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

Tuesday, October 16, 2018

We Remember: Pregnancy and Infant Loss


October is Pregnancy and Infant Loss Awareness Month. I have a number of friends who have lost babies to miscarriage, stillbirth, or early death. It's more common than you might think. My heart always is heavy when I think of the babies missing in their lives, of who these babies might have become.

If you know someone who has lost a baby to miscarriage, stillbirth, or early infant death, please give them sympathy and a listening ear. Don't tell them how to feel or second-guess their situation, but just listen. If the time seems right, ask them how they are doing or offer to just hold them. They may not want to grieve in front of others, so a card or a message of love and support can be helpful yet still allow them to grieve in private. Take your cue from the mother as to what kind of support she needs. Don't assume she'll be "over it" in a month or two. That loss will likely live on in her heart forever.

We remember:
the babies born sleepingthose we carried,
but never held,
those we held,but could not take home.those who came home,
but could not stay.



Tuesday, October 9, 2018

Women Are Dying From This: Taking Cesareans Seriously


When women have cesareans, they are rarely warned that a possible complication can be placental problems in future pregnancies.

Many women (and especially higher weight women) are pressured into cesareans in their first pregnancy. Many of these same women are counseled away from Vaginal Birth After Cesarean (VBAC) and into repeat cesareans in subsequent pregnancies.

Few of these women have been told that cesareans raise the risk for Placenta Accreta, a very serious complication, and that every cesarean increases the risk for it. I know *I* wasn't told this. This is a tremendous disservice to parents and to the importance of informed consent.

About Accreta

In Placenta Accreta, the fertilized egg implants near or on scar tissue in the uterus. This scar tissue is usually from a prior cesarean, but can also be from a D&C procedure, fibroid removals, a perforation from an IUD, or any uterine surgery or instrumentation. The placenta then grows into the uterine wall in this scar tissue. After the baby is born (often prematurely), the placenta can't separate properly and bleeding can become prolific. If the bleeding is not resolved, the mother can die.

There are degrees of Placenta Accreta. When the placenta grows into the uterine wall, that's Placenta Accreta. 

When the placenta invades the muscles of the uterus, that's known as Placenta Increta.

When the placenta grows through the uterine wall and into nearby organs like the bladder, that's called Placenta Percreta. All are extremely serious conditions, but percreta is the most serious of all.

The accreta rate has risen over the years as the cesarean rate has increased. Doctors are seeing more and more cases these days of what used to be a very rare complication. Some data indicate that the accreta rate has risen from about 1 in 4000 in the 1970s to about 1 in 533 now.

You can read more about this in my blog series on Placenta Accreta.
  • Part One - What Is Placenta Accreta?
  • Part Two - Life-Threatening Complication of Prior Cesarean 
  • Part Three - Risks to Mother and Baby
  • Part Four - Diagnosis, Treatment, and a Cautionary Story
The absolute numerical risk of accreta occurring in any one person is low, even with prior cesareans. Most women who have had cesareans will not experience an accreta. However, it is such a life-threatening condition that even a relatively small incidence carries a tremendous burden of complications, cost, and potential loss of life.

The more cesareans you have had, the greater the risk for accreta. In one very large study (Silver 2006), accreta was present in:
  • 0.24% of women undergoing their first cesarean (previously unscarred)
  • 0.31% of women undergoing their second cesarean (one prior cesarean)
  • 0.57% of women undergoing their third cesarean (two prior cesareans)
  • 2.13% of women undergoing their fourth cesarean (three prior cesareans)
  • 2.33% of women undergoing their fifth cesarean (four prior cesareans)
  • 6.74% of women undergoing their sixth or more cesarean (five or more prior cesareans)
This is why it is important to avoid automatic repeat cesareans and to keep VBAC a viable choice. Multiple repeat cesareans are the single most preventable factor for accretas. 

Accreta does sometimes occur after only one cesarean, like the woman in the video below, and that's why it's important to prevent a first cesarean whenever possible as well.

One Mother's Accreta Story

This mother had only had ONE prior cesarean, but still developed accreta with baby #2. Her first cesarean was a planned cesarean, urged by her OB. She was never warned that her cesarean meant accreta was a potential risk for the future.

THIS is why the high cesarean rate matters. On a case-by-case basis, a cesarean can be a good thing. But the public health implication of a high cesarean rate is that more women will develop life-threatening complications like placenta accreta, more babies will be born prematurely, and more women will die or experience permanent damage. Sometimes even after only one cesarean.

If we want to decrease maternal mortality rates and prevent complications from accreta, we MUST decrease cesarean rates. As the mother in the video below states:
A cesarean can be a life-saving intervention. The goal is not to eliminate cesareans. The goal is to make decisions regarding cesareans appropriately, and to recognize that even an uncomplicated cesarean and recovery can still put the mother at significant future risk....


She continues:
"There are too many cesareans now, 1 in 3 births, and researchers estimate that as many as 50% of those are unnecessary. 
And since a prior cesarean is a significant risk factor for developing a future accreta, that means that there are women developing accreta when it could have been prevented. So the easiest way to reduce the amount of accretas is to reduce cesarean levels... 
Women are dying from this, and mothers are dying from this. We need to take the risks of a cesarean seriously."


Sunday, September 30, 2018

Exercise Reduces the Risk for Gestational Diabetes in Higher Weight Women

The Padded Lilies
Here is a recent research review that found that physical exercise reduced the risk for gestational diabetes (GD) in "obese" and "overweight" women during pregnancy.

Here is a summary of the research review, and also a discussion of how to use exercise and food timing and choices to keep your  blood sugar as normal as possible during pregnancy.

Quick View of Study Details

The authors reviewed 13 studies with a total of 1,439 participants. On the up side, they found that physical exercise reduced gestational weight gain and the risk of gestational diabetes (GD). This is good news.

On the other hand, exercise made no difference in the risk for blood pressure issues, macrosomia (big babies), cesarean rates, or premature births. This isn't bad news, but it does point out that exercise is not the panacea that some doctors hope it would be.

How significant are these findings? Well, it depends on the finding.

The weight gain finding is negligible. The difference in weight gain between groups was extremely small, about 1.14 kg. That's about two and a half pounds total. Not exactly a lot, and not enough to really make a difference in outcomes between groups. But doctors being doctors, you know they are doing cartwheels over even that. (Like 2 or 3 pounds makes a big difference in complication rates.)

However, the difference in risk for GD was more substantial. The relative risk of getting diagnosed with GD was 0.71 in the groups that had more exercise. That's nearly a 30% cut in risk for getting GD, which is significant. That should be paid attention to by people of size and their medical professionals.

The strength of this review was that it didn't just rely on results from one or two studies. They reviewed thirteen studies, which makes for stronger conclusions because the results are less likely to be from chance.

One weakness of the review is that 1,439 participants is a bit small for 13 studies. That means a lot of the individual studies were on the small side, and small studies run the risk of biasing the results. The review also noted that there was little information on newborn outcomes and that future studies should account for these concerns in their study design.

These are all important points. Better studies with more participants and tracking of neonatal outcome are needed. But what we have so far suggests that exercise is helpful in larger women.

Pregnancy Exercise for Plus-Sized Women

Women of size vary in their utilization of exercise. It's a myth that fat people never exercise. Some do lots of exercise, some don't do any, while most are somewhere in the middle. Here are some practical suggestions for increasing exercise in pregnant women who recognize the importance of exercise.

Exercise doesn't have to mean running marathons or even running at all. Forget the little skinny doctors who tell you that the only "real" exercise is running. Walking is one of the best exercises for pregnant folks, and it's much easier on the knees and hips. All you need are comfortable clothes and supportive shoes. Just go outside and take a walk around your neighborhood.

If your neighborhood is unsafe or not conducive to walking, walk around your yard or inside your house. Or get a second-hand treadmill or exercise bike for cheap off of eBay and use that inside.

Swimming or water aerobics is another exercise that works particularly well for women of size. While it's a pain to get in and out of a swimsuit when extremely pregnant, the buoyancy in the water is incredibly soothing to larger bodies. And water immersion has a strong beneficial effect on reducing swelling near the end of pregnancy, which can be quite helpful. Plus it just feels great! 

Water immersion can be particularly important for women with lipedema. The hormone changes of pregnancy can sometimes cause lipedema to get worse. But the pressure of having your legs underwater forces fluid back into your lymph system and helps it flow more freely. Remember, the lymph system doesn't have a pump like the heart directing it; it relies on exercise to improve lymph flow. If you have any degree of lipedema, it's especially important to be in water as much as you can. Even if you don't swim, just walking around in the pool is helpful.

Prenatal yoga can be another excellent choice. It's not as aerobic as other forms of exercise but the stretching and strengthening can be very helpful. The relaxation poses at the end of most classes are great for helping blood pressure and stress levels. And prenatal yoga classes tend to be more size-accepting and tolerant of different fitness levels than regular yoga classes.

If the weather outside keeps you from getting your usual exercise in, try walking or dancing around your house, going up and down the stairs, or some vigorous vacuuming. Even just using some cans to do a set of arm curls can help. [Don't laugh! I did all of those things during icy weather in my pregnancies, and even just vacuuming showed a difference in my blood sugar readings. These things helped me keep my blood sugar normal.]

If you haven't exercised much recently or are out of shape, start with what you can do and don't judge yourself about it. Start slowly, then increase the amount and frequency of what you are doing. Building a regular time for exercise in your daily routine is helpful. If you miss a workout, don't stress over it; just get back into it as soon as you can. Remember, any exercise is better than no exercise.

If you already exercise regularly, good for you! Give yourself props for what you are doing. Consider intensifying your routine by adding more sessions or changing up the kind of exercise you do. Keeping it fun helps keep it a part of your life.

Sometimes people sabotage their exercise by focusing on the wrong things. They compare themselves to others as they exercise, they feel self-conscious in front of others, or the peanut gallery in the brain keeps a running commentary of negative remarks. Put aside the negativity. Do what you can and don't beat yourself up about your fitness level, your looks, your shape, or whatever your personal demons are. Don't indulge in negative self-talk but instead focus on your improvement. Think or say body affirmations or pregnancy affirmations during your workouts. The repetition of positive affirmations during exercise can be powerful.

Exercise and Food for Managing Blood Sugar


As the study review shows, exercise can be an important part of managing blood sugar in pregnancy for women of size. However, there are ways to increase the effectiveness of exercise even more.

These are suggestions taken from the experiences in my own four pregnancies and from helpful advice from medical professionals to me and others. In my first pregnancy, I had a marginal glucose test result and was diagnosed with GD. I was put into a program to learn how to manage my blood sugar and given a glucometer. My pregnancy went fine and my baby was healthy, but that diagnosis made me subject to many more interventions than I truly needed. So I became determined to be as proactive as possible for any future pregnancies.

In my next three pregnancies, I never had GD again, despite being about the same size each time and getting older. I didn't change my weight or what I ate, but I did change how much I exercised and the food combination and timings of what I ate. Just doing that helped me avoid GD again, but I never took it for granted. I always considered myself borderline to be cautious, and I used my glucometer regularly every day to help make sure my blood sugar was staying normal.

If your family history (strong history of diabetes), prior medical history (prediabetes or prior GD), or medical condition (PCOS or reactive hypoglycemia) put you at extra risk for GD, then you should probably consider buying a glucometer and measuring your blood sugar regularly. That will give you information to guide you in what your "danger times" are, how you respond to various foods, and when adding exercise would be most beneficial. Glucometers are pretty affordable and can be bought at your local pharmacy. However, if money is an issue, your care provider may have one that you can borrow for free, leaving you just the cost of testing strips.

If you have a glucometer, you can see how your particular body responds to the blood sugar challenges of pregnancy. For example, some pregnant women have the most trouble after meals, while others have the most trouble with their fasting numbers first thing in the morning. The way you manage each is different.

Generally speaking, exercise intensity is less important than exercise frequency from a blood sugar point of view. It's not how hard you work out that matters most, but the regularity with which you do it.  In other words, walking even just a little every day is better for your blood sugar than a more intense workout once or twice a week. You are trying to lessen insulin resistance and make the insulin you have work more efficiently, and regular daily exercise works the best at this. Intensity is important for improving aerobic response, but frequency is the most important factor for blood sugar regulation. Try to exercise every day if possible, or at least five days a week.

Timing of exercise and smart food combinations are also important. Pregnant women tend to have several problem spots, like early mornings or after meals or certain foods. Placental hormones increase insulin resistance in order to increase the energy available to the baby. That means a meal that might not make your blood sugar high when not pregnant can result in a high reading during pregnancy. Or you get high readings from certain foods that don't normally raise your blood sugar when not pregnant.

If you find that your blood sugar is most volatile in the morning after breakfast, rest assured that this is a common problem for pregnant women. Many people do not eat protein with breakfast but consume very carb-intense breakfast meals like cereal with milk, a glass of juice and a muffin, or similar meals. Protein slows down the energy spike from a carb-heavy meal and keeps it from crashing later. So adding a protein food to your breakfast is one of the best things you can do to reduce morning blood sugar spikes. Taking a quick walk after breakfast is also great at smoothing out blood sugar spikes. Doing both (adding protein and going for a walk after breakfast) works best for blunting the post-breakfast spike common in many pregnant women.

Some women are intensely sensitive to certain foods at breakfast and can get blood sugar spikes from them in the morning, but no spikes from the same food later in the day. It has to do with the surge of placental hormones that often happens in the mornings. Some women who are especially sensitive simply cannot drink milk or juice at breakfast or even have fruit, but later in the day those foods are okay. The glucometer can help you discover whether you have problems with certain foods or at certain times.

If your blood sugar is running a little high routinely after all your meals, a couple of short walks each day after meals is helpful. Remember, shorter walks done more often is better than a longer walk every few days. If meals are your vulnerable time, then schedule your exercise times to happen after meals. Just work on getting your heart rate up for a sustained amount of time.

Avoiding heavy intake of carbs is helpful to improving blood sugar after meals. There's no need to eliminate all carbs, but avoid or minimize carb-intense foods like breakfast cereal, juice, muffins, pizza, bagels, and other obvious foods. Try to keep your carb intake to around 60g or less with each meal (a piece of bread is usually around 15g of carb). If you are not sure of the carb content of a food, look at the label. If there is no label, google it to get a general idea. If you do decide to have a carb-intense meal or snack for a special occasion, taking protein with your carbs or getting in some exercise afterwards can often improve blood sugar markedly, but don't do this often because it is easy to overdo.

Some people don't have much trouble with high blood sugar after meals, but instead have problems first thing in the morning after the overnight fast. If you have a tendency to high fasting blood sugars first thing in the morning, you need to investigate further because your approach to managing it will be different depending on its cause.

If your morning fastings are running just a bit high and you don't know why, try a substantial protein snack late in the evening and then take a short walk or workout before bed. Sometimes a little snack and exercise before bedtime is all you need to help the blood sugar normalize overnight.

Some women have high fasting blood sugar because they experience a "bounce." In other words, their blood sugar goes too low in the night so the body compensates by burning fat for energy, thus raising the blood sugar sharply to create enough energy for the baby. A side effect of going too low at night is spilling ketones, which is a by-product of burning fat for energy. A small amount of ketones on occasion is not a reason for concern, but a large amount of ketones on a regular basis is potentially risky for the baby. You can buy ketone sticks over the counter at local pharmacies if you want to keep track of that.

The best way to treat a "bounce" is to prevent it in the first place. Going too long without eating is a classic cause of a bounce. If you eat dinner at 6 the night before and then don't eat breakfast until 8 the following morning, that's a 14 hour fast. While that might be fine in a non-pregnant person, it's too long for many pregnant people. The body will respond by burning fat for energy and causing the morning blood sugar to go high. Keep your overnight fasts to 8-10 hours if you are having trouble with high fasting numbers in the morning.

Another common cause of a morning "bounce" is exercising before breakfast. You would think that this would be helpful in preventing high blood sugar, but again, it may cause you to go too low after an overnight fast. The liver produces glucagon and the body burns fat in order to give you the energy you need for the workout, but the price is that your blood sugar becomes elevated. Eating first and then exercising can solve that problem quite easily.

If you suspect you are experiencing an overnight bounce, the solution is to add a good snack before bedtime. However, the snack must be considered carefully. Adding a high-carb bedtime snack with no accompanying protein will spike the blood sugar and then make it crash in the middle of the night, setting up a bounce when the body compensates. A better bedtime snack is a protein-heavy snack with a whole-grain carb, which should give longer-lasting, more even energy that can regulate overnight blood sugar and prevent a bounce.

Some people find that they have "trigger foods" that cause high readings. For example, when I was pregnant I found that corn tended to make my blood sugar spike. I also found I could not consume cereal without a spike. If I ate protein with my cereal, it blunted the spike, but not enough for my satisfaction, so I just eliminated cereal from my intake. It was just a food I found I could not consume during pregnancy.

If you have reactive hypoglycemia (a tendency towards very uneven blood sugar), then eating protein every 2-3 hours is helpful. It keeps your blood sugar much more even and less prone to spikes and crashes. Eating protein every 2-3 hours is also great for people who are having a lot of pregnancy nausea, which is often related to unstable blood sugar. That doesn't mean it will prevent all vomiting; it won't. But it might well lessen it. Even if you throw up, go rinse your mouth, rest for a few moments, and then eat a small amount of protein. The secret is to avoid large amounts of food at once, but to graze frequently during the day, emphasizing protein foods with any carbs. That will help blunt the spike/crash cycle that can be so hard on the body and the baby. People with hypoglycemia also should eat well before their exercise routines and carry some quick energy foods with them in case they go low during exercise.

If you have tried all of these ideas and you are still getting high blood sugar numbers, you may need additional help to normalize your blood sugar. Your medical professional will help you decide whether to use medications like metformin or insulin. If you do end up needing insulin, it doesn't mean that you have failed, just that your pancreas cannot create enough insulin anymore to compensate for the insulin resistance from the increasing hormones of late pregnancy. Progesterone in particular peaks in the third trimester a month or more after the usual GD tests, so you may start out fine with dietary control and still end up needing insulin. Either way, don't feel guilty; it's just the way your body copes with pregnancy hormones.

These are just a few ideas that many women have found helpful in managing blood sugar during pregnancy. However, it's important to emphasize that not all GD can be prevented. Sometimes people still get GD no matter how hard they work at healthy eating and regular exercise. And while most people can manage their blood sugar with diet alone, some may also need medications or insulin to keep their blood sugar normal. If you get GD, don't view it as a personal failure. Just remember that with good care, most women with GD have good outcomes. Dealing with GD is just what you need to do to help give your baby the best possible start.

Take Home Message

The most important message from this review of studies is that exercise in pregnancy may be very helpful in people of size in lowering the risk for GD. 

If GD does occur, exercise plays an important role in managing the GD and minimizing its risks. So does careful consideration of food intake and timing. Getting a glucometer so you can monitor your results at home helps you manage things based on your own needs and responses. Although it's a pain to test, it really does allow you more control over the whole process and outcome.

Since doctors tend to get all uptight about gestational diabetes in higher weight women and a GD diagnosis is the beginning of many interventions, anything women can do to lower their risk for GD is potentially very helpful. Exercise is one of the most powerful interventions women can make on their own behalf.



References

Birth. 2018 Sep 21. doi: 10.1111/birt.12396. [Epub ahead of print] Effects of physical exercise during pregnancy on maternal and infant outcomes in overweight and obese pregnant women: A meta-analysis. Du MC, Ouyang YQ, Nie XF, Huang Y, Redding SR. PMID: 30240042
...The purpose of this meta-analysis was to assess the effect of physical exercise on maternal and infant outcomes in overweight and obese pregnant women... RESULTS: Thirteen studies involving 1439 participants were included. Physical exercise reduced gestational weight gain (mean difference = -1.14 kg, 95% CI = [-1.67 to -0.62], P < 0.0001) and the risk of gestational diabetes (RR = 0.71, 95% CI = [0.57-0.89], P = 0.004) in overweight and obese pregnant women. There were no significant differences in other outcomes such as gestational hypertension, preeclampsia, cesarean delivery, birthweight, large for gestational age, small for gestational age, macrosomia, and preterm birth. CONCLUSIONS: Prenatal exercise interventions reduced gestational weight gain and the risk of gestational diabetes for overweight and obese pregnant women, which reinforced the benefits of exercise during pregnancy. However, no evidence was found with respect to benefits and/or harm for infants. Consideration should be taken when interpreting these findings as a result of the relative small sample size in this meta-analysis. Further larger well-designed randomized trials may be helpful to assess the short-term and long-term effects of prenatal exercise on maternal and infant outcomes.
*For more information on troubleshooting  high blood sugar numbers with GD, read my article on it. Be aware it's from my old website (which I can no longer update), so some information is outdated, but most of it is still valid.