarean delivery.


Wednesday, January 2, 2019

Hospitals with Midwives on Staff Have Better Outcomes


Here are two recent studies showing that hospitals with midwives and doctors practicing together ("interprofessional" centers) have better outcomes than hospitals with only doctors. One study is on first-time mothers (nulliparous), and the other study is on women who have given birth before (multiparous), to separate out the possible effects of parity.

In first-time mothers, women were much less likely to be induced or have oxytocin augmentation of labor in interprofessional/collaborative centers. The cesarean rate was 12% lower in interprofessional centers too.

For multiparous mothers (multips), women were again much less likely to be induced or have augmentation of labor in interprofessional centers. The first-time cesarean rate was 36% lower, and the Vaginal Birth After Cesarean (VBAC) rate was 31% higher than in institutions with only doctors. Neonatal outcomes were similar between the two types of centers.

The implication here is that not only do midwives lower the rates of interventions without endangering outcomes, they also influence the hospital culture in a positive way. Doctors who work with midwives tend to be more flexible about interventions, less likely to push a cesarean without need, and more likely to support VBACs.

If you are considering a hospital birth, try to choose a hospital with both doctors and midwives on staff, one with low overall cesarean rates, and strongly consider hiring a doula for professional labor support. Most women can safely be attended by a midwife, so make that your first choice if you can. If a risk comes up that means that you need to see an OB or high-risk maternal fetal medicine (MFM) specialist, the midwife will refer you to one, probably one that is supportive of the parents' birth wishes whenever conditions allow.



References

Birth. 2018 Nov 11. doi: 10.1111/birt.12407. [Epub ahead of print] Midwifery presence in United States medical centers and labor care and birth outcomes among low-risk nulliparous women: A Consortium on Safe Labor study. Neal JL, Carlson NS, Phillippi JC, Tilden EL, Smith DC, Breman RB, Dietrich MS, Lowe NK. PMID: 30417436
...Our objective was to compare labor processes and outcomes for low-risk nulliparous women birthing in United States medical centers with interprofessional care (midwives and physicians) versus noninterprofessional care (physicians only). METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982). .. women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24-0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22-0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79-0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled. CONCLUSIONS: The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both.
Birth. 2018 Nov 9. doi: 10.1111/birt.12405. [Epub ahead of print] Influence of midwifery presence in United States centers on labor care and outcomes of low-risk parous women: A Consortium on Safe Labor study. Carlson NS, Neal JL, Tilden EL, Smith DC, Breman RB, Lowe NK, Dietrich MS, Phillippi JC. PMID: 30414200
...We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women. METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n = 12 125) or noninterprofessional care centers (n = 8996). .. women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes. CONCLUSIONS: Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes.

Thursday, December 27, 2018

External Cephalic Version after Prior Cesarean - 2018 study


People whose babies are breech and have a history of a prior cesarean are often told that External Cephalic Version (ECV), manually encouraging the baby to turn head-down, is simply not a choice for them. The fear is that manipulation done during an ECV might make the uterus rupture along the scar from the prior cesarean.

We have discussed ECV after a Prior Cesarean extensively before. The results of all the studies so far suggest that ECV after prior CS is not unduly risky and can avoid many unnecessary repeat cesareans. ECV should be offered to women at term with a breech presentation, regardless of prior cesarean status. Unfortunately, ECV is woefully underutilized. One study from New Zealand estimated that only 26% of eligible patients with breech presentations were referred for ECV.

2018 Study

Recently, a new study (Impey 2018) was published that looks again at the question of ECV after prior cesarean (CS). Its results were both encouraging and disappointing.

In this new U.K. study, researchers looked back retrospectively over a 16 year period and found 100 cases where babies of women with a prior cesarean presented breech at term, were offered, and consented to a ECV.

Basically, the study found about a 50% rate of success in turning the baby head-down. Those who had head-down babies afterwards had a trial of labor after cesarean (TOLAC), and 68% had a VBAC.

The authors did a literature search on ECV after prior CS and found no increased rate of uterine rupture after ECV. That agrees with the literature search we did.

However, the authors chose to dilute this good news by pointing out that while ECV avoided some cesareans, only 30 women out of the 100 original group had a VBAC. In other words, while they found the practice safe, the way they word the abstract made it sound like instituting a practice of ECV after prior cesarean is not worth pursuing because it is only marginally successful.

This flies in the face of previous research. The big question is why their ECV success rate was so low. Only 50% of their ECV tries worked to turn the baby head-down. That reduced their candidates for TOLAC by half, and then only about 2/3 of these women had a VBAC. That's why the final numbers were low.

If you look at comparable studies, Weill 2016 had a 74% ECV success rate, while Burgos 2014 had a 67% ECV success rate. Why were their results so much better? That's what the UK study authors should be asking themselves. Seems like they need training on how to do ECV more successfully.

Summary

The good news from the study is that External Cephalic Version after a prior cesarean is safe. There are potential risks inherent to the procedure, of course, but these risks do not appear to be any greater in women with prior cesarean than in those without a prior cesarean. And of course, the alternative of an automatic repeat cesarean with a breech carries its own potential risks that also must be considered. The choice should be up to the mother.

The bad news from the study is how few women with prior cesareans are being offered ECV and how low the ECV success rate was. It took 16 years in the study to find a data pool of 100 women who had a prior cesarean and a breech presentation at term who were offered an external version and who accepted it. ECV is tremendously underused, especially in those with a prior cesarean. And a ECV success rate of only 50% is pitiful. Better training is obviously needed.

External Cephalic Version at term can avoid many unnecessary cesareans, yet it is woefully underused in many institutions. It is a reasonable choice that needs to be expanded, especially in women with prior cesareans. Furthermore, training to achieve greater ECV success rates in more places needs to occur.



References

Eur J Obstet Gynecol Reprod Biol. 2018 Dec;231:210-213. doi: 10.1016/j.ejogrb.2018.10.036. Epub 2018 Oct 22. External cephalic version after previous cesarean section: A cohort study of 100 consecutive attempts. Impey ORE, Greenwood CEL, Impey LWM. PMID: 30412904
OBJECTIVE: External cephalic version is commonly not performed in women with a previous cesarean section. Fear of uterine rupture and cesarean section in labor are prominent. The risks, however, of these are unclear. This study aims to document the safety and efficacy of external cephalic version in women with a prior cesarean section in a series of 100 consecutive attempts, and to perform a literature of the existing literature. STUDY DESIGN: This is a retrospective cohort study of prospectively collected data of external cephalic version attempts in women at term with a previous cesarean section, and a literature review of previously published series. External cephalic version was performed by one of 3 experienced operators, with salbutamol tocolysis if appropriate, using ultrasound to visualize the fetal heart and place of fetal parts. RESULTS: 100 women with a prior cesarean section underwent external cephalic version over a 16-year period in one institution. 68% had no previous vaginal delivery. The external cephalic version success rate was 50%, and 30 (63.8%) of these subsequently delivered vaginally. There were no cases of uterine rupture or other complications. A literature review of series containing a total of 549 cases revealed no cases of uterine rupture or perinatal death. CONCLUSIONS: External cephalic version in women with a prior cesarean section is safe but enables a vaginal birth in only about a third of women.
Aust N Z J Obstet Gynaecol. 2016 Sep 14. doi: 10.1111/ajo.12527. [Epub ahead of print] The efficacy and safety of external cephalic version after a previous caesarean delivery. Weill Y, Pollack RN. PMID: 27624629
BACKGROUND: External cephalic version (ECV) in the presence of a uterine scar is still considered a relative contraindication despite encouraging studies of the efficacy and safety of this procedure. We present our experience with this patient population, which is the largest cohort published to date. AIMS: To evaluate the efficacy and safety of ECV in the setting of a prior caesarean delivery. MATERIALS AND METHODS: A total of 158 patients with a fetus presenting as breech, who had an unscarred uterus, had an ECV performed. Similarly, 158 patients with a fetus presenting as breech, and who had undergone a prior caesarean delivery also underwent an ECV. Outcomes were compared. RESULTS: ECV was successfully performed in 136/158 (86.1%) patients in the control group. Of these patients, 6/136 (4.4%) delivered by caesarean delivery. In the study group, 117/158 (74.1%) patients had a successful ECV performed. Of these patients, 12/117 (10.3%) delivered by caesarean delivery. There were no significant complications in either of the groups. CONCLUSIONS: ECV may be successfully performed in patients with a previous caesarean delivery. It is associated with a high success rate, and is not associated with an increase in complications.
BJOG. 2014 Jan;121(2):230-5; discussion 235. doi: 10.1111/1471-0528.12487. Epub 2013 Nov 19. Is external cephalic version at term contraindicated in previous caesarean section? A prospective comparative cohort study. Burgos J, Cobos P, Rodríguez L, Osuna C, Centeno MM, Martínez-Astorquiza T, Fernández-Llebrez L. PMID: 24245964
OBJECTIVE: To determine if external cephalic version (ECV) can be performed with safety and efficacy in women with previous caesarean section. DESIGN: Prospective comparative cohort study. SETTING: Cruces University Hospital (Spain). POPULATION: Single pregnancy with breech presentation at term. METHODS: We compared 70 ECV performed in women with previous caesarean section with 387 ECV performed in multiparous women (March 2002 to June 2012). MAIN OUTCOME MEASURES: Success rate, complications of the ECV and caesarean section rate. RESULTS: The success rate of ECV in women after previous caesarean section was 67.1% versus 66.1% in multiparous women (P = 0.87). The logistic regression analysis confirmed this result (odds ratio 0.93, 95% CI 0.52-1.68; P = 0.82) adjusted by the variables associated with success of ECV. There were no complications in the previous caesarean section cohort. The vaginal delivery rate in the previous caesarean section cohort was 52.8% versus 74.9% in the multiparous cohort (P < 0.01). There were no cases of uterine rupture. CONCLUSION: Based on our data, we conclude that complications are uncommon with ECV in women with previous caesarean section, with a success rate comparable to that of multiparous women. Uterine scar should not be considered a contraindication and ECV should be offered to women with previous caesarean section with breech presentation at term.
Click here for older references on ECV after CS.

Thursday, December 20, 2018

HAES Heroes: Joanne Ikeda

Joanne Pakel Ikeda
This post is to remember and honor one of our Health At Every Size® heroes.

Joanne Pakel Ikeda died on November 27, 2018 at age 74. She was a faculty member of the Nutritional Sciences Department at the University of California, Berkeley, for nearly 35 years. She helped students gain knowledge and skills in nutrition education and counseling.

She was well-known for her advocacy for the Health At Every Size model. In fact, she and Frances Berg coined the phrase. From her obituary:
Joanne was known for her role in the development of a new approach to weight management entitled Health at Every Size® (HAES). Mid-career she came to the conclusion that subjecting large people to food restriction, body dissatisfaction, and size discrimination was futile and only resulted in physical, psychological and social damage to these individuals. She and others determined that rather than focus on weight, the focus needed to be on health. Research showed that many large people could improve all aspects of health with lifestyle modifications unaccompanied by weight loss.
The idea to focus on health instead of weight was a radical, transformative notion in the field of nutrition and medicine and turned the field on its ear. While it has gained a great deal of traction, HAES sadly remains radical to many in those fields, but she never backed down. She was especially determined to protect children from becoming casualties in the “war on obesity” by promoting a Health at Every Size approach for them instead. Here is one of the posters she lent her support to.


Joanne fought hard for size acceptance for all ages and spoke at many conferences and other occasions about Health At Every Size. She worked with NAAFA (National Association for Fat Acceptance), which is where I met her. She helped establish ASDAH, the Association for Size Diversity and Health. She backed up her beliefs with action by testifying before the San Francisco Board of Supervisors about an ordinance banning size discrimination in employment, housing, adoptions, jury selection and other domains. That took guts.

Joanne did not just specialize in weight-related issues. She also studied the nutritional habits of various ethnic groups, immigrants, and low-income people in California and developed culturally sensitive nutrition education materials. She was a visionary in her field in many ways.

She accrued so many honors, I will only list a few here. She served as President of the California Academy of Nutrition and Dietetics, then was elected President of the Society for Nutrition Education and Behavior. She was co-founder of the UC Berkeley Center for Weight and Health. In 2018 she received the Helen Denning Ullrich Award for Lifetime Excellence in Nutrition Education.

I had the honor and pleasure of hearing Joanne speak in person and getting to chat with her afterwards. She was a warm, unassuming person, but she also knew her research and her points were evidence-based. She was very modest and humble but she also knew how to make a vehement rhetorical point when needed and wasn't hesitant to call out medical professionals on their assumptions and errors. She gave me lots of warmth and encouragement for my work on pregnancy in women of size, which was much appreciated as pregnancy is very much an overlooked area in HAES and size acceptance. As a parent, I particularly appreciated her advocacy for higher weight children in the midst of virulent anti-obesity public health campaigns.

Joanne Ikeda was a god-send to the size acceptance community and people of size, and we will sorely miss her presence and influence. Our hearts go out to her family and friends.



Resources

Obituary: https://www.legacy.com/obituaries/sfgate/obituary.aspx?n=joanne-ikeda&pid=190873802

Articles:

Friday, December 7, 2018

How to Find a Chiropractor in Pregnancy: Part Two


We have been discussing chiropractic care in pregnancy and how it can be helpful towards a more comfortable pregnancy and possibly a more efficient labor and birth.

Many people are interested in seeing a chiropractor, but some know nothing about how to find a good chiropractor for pregnancy.

Basically, all chiropractors receive some training in treating pregnant women, so you could see most chiropractors and get at least some help. However, some chiropractors are more highly trained in pregnancy than others and you are probably better off with those.

Your best bet is to find a chiropractor who is trained in the Webster Technique, which is a specific protocol that looks at the alignment of the sacrum and pelvis and the balancing of soft tissues (muscles, ligaments) around it:
The Webster technique is a specific chiropractic analysis and diversified adjustment. The goal of the adjustment is to reduce the effects of subluxation and/or SI [sacroiliac] joint dysfunction. In so doing neurobiomechanical function in the sacral/pelvic region is improved.
The Webster Technique is not just for pregnant people, but can be applied to any weight-bearing person. However, its focus on relieving restrictions in the pelvis and restoring balance to the soft tissues in the area may be particularly very useful for pregnancy.

Chiropractors who have extra training in working with pregnant people can be found in several ways. There are several chiropractic professional organizations, and they can be a good place to start your search. These organizations are similar in many ways, but may have differences of opinion on certain philosophies or treatments, etc.

International Chiropractic Pediatric Association

The International Chiropractic Pediatric Association (ICPA) has a list of chiropractors who specialize in working with kids and pregnant mothers, or who have completed a training course in Webster's Technique, which addresses the specific needs of the pregnant body.

You can find a pediatric chiropractor with the ICPA at http://icpa4kids.org/Find-a-Chiropractor/.

However, this is not a complete list of all the chiropractors who are certified in the Webster Technique. The chiropractors on this list are ones who have asked to be put on this referral list. There may well be other chiropractors in your area who have been trained in the Webster Technique but did not sign up for this list. You can call the ICPA and ask if there are others in your area trained in the Webster Technique.

According to the ICPA website, the ICPA has created a tiered level of training. The first level is "Webster-Certified," which means extra class time beyond the chiropractic degree specializing in the Webster Technique for pregnancy. It is often the starting point for even more advanced training.

The next level is Pediatric Certification, but there are several levels of this. Some program participants have the initials F.I.C.P.A after their names, and undergo 120 hours of continuing education. Other participants undergo an expanded program of 200 hours and have the initials, C.A.C.C.P., after their names. The highest level of training is the Pediatric Diplomate, which requires 400 hours of continuing education, and these chiropractors have the initials D.A.C.C.P. after their names.


International Chiropractic Association

The International Chiropractic Association (ICA) has a Council on Pediatric Chiropractics. Their focus is on treating children, but their definition of "pediatrics" includes in-utero babies so they treat pregnant women as well. Many of these ICA members have gone on to become Board Certified in chiropractic pediatrics in a 3-year post-graduate course of over 360 hours. These chiropractors have "D.I.C.C.P." after their names as well as "D.C." Look here for lists of those with a DICCP diploma.

The ICA also has a list of members who are trained chiropractors who are interested in and specialize in children, but who may or may not have the further training that a "DICCP" diplomate has. Some of the chiropractors on this list are in the process of working on the DICCP diplomate program but have not finished it yet. Regardless, they may be excellent possibilities as well.

In addition, the ICA can be reached at 1 (800) 423-4690 to ask for referrals in person. Ask for a pediatric chiropractor who knows the Webster Technique. 

Other Possible Sources

Not everyone who is certified in Webster's Technique is going to be on the ICA or ICPA lists, but they are good first places to start looking. If you can't find anyone in your area from these lists, it doesn't mean there is no one to help you. Keep looking; many women who initially think there is no one in their area who can help them do eventually find help. It just may not be from the above sources.

One of the best ways to find a Webster-certified chiropractor is to try calling your local homebirth midwives, childbirth educators, and doulas and asking for a recommendation. Often they are familiar with the healthcare professionals in the area that offer pregnancy-related services and can recommend the best ones to you, saving you a lot of time and trouble.

If you cannot find a chiropractor trained in the Webster Technique in your area, you could consider a chiropractor who has extensive experience with pregnant women. Even basic chiropractic care may help enough to make a difference in your comfort level. But if you have a choice, someone trained in the Webster technique is probably preferable. 

People in countries that don't have chiropractors may want to try an osteopath. Osteopaths also do body manipulation to help align the body and relieve restrictions, although not quite in the same way as chiropractors. However, not all osteopaths do manipulations anymore. You might need to find one who has had classical osteopath training.

In some areas, chiropractors can be hard to find. If all else fails, try cold-calling all the chiros and/or osteopaths in your area. Ask them:
  • If they have experience and training in treating pregnant women (and what that training might be)
  • How much of their practice is devoted to pregnant women and babies
  • What kind of special equipment they have for accommodating the growing belly of pregnant women
  • If they have been trained in either Webster Technique, the pelvic "diaphragmatic release," or any other technique which might be especially helpful to a pregnant person
  • If they have not been trained in any of these techniques and/or are not experienced with pregnant women, do they know of any chiropractors in the area who are?
Talk to them on the phone if you can and get an idea of how experienced they are and whether they "click" with you. If they sound good, consider trying them for one visit to see how things go. Some chiropractors will do a free consultation so you can visit their practice and check them out. Others might let you observe someone else's treatment (with the patient's permission) so you can see the techniques in action. Ask how many pregnant women the doctor usually sees. Ask for referrals from other patients. Call the midwives in your area and see if they have any experience with that chiropractor.

Remember, all chiropractors are not alike. Some use pretzel adjustments by twisting and turning the patient's body. Some use a drop table to give a little bit of extra force to the adjustment without having to push on the patient as hard. Some use an activator, a spring-loaded small tool that exerts less force for those who dislike traditional adjustments. Some do hands-on work so subtle it's hard to know they are doing anything. There are many, many techniques and styles out there.

Keep your "quackometer" on alert and don't be afraid to try a different chiropractor if one doesn't seem right to you, if the treatment seems unreasonable or ineffective to you, or if they seem too profit-driven. If one chiropractor doesn't work well for you, it doesn't mean that none will. Sometimes it's just a matter of finding the one that fits you and your needs.

If in the end you decide that chiropractic care is not for you, that is a perfectly legitimate choice as well. Many women go through pregnancy without chiropractic care and do just fine. But if you have lots of back pain, pelvic pain, or a history of falls and/or accidents, it may be worth searching a little harder to find the right chiropractor for your needs. 

My Chiropractic Search Story


Although I didn't really experience much significant back problems before pregnancy, once I was pregnant I began to have tremendous back pain, sciatica, and pubic symphysis pain, probably from a series of minor car accidents years before. My care providers shrugged my pain off as a normal part of pregnancy, but by the end of my second pregnancy I could hardly walk at times. This certainly didn't seem normal to me, so I decided to consider a chiropractor.

My search for a chiropractor was long and involved. At the time, there were no lists from the ICA or the ICPA to check, and the local chiros I consulted did not even know about the Webster Technique. I saw several different chiros or osteopaths (D.O.s) over the years, looking for some help. It took a long time to find the right one. 

The first chiro I tried was a sports specialist available through the local family doctor's office. Unfortunately, he was majorly fat-phobic and obviously disgusted by my body. He never physically evaluated my back or pelvis, and he never touched me. He told me that my back pain was because I wasn't getting enough exercise, and gave me some special exercises to do for the muscles in the area. I tried them; they didn't help. I gave up the idea of chiro care for several years.

In my third pregnancy, I stepped up the effort to find some help. None of the doctors or midwives I saw knew of anyone who knew the Webster Technique. I saw an osteopath who had never heard of the Webster Technique, told me my back and pelvis were fine despite all my pain, and was basically no help.

My prenatal yoga teacher in that pregnancy eventually mentioned a chiropractor who used a less forceful "Network" technique for adjustments and who specialized in sacrum pain. I decided that this was better than nothing and saw this chiro. These treatments did not really help much but he happened to know of a young chiropractor in the area who was in the process of getting her DICCP diplomate from the ICA, so he referred me to her.

Amazingly, this chiro had just learned the Webster Technique at a recent class session and was able to help me out. She was shocked at how badly my back and pelvis were out of alignment. My back and pubic symphysis pain improved greatly within an hour or two after treatment. Although we weren't trying to turn the baby with the adjustment, the baby turned from posterior to anterior within an hour after the adjustment, the first time any of my babies had been anterior in three pregnancies. I went on to have a few more appointments in that pregnancy to keep things aligned and fine tune everything. Two weeks later, my baby was born by VBAC, Vaginal Birth After Cesarean.

My third labor and birth was SO much easier than my first two. In my first pregnancy, I had pushed for 2 hours with a malpositioned baby, then had a cesarean. In my second pregnancy, I had pushed for 5 hours with a posterior baby, then had a cesarean. In this pregnancy, I pushed for 12 minutes and the baby was born. He was born so quickly the doctor didn't even make it to the birth; the nurse had to catch the baby. I attribute the relative ease of this birth to the chiropractic care and the fact that the baby had turned to anterior, unlike my previous babies. 

In my fourth pregnancy, I tried an ICPA-trained chiro who was located much closer to home because I was tired of the long drive to my usual chiropractor. The new chiro was perfectly nice and very competent, but she didn't "get" my body and was not able to give much relief. So even though this chiropractor knew the Webster Technique, was very well-trained and knowledgeable, and was certified through the ICPA, she wasn't the right chiropractor for me. 

At one point, I also tried a different osteopath, one with more "classical" manipulation training, and did not find those results as effective either. I eventually went back to a chiropractor trained by my original chiropractor, realizing that a long drive was well worth the trouble to get better results. He focused not only on my back/sacrum, but especially on my pubic symphysis and supporting ligaments because of my pain there, and we found that I tended to respond to that protocol best.

I gave birth to my ten-pound baby (a pound bigger than my cesarean babies) with just 24 minutes of pushing. I'm sure it was not all due to just chiropractic care, but I do believe that a lot of it was. I was glad I had persevered in my chiropractic search.

Summary

Finding a good chiropractor for pregnancy is not always easy. Just as not every OB or midwife is equally effective for everyone, it's important to find a chiropractor that "gets" your body, uses techniques that you find helpful, and is always respectful and responsive to your concerns.

Don't just stop at the first chiro you find, try it once, and then conclude that chiropractic care is not for you. Try out several different styles if you can. If you can't do that, get the advice of local midwives and doulas because they often know the very best people in the area to recommend. Their guidance can save you a lot of time and effort. Remember, just as with an OB or midwife, it's all about finding a provider who is compatible with you.

My own story shows the importance of searching for the practitioner who is right for you. The first chiros and osteopaths I tried were not able to help me. Had the ICA or ICPA lists been available then, my original pregnancy chiro would not have been listed because she was still in the process of training. An ICPA-trained chiro that I tried later looked great on paper but was not effective for me. The chiros I saw saw for the fourth pregnancy were not listed because neither of them is a DICCP diplomate ─ but they were trained by a DICCP diplomate and so were familiar with the techniques needed. The chiropractor that was the closest and most convenient to me did not turn out to be the best chiropractor for my body. It took quite a bit of "shopping around" to find a chiro that worked well for my needs, but in the end it was well worth the work.

There are no easy or quick answers to searching for a good chiropractor for pregnancy. If at first you don't find a Webster Technique chiropractor, keep trying. If the chiro you try at first doesn't seem able to help you or you don't get good results with them, be willing to try others. Good and bad chiros are all over; lists can be a good place to start your search but ultimately they don't tell you much about the quality of the chiropractors themselves.

Nothing substitutes for actually trying something and keeping the search up till you find one that really clicks with your needs.

Wednesday, November 28, 2018

Chiropractic Care in Pregnancy: Part One


Many people experience back and pelvic pain in pregnancy.

For some this is just a passing phenomenon, a little discomfort that goes along with the hormones of pregnancy relaxing the pelvis and helping it expand for the birth. Some mild back and joint discomfort is common in pregnancy and does not have to be a problem.

For others, however, back and joint pain becomes a significant and long-lasting problem that can become debilitating. Some find it difficult to turn over in bed, to get dressed in the morning, to walk any distance, or even to sit comfortably for long. Some are in constant pain from it; a few even end up using a walker or in a wheelchair, unable to walk without aid.

Fortunately, chiropractic care is often helpful in these cases. Many pregnant people report pain relief and more mobility with chiropractic care. Yet some are not sure about the wisdom of chiropractic care in pregnancy.

Here are some answers to the most common questions about chiropractic care for pregnancy, and help in finding a pregnancy chiropractor for those who want it.

Purpose of Chiropractic Care During Pregnancy


While many doctors say that back and pelvis pain is "normal" in pregnancy and there is nothing that can be done to help it, chiropractors do not believe that significant or long-lasting pain is "normal" at all, and they know from experience that much of it can be helped.

They believe pain occurs when the spine or pelvis are out of alignment or the muscles and soft tissues around them are unbalanced. This can present as back pain, pain in the buttocks that radiates down the leg (sciatica), pubic symphysis pain in the front of the pelvis, hip pain, tailbone (coccyx) pain, stabbing pains in the abdomen when the mother moves too quickly or sneezes (round ligament spasm), neck pain, difficulty walking, difficulty turning over or lifting one leg, difficulty getting in and out of cars, and sometimes shoulder or rib/side pain.

If you are experiencing this kind of pain in pregnancy, chiropractic care may help make pregnancy more comfortable. Chiropractors believe that chiropractic care can help pregnant people in several different ways:
  • By creating more room in the pelvis for baby to maneuver through
  • By improving nerve function so that contractions are more effective
  • By relieving imbalances or tensions in the ligaments and soft tissues supporting the uterus
The most basic component of chiropractic care is to make sure the bony passage around the baby (the pelvis) is as open and well-aligned as possible, creating the largest possible space for the baby to move through.

Many women who have had cesareans have been told that their "sacrum is too prominent" or "too flat," that their pubic arch is "too flat/narrow," that "there is a bone in the way," or simply that their "pelvis is too small/narrow" for a baby to maneuver through. However, after chiropractic care, many of these same women have gone on to give birth to bigger babies than their "stuck" cesarean babies, simply because the pelvic passage is now optimized and the baby has more room. It doesn't seem like such treatment would make much more space, but getting into good alignment can actually make enough difference to maximize the space and help make an easier birth.

Chiropractors also place great importance on good nerve function. They believe that a misaligned spine impedes nerve function. They believe that poor alignment can not only affect the body physically by making less room for the baby to get out, but also by causing ineffective, uncoordinated contractions because of poor nerve function. From his article on "The Safety of Chiropractic Care in Pregnancy," Dr. Jason Lindekugel (D.C.) writes:
Chiropractic manipulation seeks to balance the joints of the body in order to normalize nerve function...In restoring joint function, chiropractors are relieving nerve irritation which in turn relaxes muscles and the ligaments of the pelvis and uterus. So, proper nerve function is the goal, not just “cracking” joints.
Finally, chiropractors believe that by relieving any misalignments, they will create more space and improve nerve function, lessening the risk for dystocia (slow, unproductive labors) and hopefully resulting in safer, faster, and more effective labors and births.

Some people mistakenly think that chiropractors are practicing obstetrics and manually trying to turn babies into position. This is not true. Chiropractors are trying to create conditions to normalize the body's functions so the mother has the best possible chance at an effective labor and birth.

Effectiveness of Chiropractic Care in Pregnancy

But is seeing a chiropractor in pregnancy that helpful? What does the research say?

Traditionally, chiropractors have done research differently than mainstream medicine. They have  relied more on case reports and case series rather than gold-standard randomized studies. They often didn't use control groups because they were loathe to deny anyone care, especially in pregnancy. Even when mainstream studies were done, sample sizes tended to be small. So there are limits to many studies done in the past.

However, there are now a number of studies and reviews using more rigorous methodology that are reassuring. Here is a summary of a few.

A 2013 prospective randomized study in pregnant patients with low back and pelvic pain compared usual obstetric care with obstetric care plus additional chiropractic care. It found that those patients who received the additional chiropractic care improved significantly, while those who received just standard obstetric care did not improve at all.

A 2014 study found that the improvement from chiropractic care was long lasting. Nearly 90% of study participants were improved a year later. Several other studies (see references below) have also found significant improvement with chiropractic care in pregnancy, with few adverse events.

A 2012 Canadian review stated:
Massage therapy and chiropractic care, including spinal manipulation, are highly safe and effective evidence-based options for pregnant women suffering from mechanical low back and pelvic pain.
In 2015, the Cochrane Collaboration, a leader in evidence-based care, reviewed a series of studies on alternative care practices in pregnancy like acupuncture, craniosacral therapy, and osteomanipulation (basically chiropractic care). They found the quality of evidence "moderate," and that osteomanipulative therapy did significantly  reduce low back and pelvic pain in pregnancy. Furthermore, any adverse events were "minor and transient."

It should be noted that no matter what the research says, some people will never be comfortable trying chiropractic care, and that's okay. If chiropractic care is not for you, don't feel pressured into it. Women have been having babies for thousands of years without having chiropractic care. Most will do fine without it. However, if you are having lots of back pain or pelvic pain, you might want to reconsider it.

If you are still not sure, you might try exploring the possibility further without committing to it. Ask local midwives and doulas for recommendations of good pregnancy chiropractors, then call and ask if you can do a non-treatment consult about your case. Find out how the chiropractor makes room for the pregnancy belly during treatment and the techniques they might use. See if you can observe treatment during an appointment (if the patient gives permission). Often this is enough to reassure people that chiropractic care in pregnancy is reasonable and safe. However, whatever you decide, remember that it's always your choice.

When To See a Chiropractor and How Often

Photo credit: Garden State Chiropractic 
If you do decide to see a chiropractor in pregnancy, one common question is when to start seeing them and how often. Unfortunately, there is no simple answer to this. The answer totally varies from woman to woman, depending on each person's unique needs.

Ideally, people would start seeing a chiropractor before or between pregnancies so that any serious issues can be taken care of before the hormones of pregnancy start softening and loosening the ligaments, making it hard to maintain chiropractic adjustments. The more serious a person's issues, the smarter it would be to start care before pregnancy instead of waiting till after they are pregnant.

However, many people only start experiencing significant pain once they are already pregnant. Others may have limits on the amount of chiropractic visits that are covered under their insurance, or they have no chiropractic coverage and must pay cash. Therefore, many want to try and maximize the benefit of the visits by timing them carefully, and that may mean limiting them to pregnancy only, or even to the last third of pregnancy only.

The problem is that no two people's problems are alike, and there is no one prescription that fits all everyone's needs. The loosening hormones of pregnancy increase as pregnancy progresses, so generally speaking it's better to start treatment sooner than later. However, if you have only a few visits that are covered by insurance or you have limited ability to pay for them out-of-pocket, then you may want to save your visits for the third trimester. However, if you do this and you have really significant alignment issues, you also run the risk of not getting enough treatment to really fix the problem in time. So there is no one answer for every woman. It really depends on the unique circumstances of your particular situation. If you are in a significant amount of discomfort, that usually indicates a problem that should be addressed sooner than later.

Generally speaking, chiropractors prefer to see women before they become pregnant to start resolving any long-standing misalignment issues. Once you become pregnant, most chiropractors want to see you on the same approximate schedule that a doctor or midwife sees you, which is about once a month in the first 2 trimesters, bi-weekly in weeks 32-36, and every week after 36 weeks until the baby is born.

Now obviously, that's the ideal schedule. A lot depends on what's happening with the body. If a pregnant woman comes in as a new patient and has a lot of major alignment issues going on, most chiropractors are going to want to see her weekly (or more) until her alignment issues are better, and then they will go back to the standard schedule noted above.

Other women may not need to be seen even every month. If the chiropractor finds that there is nothing to adjust, then he/she should send you home and elongate the time between visits. Some lucky women find that their pain goes away after a couple of chiropractic treatments and then they're done and never need to go back.

On the other hand, some women need to visit more often than weekly. When treatment is first initiated, frequent visits are important to start retraining the body's muscles and ligaments to "remember" the new alignment consistently. So there may be a flurry of frequent visits in the beginning that slowly space out farther and farther as the woman's body adapts to the new patterns, and then visit frequency comes and goes, depending on the woman's needs. In women with a history of major alignment issues, it's not unusual for the woman to go back to seeing the chiropractor very frequently near the end of pregnancy because the ligaments are so loose by then that it's difficult to maintain any adjustments. It all depends on the needs of the woman and her comfort levels.

However, a chiropractor should not force you to buy a pre-packaged bundle of "x" amount of visits for "x" cost. Some doctors offer this as a way for patients to save money, but the package should be flexible so that if you didn't end up needing "x" amounts of visits, you wouldn't have to have them. Furthermore, a pre-defined schedule of visits cannot anticipate what your body will need and how it responds to treatment; for some people more frequent visits might be needed, while others may need much less. A "one size fits all" package is a sign you should seek out a different chiropractor instead.

Unfortunately, there are bad chiropractors/quacks out there, just as there are quack doctors. Because of this, some people reject all chiropractors altogether. But the reasonable response to quack doctors is not to ignore all medical advice and shun all doctors, but instead to find a better, reputable doctor, one whose treatment philosophy and methods align with your preferences.

The same goes for chiropractors. If you find a bad one, don't be afraid to leave and try another one. Get recommendations from other mothers or childbirth professionals to help guide you to the more reputable and helpful practitioners. Also, there are many different styles of chiropractic care and ways to adjust people. If you don't like one style, keep trying till you find a chiropractor that uses techniques you are comfortable with and seems to "get" your particular body needs. Listen to your instincts; if your intuition is saying that a particular chiropractor is not for you, then find a new one.

Fortunately, most chiropractors are legitimate professionals and are not just out to make a quick buck. They should evaluate your condition, suggest a plan of care, and then keep re-evaluating your need for visits based on how well you respond to treatments. Their care plan should be dynamic and changing in response to your own needs and comfort.

In short, there is no one pattern of visits that you "should" follow. Ideally, you should try to start chiropractic care before pregnancy, and then in pregnancy see the chiropractor monthly, then bi-weekly, then weekly in the last month. However, this schedule is not set in stone and should be adjusted to the unique needs of each person.

Summary

To summarize, the purpose of chiropractic care during pregnancy is to:
  • Keep the body well-aligned to make the maximum possible space available for baby to pass 
  • To optimize nerve function so that contractions can be effective and coordinated
  • To balance joints, ligaments, and muscles of the uterine supporting structures so baby has the best chance to assume the easiest possible position for being born 
In other words, chiropractic care during pregnancy may help pregnancy be more comfortable, and hopefully help labor and birth be easier for mother and baby. Although further research is needed, the research we have so far suggests that chiropractic care in pregnancy can be very helpful for low back and pelvic pain.



References

Chiropractic Care for Low Back and Pelvic Pain in Pregnancy

Cochrane Database Syst Rev. 2015 Sep 30;(9):CD001139. doi: 10.1002/14651858.CD001139.pub4. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Liddle SD, Pennick V. PMID: 26422811
"...There was moderate-quality evidence...from individual studies suggesting that osteomanipulative therapy significantly reduced low-back pain and functional disability, and acupuncture or craniosacral therapy improved pelvic pain more than usual prenatal care. Evidence from individual studies was largely of low quality (study design limitations, imprecision), and suggested that pain and functional disability, but not sick leave, were significantly reduced following a multi-modal intervention (manual therapy, exercise and education) for low-back and pelvic pain.When reported, adverse effects were minor and transient."
Am J Obstet Gynecol. 2013 Apr;208(4):295.e1-7. doi: 10.1016/j.ajog.2012.10.869. Epub 2012 Oct 23. A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. George JW, Skaggs CD, Thompson PA, Nelson DM, Gavard JA, Gross GA. PMID: 23123166
...We examined whether a multimodal approach of musculoskeletal and obstetric management (MOM) was superior to standard obstetric care to reduce pain, impairment, and disability in the antepartum period.  STUDY DESIGN: A prospective, randomized trial of 169 women was conducted. Baseline evaluation occurred at 24-28 weeks' gestation, with follow-up at 33 weeks' gestation.... Both groups received routine obstetric care. Chiropractic specialists provided manual therapy, stabilization exercises, and patient education to MOM participants. RESULTS: The MOM group demonstrated significant mean reductions in Numerical Rating Scale scores (5.8 ± 2.2 vs 2.9 ± 2.5; P < .001) and Quebec Disability Questionnaire scores (4.9 ± 2.2 vs 3.9 ± 2.4; P < .001) from baseline to follow-up evaluation. The group that received standard obstetric care demonstrated no significant improvements. CONCLUSION: A multimodal approach to low back and pelvic pain in mid pregnancy benefits patients more than standard obstetric care.
Chiropr Man Therap. 2014 Apr 1;22(1):15. doi: 10.1186/2045-709X-22-15. Outcomes of pregnant patients with low back pain undergoing chiropractic treatment: a prospective cohort study with short term, medium term and 1 year follow-up. Peterson CK, Mühlemann D, Humphreys BK. PMID: 24690125
...RESULTS: 52% of 115 recruited patients 'improved' at 1 week, 70% at 1 month, 85% at 3 months, 90% at 6 months and 88% at 1 year...CONCLUSIONS: Most pregnant patients undergoing chiropractic treatment reported clinically relevant improvement at all time points. No single variable was strongly predictive of 'improvement' in the logistic regression model.
J Midwifery Womens Health. 2006 Jan-Feb;51(1):e7-10. Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series. Lisi AJ. PMID: 16399602
...This retrospective case series was undertaken to describe the results of a group of pregnant women with low back pain who underwent chiropractic treatment including spinal manipulation. Seventeen cases met all inclusion criteria. The overall group average Numerical Rating Scale pain score decreased from 5.9 (range 2-10) at initial presentation to 1.5 (range 0-5) at termination of care. Sixteen of 17 (94.1%) cases demonstrated clinically important improvement. The average time to initial clinically important pain relief was 4.5 (range 0-13) days after initial presentation, and the average number of visits undergone up to that point was 1.8 (range 1-5). No adverse effects were reported in any of the 17 cases. The results suggest that chiropractic treatment was safe in these cases and support the hypothesis that it may be effective for reducing pain intensity.
J Chiropr Med. 2016 Jun;15(2):129-33. doi: 10.1016/j.jcm.2016.04.003. Epub 2016 May 25. Chiropractic Management of Pregnancy-Related Lumbopelvic Pain: A Case Study. Bernard M, Tuchin P. PMID: 27330515
...A pregnant 35-year-old woman experienced insidious moderate to severe pregnancy-related lumbopelvic pain and leg pain at 32 weeks' gestation. Pain limited her endurance capacity for walking and sitting. Clinical testing revealed a left sacroiliac joint functional disturbance and myofascial trigger points reproducing back and leg pain...The patient was treated with chiropractic spinal manipulation, soft tissue therapy, exercises, and ergonomic advice in 13 visits over 6 weeks. She consulted her obstetrician for her weekly obstetric visits. At the end of treatment, her low back pain reduced from 7 to 2 on a 0-10 numeric pain scale rating. Functional activities reported such as walking, sitting, and traveling comfortably in a car had improved. CONCLUSION: This patient with pregnancy-related lumbopelvic pain improved in pain and function after chiropractic treatment and usual obstetric management.
Further articles: http://icapediatrics.com/resources/articles/pregnancy-and-chiropractic/

Safety of Chiropractic Care, Attitudes Towards Chiropractic Care

JAMA. 2017 Apr 11;317(14):1451-1460. doi: 10.1001/jama.2017.3086. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. Paige NM. PMID: 28399251
OBJECTIVE: To systematically review studies of the effectiveness and harms of SMT for acute (≤6 weeks) low back pain...Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.
Chiropr Man Therap. 2012 Mar 28;20:8. doi: 10.1186/2045-709X-20-8. Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature. Stuber KJ, Wynd S, Weis CA. PMID: 22455720
CONCLUSIONS: There are only a few reported cases of adverse events following spinal manipulation during pregnancy and the postpartum period identified in the literature. While improved reporting of such events is required in the future, it may be that such injuries are relatively rare.
Can Fam Physician. 2013 Aug;59(8):841-2.Optimizing pain relief during pregnancy using manual therapy. Oswald C, Higgins CC, Assimakopoulos D. PMID: 23946024
...As pregnant women move into their second and third trimesters, their centres of mass shift anteriorly, causing an increase in lumbar lordosis, which causes low back and pelvic girdle pain. Increasing recent evidence attests to the effectiveness and safety of treating this pain using manual therapy. Massage therapy and chiropractic care, including spinal manipulation, are highly safe and effective evidence-based options for pregnant women suffering from mechanical low back and pelvic pain.
J Evid Based Complementary Altern Med. 2016 Apr;21(2):92-104. doi: 10.1177/2156587215604073. Epub 2015 Sep 8. Attitudes Toward Chiropractic: A Survey of Canadian Obstetricians. Weis CA, Stuber K, Barrett J, Greco A, Kipershlak A, Glenn T, Desjardins R, Nash J, Busse J. PMID: 26350243
We assessed the attitudes of Canadian obstetricians toward chiropractic with a 38-item cross-sectional survey...Overall, 30% of respondents held positive views toward chiropractic, 37% were neutral, and 33% reported negative views. Most (77%) reported that chiropractic care was effective for some musculoskeletal complaints, but 74% disagreed that chiropractic had a role in treatment of non-musculoskeletal conditions. Forty percent of respondents referred at least some patients for chiropractic care each year.... 

Friday, November 2, 2018

The High Price of Multiple Cesareans


A recent study once again reinforces the message that the more cesareans are done, the higher the risk for complications.

In previous posts, we have mostly discussed cesarean risks in terms of future pregnancies. We have written about Placenta Accreta Spectrum several times here already. This is where the placenta implants too deeply into the uterus. This is a life-threatening potential complication of pregnancies after cesareans, and the risk goes up with the number of prior cesareans. 

However, the risks with multiple cesareans aren't limited only to future pregnancies.

This new study highlights that the risk for other problems occurring during and after surgery also rises with the number of prior cesareans. The study found that: 
  • After 2 cesareans, the risk for organ injury and hysterectomy increased
  • After 3 cesareans, the risk for hemorrhage (massive bleeding) and surgical site complications increased
Injuries to organs around the area are serious because they usually involve the bladder or intestines. The more abdominal surgery someone has, the greater the risk for adhesions, scar tissue that can cause internal organs to stick together. This can make it difficult to operate in the area without causing collateral damage to organs nearby. If organ injury occurs, it can have lifelong consequences for the mother's urinary and/or G.I. system. Even if organ injury does not occur, adhesions alone can cause significant pain. For some people, it causes life-long severe pain. 

Obviously, the risk for major bleeding increases with surgery. Each successive surgery takes longer because of the scar tissue, and that increases the risk of hemorrhage even more. Some women need blood transfusions during or after the surgery. Many suffer problems with anemia, which can affect milk supply. Those with very severe hemorrhages may even experience Sheehan's Syndrome, life-long endocrinological problems because severe bleeding affected the pituitary gland. 

The risk for completely losing your uterus (hysterectomy) also increases with more cesareans. This is usually due to cases of accreta or in response to severe bleeding. The placenta cannot detach properly with accreta, or the uterus doesn't clamp down properly during surgery and the bleeding can't be stopped. Often the only way to keep the mother alive may be to take her uterus out, forever altering her fertility. . 

In addition, surgical site complications increase with each surgery. These can include infections, which can go septic and spread to the entire body. Although rare, some women die due to infections after cesareans. Others lose their uterus. Other surgical complications include seromas and hematomas (pockets of fluid or blood around the wound), and the surgical wound not healing (dehiscence). While these can be treated, they often cause long-term wounds and a painful recovery. They complicate recovery and make mothering difficult.

The Take Away Message

Sometimes when cesareans are questioned, people get all defensive. Mothers who had their babies by cesarean may feel like they are being judged or that some may think them less of a mother because of their cesarean. Doctors may feel defensive and point out the many times that cesareans have saved lives.

That's not what this is about. This is not about any one person's cesarean or a judgment about whether that cesarean was necessary or lifesaving. This is a public health issue about the overuse of cesareans and the potential consequences of that. The take away message here is:
All of the potential complications of cesareans need to be taken more seriously and cesareans used only when truly necessary. 
Cesareans are not evil. They can be a wonderful, life-saving intervention, and no one should feel like less of a mother because they had a cesarean. However, cesareans do carry risk. When overused or done without need, they can cause severe problems and even death, especially when multiple repeat cesareans are being done. 

National Public Radio has been running an excellent series on maternal mortality in pregnancy, as well as on near-misses (where the mother almost dies during or just after pregnancy), that highlights many of these complications: 
...according to the CDC, the rate at which women are suffering nearly fatal experiences in childbirth has risen faster than the rate at which they're dying. Based on the rate per 10,000 deliveries, serious complications more than doubled from 1993 to 2014, driven largely by a fivefold rise in blood transfusions. That also includes a nearly 60 percent rise in emergency hysterectomies — removal of the uterus and sometimes other reproductive organs, often to stem massive bleeding or infection. In 2014 alone, more than 4,000 women had emergency hysterectomies, rendering them permanently unable to carry a child. The rate of new mothers requiring breathing tubes increased by 75 percent, as did the rate of those treated for sepsis, a life-threatening inflammatory response to infection that can damage tissues and organs. 
"These numbers are really high, and far too many of them are preventable," said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative and a national leader in efforts to reduce maternal deaths and injuries...
...more than 135 expectant and new mothers a day — or roughly 50,000 a year, according to the Centers for Disease Control and Prevention — endure dangerous and even life-threatening complications that often leave them wounded, weakened, traumatized, financially devastated, unable to bear more children, or searching in vain for answers about what went wrong.
Although certainly not the only factor in the rising rate of complications, many of these near-death and fatal experiences begin with cesareans. The same NPR article noted:
Only about one-third of U.S. C-sections are medically justified, according to [Eugene]  DeClercq, the Boston University maternal health expert. A web of factors explains the rest, including hospital culture (C-section rates vary widely from one institution to the next); efforts to make childbirth more convenient (C-sections can be scheduled); and indirect financial incentives. Because C-sections normally take much less time than vaginal deliveries, they are more cost-effective for hospitals and providers. Additionally, several studies point to the influence of "defensive medicine," a term for doctors' fears of being blamed by their patients for not having done everything possible to avoid medical problems.
The culture of cesareans is strong in many hospitals, and as a result many unnecessary cesareans are being done. And once a woman has had a cesarean, she is often pressured into further cesareans by doctors who say Vaginal Birth After Cesarean (VBAC) is "too risky." But the fact is that multiple repeat cesareans are not risk-free either. Both VBAC and Repeat Cesarean have risks to mother and baby that must be carefully weighed. It should be up to the mother to decide which choice to pursue.

Research is clear that taken as a group, cesareans are not risk-free and should not be taken lightly or done routinely. 



References

Am J Perinatol. 2018 Oct 29. doi: 10.1055/s-0038-1673653. [Epub ahead of print] Risk of Maternal Morbidity with Increasing Number of Cesareans. Sondgeroth KE, Wan L, Rampersad RM, Stout MJ, Macones GA, Cahill AG, Tuuli MG. PMID: 30372778
OBJECTIVE: To estimate the risk of perioperative morbidity with increasing number of cesareans. STUDY DESIGN: We conducted a retrospective cohort study from 2004 to 2010. Patients delivered by cesarean were included. Outcome measures were a composite organ injury (bowel or bladder), hysterectomy, hemorrhage requiring transfusion, severe morbidity, or surgical site complications... RESULTS: Of the 15,872 women in the cohort, 5,144 had cesarean delivery: 3,113 primary, 1,310 one prior, 510 two prior, and 211 three or more prior cesareans. There was a significant increase in organ injury, hysterectomy, and surgical site complications with increasing number of cesareans. In multivariable analysis, the risk of organ injury and hysterectomy was increased compared with primary cesarean after two prior cesareans, and after three or more cesareans for hemorrhage requiring transfusion and surgical site complications. CONCLUSION: The risks of organ injury and hysterectomy are increased after two or more prior cesareans, and risks of hemorrhage and surgical site complications are increased after three or more cesareans.
Arch Gynecol Obstet. 2017 Feb;295(2):303-311. doi: 10.1007/s00404-016-4221-8. Epub 2016 Oct 21. Incidence of adhesions and maternal and neonatal morbidity after repeat cesarean section. Arlier S, Seyfettinoğlu S, Yilmaz E, Nazik H, Adıgüzel C, Eskimez E, Hürriyetoğlu Ş, Yücel O. PMID: 27770246
PURPOSE OF INVESTIGATION: We investigated the effect of repeat cesarean sections (CSs) and intra-abdominal adhesions on neonatal and maternal morbidity. MATERIALS AND METHODS: We  analyzed intra-abdominal adhesions of 672 patients. RESULTS: Among the patients, 173, 206, 151, and 142 underwent CS for the first, second, third, and fourth time or more, respectively. There were adhesions in 393 (58.5 %) patients. Among first CSs, there were no adhesions, the rate of maternal morbidity [Morales et al. (Am J Obstet Gynecol 196(5):461, 2007)] was 26 %, and the rate of neonatal morbidity (NM) was 35 %. Among women who have history of two CSs, the adhesion rate was 66.3 %, the adhesion score was 2.05, MM was 14 %, and NM was 21 %. Among third CSs, these values were 82.1, 2.82, 23, and 14 %, respectively. Among women who have history of four or more CSs, these values were 92.2, 4.72, 31.7, and 18 %, respectively. Adhesion sites and dense fibrous adhesions increased parallel to the number of subsequent CSs. Increased adhesion score was associated with 1.175-fold higher odds of NM and 1.29-fold higher odds of MM. The rate of NM was eightfold higher in emergency-delivered newborns (emergency: 39.4, 40 %; elective: 4.9 %). MM was 20 and 26 % for elective and emergency CSs, respectively. CONCLUSIONS: Emergency operations and adhesions increased complications.

Thursday, October 25, 2018

Remaking Jam That Didn't Gel


I've been preserving and canning food for a while now. I'm no expert but I've had pretty good luck so far with applesauce, chutney, jellies, and all kinds of jams.

Until now.

Yep, I just had a couple of large batches of jam fail spectacularly.

The Backstory

This summer we had a HUGE crop of plums in our yard from just two plum trees. Stupendously big crop. SO. MANY. PLUMS.

We gave plums away, we dried plums, we made plum chutney, we made plum sauce, we made plum pies. And still we had plums coming out our ears.

So we decided to try to make plum jam. This is not a jam I'd ever made before. A friend made me plum jam from a different type of plum a few years ago and I didn't like it at all. Thus, we'd never tried plum jam with our plums...but we were ready to try anything to get rid of all these plums!

So we made a few successful batches of plum jam, and I tried a little on toast one day. WOW. I was so surprised. I loved this plum jam. I think the difference was ours was made with Italian plums which makes a delicious, thick, extremely flavorful jam. I immediately knew I'd be making more.

We finished picking all the rest of the plums...we got like 3-4 big buckets more. So we decided to make several batches of jam, using up the last of the regular pectin (Sure-Jell) in my cupboard. The first batches went well, no problems. The last batch, though, was a full-sugar recipe (which I rarely use because I find it too sweet). But I was out of my preferred pectin, and I'm loathe to waste food. So we winced and made full-sugar plum jam. We thought we followed all the directions correctly, but in the end it never gelled.

So now I had a whole bunch of jars full of plum syrup. This is not something I am likely to use. I have some raspberry syrup from a batch of raspberry jelly that didn't set up a couple of years ago and we are still trying to use it up. Mostly we add it to lemonade to make Raspberry Lemonade, but it doesn't take much so it takes forever to use up. All those jars of Plum Syrup were never going to get used.

So I thought, let's see if we can remake that jam and get it to set up properly.  I'd never done this before so I did a little research and found some articles online.

Keep in mind, the information below is pertinent only to jams with an added pectin like Sure-Jell (either the pink box or the yellow box).

Cooked jam without any added pectin is another story entirely and not covered here; Food in Jars is a good website for that type of jam. Directions for remaking jams with Pomona Pectin can be found on the Pomona Pectin website.

General information about different types of pectins and the pros and cons of each can be found in my article on pectins. This article gets a lot of online traffic so hopefully people are finding it useful.

Why Gelling May Fail



When it comes right down to it, making jams and jellies is really a chemistry experiment. Certain reactions are needed in order to make gelling action happen. Basically you cook up mashed fruit, then add a certain amount of sugar, acid, and pectin in order to make those reactions happen. Get the balance right and you get lovely jam or jelly. Get the percentage wrong and you get a runny mess.

Fruits naturally have some pectin in their cell structures, especially in the skins and seeds. The goal of cooking the fruit is to break down the pectin in the individual fruit so it can then build a mesh with the pectin from other fruits. This makes a gel where fruit bits are suspended in a latticework of pectin.

The problem is that pectin molecules repel each other. Acidity is needed to overcome this and let pectin molecules bond with each other to make the lattice structure. Sugar is needed to bond with the water so the water doesn't overwhelm the pectin. So all of these, heat, sugar, acid, and pectin, are needed in just the right amounts and timing to make jam or jelly.

Here is a quote about the process from a science blog:
The whole chemistry of jam making is all about making this pectin that's in the fruit break down and become water soluble. That then recombines, and all of those hydrogen bonds that are holding it together recombine in a chemical reaction with the fruit acid and with the sugar, and that makes a lovely network that forms a gel, and that's the kind of jelly-like substance of jams. 
So you need to get that chemical reaction right, the pectin amount right, the fruit acid right, and the amount of sugar right so that you make the right consistency of that network that will hold your jelly together, your jam together, so you don't get fruit sauce.
Fruits that are naturally high in pectin and acidity like quince, underripe apples, red currants, cranberries, and gooseberries are an exception. They often don't need anything except cooking in a little water to set up and gel.

Here are a few reasons why an added-pectin jam of most other fruit may fail to set up/gel:
  • Not enough acidity - Some fruits have enough acidity on their own to gel without adding lemon juice, but most fruits need added acidity via lemon juice, lime juice, vinegar, or other acids. If you didn't add enough acid, the fruit won't gel
  • Not enough sugar - Box pectin jam recipes should not be altered. If you use less than the full amount of sugar, the jam will not set up. Therefore, follow the recipe on the box and measure exactly; don't try to make it "healthier" by using less sugar. The recipe depends on that exact amount of sugar. The exception is Pomona Pectin, which uses a type of pectin that doesn't need sugar to activate it; it uses calcium instead. If you want to reduce sugar in jams, use Pomona Pectin, but remember that most jams need at least some sweetener for the sake of taste 
  • Too much water added - Using too much water to cook the fruit can throw off the balance of pectin, acid, and fruit. Use only enough to keep the fruit from burning 
  • Doubling a batch or making too large a batch - Jam batches need to be made one at a time, no more than 4-6 cups of fruit at a time. You can't double a batch and expect it to set up properly. One of the annoying things in jamming is having to make and clean up each batch separately. But that's better than having to throw it all away!
  • You didn't get a hard enough boil - Added pectin needs a hard boil of about a minute in order to activate properly. If you didn't boil the pectin long enough, the gel may fail. If the pan boiling the fruit plus pectin was too deep, then the heating may be uneven, affecting the gel
  • Cooked too long - Some jams turn out runny because they were boiled too long. Overcooking can destroy the ability of the pectin to sustain its structure
  • Using over-ripe fruit - The riper the fruit, the less acid and pectin it contains, and the runnier the resulting jam. If you use very ripe fruit, either add more pectin and acid or add some under-ripe fruit to balance the batch. Another choice can be to add in fruit naturally rich in pectin and acid like the ones listed above if you don't mind the extra flavors in your jam 
  • Pectin too old - Some types of pectin lose their effectiveness if not used within the first year. Pomona Pectin does not have this issue but it's the only one that is reliably long-lasting
  • Leaving the jars in hot water too long - If you put the jars into the canning pot too soon, before the water has boiled, the total exposure to heat may become too much and break down the pectin structure. Likewise, if you leave the jars in the hot water too long afterwards, that can also break down the pectin. After the 10 minute canning time and the 5 minute rest time afterwards in the canning pot, take the jars out immediately and place on a towel on the counter
  • Tipping the jars - Some resources say that tipping the jars to the side as you take them out of the canning pot (or while they are cooling on the counter) can destroy the pectin bonds that are trying to form. Pick jars straight up out of the canner and leave them on the counter. Resist the temptation to tip them and check the set until at least 24 hours have passed 
  • Not waiting long enough - Some jams with some pectins don't set up for a long time, even a week or two. You can always just let them set on the counter and see if the gel improves
Bottom line, if your jam didn't set up, the most likely cause is that you were out of balance with your sugar/acid/pectin, or you didn't cook it for the right amount of time. However, there are a few other nitpicky mistakes that even experienced jammers can make. If you have a significant jam failure, review the list and see if any apply.

Remaking Syrupy Jam



Whatever caused your syrupy jam, don't throw it away. Even very experienced jammers have had batches fail, so they have certain techniques for fixing a failed gel. They don't always work but they are worth a try. The following is the most commonly recommended technique for remaking jam.

First, be sure you have everything you need ready to go ahead of time. This includes a canner full of hot water; funnels, jar-lifters, and ladles clean and ready to go; extra new lids for the jars; and enough extra sugar, pectin, and lemon juice to remake the jam.

Open the lids of the runny jam (these lids cannot be reused for canning). Pour the jam out into a glass measuring cup until it makes a total of 4 cups. Clean the old jars in soapy water and rinse, or use new clean, sterilized jars. 

Mix 1/4 cup sugar, 1/2 cup water, 2 tablespoons bottled lemon juice, and 4 teaspoons powdered pectin. Heat up until it has been brought to a rolling boil. 

Add the 4 cups of syrupy jam. Stir continuously until the whole thing has been brought to a rolling boil. Keep boiling for at least 30 seconds more, but don't overboil. 

Remove from heat, ladle into jars, put on NEW lids, add screwtops, then can in a waterbath canner for 10-15 minutes, depending on the size of the jars. Turn off heat and let jars sit in water for 5 more minutes, then immediately remove jars straight up out of the canner without tipping them. Put them on a towel on your counter overnight.  Don't check or tip them until 24 hours have passed. 

Some people report that chia seeds can be used to thicken up a runny jam, if you are open to that. Personally, I dislike chia seeds so I have never tried this but if you like them it may be worth a try.

Remain Philosophical About Results


Sometimes you can seemingly do everything right and a jam will simply not set up. Who knows what went wrong? All you can do is give it your best shot at redoing it. About half to two-thirds of the time, you can fix a runny jam. Sometimes you never do. Don't be afraid to just give up and call it Syrup at some point. Feel free to pretend that's what you wanted all along. Plenty of cooks before you have done the same!

Don't throw away your results. People use syrupy jam as toppings for pancakes, waffles, ice cream, yogurt, or desserts like poke cake. Our family sometimes adds it to lemonade to make a special drink during the summer. It can also be dehydrated into fruit leather, like above. Or you can add a little corn starch and use it as a glaze for roasted meats. It's surprisingly tasty as a glaze with pork in particular. (If that sounds weird, think about cranberry sauce with turkey at Thanksgiving. Same principle of fruit with savory.)

My first try at remaking syrupy plum jam was a mixed success. Some of it came out perfectly; no problem with the set the second time around.

However, about half of it didn't set again. Oh well. Considering how many batches of plum jam we made, that still left me with a lot more Plum Syrup than I wanted. On the other hand, we saved half the batch. I consider that a win.

I'm not quite sure why some batches failed in the original jam. My guess is we got sloppy in our measuring because of how much fruit there was and used too much fruit at once. I also think the last batch of pectin was from an older box. Also, my daughter helped, so she may have cooked it too long; I'm not sure. But at least we were able to rescue about half of the runny batches and remake them properly.

The rest of the syrupy jam we just made into Plum Fruit Leather, using both the oven and a dehydrator. Same great flavor, and at least we didn't waste it!


Resources and References