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.... 

Thoughts for the Old, Fat and Pregnant

Picasso

This is a comment turned post from here.*

A fat woman shared on a forum that she was unexpectedly pregnant in her 40s and was asking for resources and hints on pregnancy in this situation.  Several folks responded by recommending my sites (thanks for recommending me, folks!), which alerted me to the post.

I left a comment about things to think about as a fat, old pregnant person.  Then it struck me that I really should expand on this for my blog!  Who knows this topic more personally than I do?

I know pregnancy as a fat and old person.  I had three of my four children at "advanced maternal age" (35 or over) and my last was at age 42.  I was "morbidly obese" for all four pregnancies.  I know pregnancy as an old, fat chick.

And having done it several times, I definitely have some suggestions for things to consider for those contemplating the journey.

Find Your Tribe

Honestly, pregnancy as an old fat chick was really no big deal, at least to me.  My babies were healthy every time, and everything was fine.  Did I worry?  Yes, but what mother doesn't?  I didn't obsess about age.

The doctors, on the other hand, were a different story.  Some saw me as a ticking time bomb.  They particularly feared what they saw as the additive risks of being both an older mom and a morbidly obese one.  They slated me for all kinds of extra tests, induction of labor, and extra monitoring. They assumed that I would develop a complication, not that I might develop one.

I was pressured into the high-tech, highly-tested route with my first child (ironically, the only one not born at advanced maternal age), and was traumatized by the fear-laden, interventive "birth" that followed. When I saw that even more interventions were being suggested for the next pregnancy, based on my age, I bolted.  I found that my sanity was better when I found caregivers who didn't freak out about my age or size, which for me meant midwives.  I also had way easier births when I saw less-interventive caregivers.

However, that was me.  You have to find the level of care that YOU are comfortable with. I found I strongly preferred the less-interventive care model, but not everyone does. Some older or bigger moms are comforted by more intervention. Some just want it. A few truly need it. There's no "right" or "wrong" approach here, just one that aligns with your personal birthing preferences and medical needs.

Therefore, I'd recommend exploring different birth options and figuring out ahead of time which care model you prefer and which is appropriate for your unique needs.  (You can read more about that here.)  Interview several types of care providers, ask lots of open-ended questions about their protocols for you given your age and size, then make a decision based on their answers and your intuitive reaction to the provider and his/her practice.

Be An Educated Consumer

Go into your provider interviews knowing that it's true that there is an increased risk for certain complications when you are an older mom.  There are higher rates of blood pressure and blood sugar issues, for example, and higher rates of birth defects.  And it's true that there is an increased risk for these things as well when you are "obese."

However, being at an increased risk for a problem does not mean that this risk will occur, only that it is a possibility.  The question is how your provider responds to this possibility.

Does the provider intend to order every test under the sun?  Is he/she comfortable with you declining tests?  Or wanting a particular test?  Does the provider truly provide informed consent about tests?  The key is to become an educated consumer about the various tests and procedures that may be suggested to an older obese mother, to know the benefits and risks of each, and to weigh them against your own values.

For example, there will be lots of pressure for prenatal tests because of the potential for birth defects.  Media reports make it sound like the risk is huge, but the absolute numerical risk of a birth defect is small.  So while it's important to know that the risk is increased somewhat, it's also important to keep that risk in perspective.  The vast majority of old moms, fat moms, and old fat moms will have healthy babies.  

Remember, all prenatal tests have pros and cons. Some providers downplay the potential risks (i.e., miscarriage), and women only come to appreciate these risks after they have experienced them. Some of these tests have high false-positive rates, and may create a strong fear that something is wrong when nothing actually is.

On the other hand, prenatal testing has potential benefits. It can be helpful to know about certain conditions ahead of time because some problems can be fixed in utero. Or additional plans can be made for the birth based on baby's condition, like giving birth in a hospital with a level III neonatal care unit, or having certain specialists immediately available at the birth.

Some couples feel it is best to know about problems ahead of time so they can become more informed about the baby's diagnosis, grieve the loss of a "normal" child, and therefore be more ready to welcome that unique baby into the world at its birth.

However, this knowledge can be a double-edged sword. Some parents feel like their experiences of pregnancy and birth were tainted by foreknowledge of a baby's problems, and that knowing of even very minor problems took much of the joy and anticipation out of their pregnancies. And all these tests raise the specter of what you would do if tests indicated a problem.

So the prenatal testing decision is a complex one. Parents need to be sure they really understand the following issues before any prenatal test takes place:

• What is being tested for
• What the test measures and how accurate it is
• The difference between a screening test and a diagnostic test
• What it means if they get a non-reassuring screening test result
• What their choices would be if they had a non-reassuring test result
• What further testing might be available
• What kind of possible treatment might be available if a condition did exist
• Whether this information before birth would be an advantage or disadvantage to them
• What they would do with the information once they got it

Some older and larger moms choose to have these tests, some don't. Some love the tests, some do not.   It's really a very personal thing.

I was pressured into having all the prenatal tests in my first pregnancy and had a terrible experience with them, so I chose much more limited testing in future pregnancies, despite an older age each time.  However, I did choose to have at least an ultrasound each time, so I didn't refuse all testing either.  I found a middle ground that met my comfort level and needs.

Like me, some women feel that these tests are a mixed blessing and choose to opt out of them or to use them in limited ways.  Other women have good experiences with these tests and felt very reassured by having them.

No one can tell you what's right for you in the prenatal testing realm, but do know that it's always YOUR choice how much and what testing to do.  You don't "have" to do anything just because of your age or weight.  Research the issue and then find a provider who is supportive of your choices.

(You can read more about certain types of prenatal testing and how they are impacted by a high BMI here.)

Consider Delivery Protocols

Pressure for early delivery can be intense in both older pregnancies and in the pregnancies of women of size.  This intense pressure to deliver no later than the due date means the induction rate in both groups is very high, and is intricately related to the high cesarean rates in these groups.

Much of the pressure for early delivery is because of the fear of stillbirth. Providers rightly point out that the risk of stillbirth at term is higher in older mothers, and is probably higher in high-BMI women too (although some research suggests that this risk may be more limited to those with growth-restricted babies, or is particularly strong in black women).

However, while elevated, the risk for stillbirth in these groups is still relatively low in absolute numerical terms, even for the oldest mothers.  It is a concern, but one that must be kept in perspective.

This concern over stillbirth leads many providers to routinely induce all older women and heavier women at 39-40 weeks, even when there is no other medical indication for induction.  The question is whether early induction helps lower the risk for stillbirth, or whether it stresses the baby and leads to more complications than it alleviates. Certainly, it likely strongly increases the chances for a cesarean.

In other words, is the risk of continuing the pregnancy higher than the risks of an induction?  Frankly, that is not clear at this point.  Most care providers simply assume inducing early will lower stillbirths in these groups, but more research is needed.  However, there are alternatives.  For some providers, the increased risk for stillbirth is simply seen as an indication for more prenatal monitoring, with early delivery only being considered if the results are not reassuring. This will likely catch some cases where stillbirth might be preventable, but realistically, will not prevent all stillbirths.

Some women are uncomfortable with any possibility of increased risk of stillbirth, and are happy to agree to early induction or even elective cesareans, despite the known potential harms of inductions and cesareans.  And of course, that's their right.  These women will be most comfortable with the delivery protocols of most OBs, and will probably feel reassured by frequent prenatal monitoring near term.

On the other hand, many women recognize that even with a somewhat elevated risk, the likelihood of stillbirth is still quite low and they are comfortable not rushing the birth process at all.  These women are more likely to be comfortable with a hands-off midwife or OB, one who won't require delivery by a certain date on a calendar.

Either way, it is very important for you to be "in sync" with your provider's philosophy and protocols for due dates in older or heavier women.  Ask about their concerns and protocols ahead of time so there are no surprises.  Don't be afraid to switch to a provider that is more in line with your preferences.  It's better to switch now than to try and fight a protocol you don't want later on.

If you choose induction at 39 or 40 weeks, remember that inductions are more successful if done when the cervix is ripe and the baby is in a good position for birth.  Ask what your Bishop's Score is and if the baby is anterior.  See if you can hold off inducing if your Bishop's Score is low, and do what you can to ripen the cervix ahead of time.  Serial induction (doing a slow induction over several days) and avoiding breaking the water too early may increase the chances for a vaginal birth.  There is also research to suggest that more patience may be needed in the labors of induced mothers; as long as baby is doing well, make sure your provider is not too quick to intervene surgically.

If you think induction is likely because of a medical issue or a strict due dates protocol from your provider, acupuncture can help gently prepare your body for labor. That way, if an induction happens, it is more likely to be successful.  The key with acupuncture is to allow it enough time to work.  It's not like medical induction, meant to work in a short period of time. It's most effective when it's done gradually, over a period of several weeks, rather than done once or twice near the very end of pregnancy when there's no time left.

It's important to know that there are also providers who are supportive of waiting for spontaneous labor, even in older, heavier women.  You may have to ask a lot of questions and interview a lot of providers to find one, but they are out there if you want one.

Because I was healthy (no blood pressure or blood sugar issues) and my baby looked good, the midwives in my last pregnancy were comfortable waiting for spontaneous labor, even though I was 42 and "morbidly obese."  Baby was born at almost 43 weeks by LMP; just over 41 weeks by adjusted due date.  We were both fine, and it was my easiest birth by far.  However, my choices are my own and may not be right for you.

It's not easy to know what to do about due date protocols when you are in a group that is at increased risk for stillbirth.  Early intervention may sometimes save lives, but that may come at a price of a very high c-section rate and all the harms that can come from inductions and cesareans.  Bottom line, it is a question that deserves careful contemplation and great care when choosing a provider.

Be Proactive

Although no one can promise mothers of any age a perfectly healthy pregnancy, being proactive in your health habits may increase your chances of avoiding the more common complications.

Primary among these is the importance of getting good nutrition and regular exercise. Older women and fatter women are both at increased risk for blood pressure and blood sugar issues, so a woman who is both older and fat is at significant risk for these issues.  The good news is that nutrition and exercise can go a long way towards reducing those risks.

For example, some research suggests that regular, daily exercise can lower the risk for blood pressure/pre-eclampsia issues.  Some research also suggests a similar effect for blood sugar issues.  The beneficial effect is marginal in average-sized women but may be more powerful in women of size, so that's even more reason for older, heavier women to be proactive about this.

Sensible nutritional hints, like avoiding large amounts of simple carbohydrates at once, eating a lower-glycemic or moderate carb diet, and eating protein with your carbs may also lower your chances for blood sugar issues. There is no need to be neurotic about this, but a sensible, moderate approach is a reasonable goal that may help reduce risks.

For those at particularly high risk for pre-eclampsia (i.e., women with a history of prior pre-eclampsia, a family history of it, those with blood clotting issues), there may be other options to consider as well.  For example, some research suggests that low-dose aspirin or supplemental calcium may be helpful in lowering the risk for pre-eclampsia in high-risk women.

For those women at particularly high risk for gestational diabetes (i.e., women with severe PCOS, a strong family history of diabetes, or preexisting impaired glucose tolerance), other choices might include considering metformin or supplements like chromium, d-chiro inositol or myo-inositol prophylactically.

However, decisions on medications and supplements are ones that should only be considered in conjunction with your care provider, since they also may carry risks as well as benefits. Discuss these carefully before proceeding with any of them.

The benefit of a strong focus on nutrition and exercise is that a reasonable lifestyle approach has many potential benefits and very little risk.  For those at particular risk for complications, further interventions may be helpful, but pros and cons have to be weighed first.  Good nutrition and regular exercise doesn't have that downside.  It's one of the strongest and most effective things you can do to increase your chances of a healthy pregnancy and baby.

If you can avoid complications like gestational diabetes or pre-eclampsia, that goes a long way towards giving you more choices during your birth.  Develop those complications, and your choices are more limited. So it is vitally important to be as proactive about your health as possible during pregnancy.

Consider Body Work in Pregnancy

There's no question that pregnancy is harder on a 40-year-old body than it is on a 25-year-old body.  Life is just harder on an older body than a younger one, so you usually have more aches and pains to deal with when you are pregnant at an older age.  However, that doesn't mean that pregnancy in a 40-year-old is all that bad.  The key is to stay as active as you can, and to not be afraid to use bodywork to help you be more comfortable.

I personally found that regular chiropractic care (from a chiropractor with special training in pregnancy, like those with Bagnell or Webster Technique training) was important in helping my old pregnant body be more comfortable. It was also key in promoting a good fetal position (which makes birth a LOT easier, trust me). I think it's especially important for those with a history of car accidents, significant falls, sports injuries, or other body trauma.  Honestly, chiropractic care was one of the most important things I did for myself as an old, fat pregnant chick.  However, as always, it's a choice up to the individual.

Prenatal massage is definitely a wonderful treat for any pregnant body, young or old, and can also help with aches and pains.  There are many massage therapists who specialize in prenatal massage, and it's well worth looking into if you can afford it.  If you can't afford it, you might be able to find a massage-therapist-in-training who would work on you for free or for a reduced fee.

If you have a history of body trauma or experience significant pain in pregnancy, gentle myofascial work may be a good addition to traditional relaxation massage.  Craniosacral Therapy is another complementary bodywork technique that many women find helpful.

Acupuncture can be useful for the aches and pains of pregnancy in an older body too. It can also be extremely effective for other pregnancy complaints like blood pressure issues, heartburn, morning sickness, and headaches. I used acupuncture in my last pregnancy and found it helpful for aches and pains, for heartburn, and for headaches. I also used acupuncture during my labor for pain relief and encouraging a good labor pattern.  Although I didn't use it for ripening the cervix, it can be helpful in preparing the body for labor, for those being pressured to give birth by a certain date, as noted above.

(Not all acupuncturists see pregnant women, so check around with your local doulas and midwives to get a recommendation for one comfortable with pregnancy.)

Bodywork is one of the kindest things you can do for your body in pregnancy, especially as you get older.  If your budget allows it, it can be a wonderful addition to your prenatal care.  If your budget is strained, remember that many bodyworkers will utilize a sliding scale fee or bartering if asked, because they feel it is so important for pregnant women to receive this work.

Other Issues to Think About

Older women and heavier women may be more prone to thyroid issues during and after pregnancy, so ask your provider to watch your thyroid levels carefully, especially if you have a history of depression or PCOS.  Thyroid levels can quickly go out of whack in pregnancy or postpartum in some folks, even those who never had a problem with it previously, so it's worth monitoring for carefully.

If you tend towards depression and are concerned about post-partum depression (PPD), some people swear by placenta encapsulation for preventing PPD.  However, this is a little more on the "alternative" side of the spectrum, so you might want to choose a midwife if you are interested in this.

Final Thoughts

Don't let the scare-mongers frighten you away from being an older mother or a fat mother.  It's definitely doable, and many of us have done it.  You can too.

Certainly, it's important to be aware of the possible risks of being an older mom (or a heavier mom), but remember that being a member of a group at risk for something doesn't guarantee anything for an individual's outcome.

However, it is a call to be particularly proactive about your self-care and your choice of provider.

• Find your tribe by finding a care provider who aligns with your birth preferences and will honor your birthing choices
• Be an educated consumer by doing your research on prenatal testing, delivery protocols, and birthing choices
• Be proactive in your health habits, with special emphasis on nutrition and exercise
• Look into bodywork for making pregnancy more comfortable and your body optimally functional during this important time

Best wishes to anyone out there thinking about becoming a mother.  Although it can be scary to read about risks, remember that most mothers, regardless of age or size, do just fine.

Be aware of the risks, but focus your energies on proactive behaviors and the knowledge that most women will have good outcomes, whatever their risk factors.

Old or fat or both, you CAN do this. Enjoy your new direction in life, and don't spend much time worrying about what-ifs.  Being a mom can be a tumultuous journey, yes, but it's also one of life's greatest blessings.  Don't be afraid to embrace it whole-heartedly, whatever your age or size.


**Do you have any experience as an older mom of size?  Do you have any great websites with information for older moms?  Share your stories or resources in the comments section.