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.

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.... 

External Version for Breech After Prior Cesarean

An External Cephalic Version (ECV, or turning the baby manually to a head-down position) is one option open to people whose babies are breech. However, if you have had a prior cesarean, you may be told that this is not an option for you.

The evidence does not support excluding those with a prior cesarean from an External Cephalic Version. It's time for obstetric societies to update their guidelines about this, and it's time for more providers to routinely offer ECV.

Background

The main benefit of External Cephalic Version is that it is often successful in getting the baby head-down, and a head-down birth is usually less risky than a breech birth.

Although many breech babies can be born vaginally just fine (especially those that meet certain criteria and/or are attended with alternate positioning), there are some increased risks to be aware of.

As a result, many care providers these days strongly prefer a cesarean or even schedule one automatically with a breech baby. Because some areas do not "allow" Vaginal Birth After Cesarean (VBAC), this can mean that all future babies must also be born by cesarean.

Therefore, getting the baby head-down via an External Cephalic Version can help prevent not just the first cesarean, but many automatic repeat cesareans and the serious complications that can happen with them.

Of course, like everything, ECV has both benefits and risks. The risks of ECV include premature labor, placental abruption (placenta detaching too early), hemorrhage, or fetal distress. Although real, these risks are relatively rare, usually less than 1%.

Obviously, sometimes ECV is also contraindicated. Most clinicians agree that ECV should not be attempted in the presence of pre-existing fetal distress, placenta previa, placental abruption, premature rupture of membranes, and certain uterine malformations. Low amniotic fluid levels may also be a relative contraindication.

A good review of the benefits and risks of ECV can be found here. Basically, ECV is able to turn babies head-down most of the time without many complications, and thus prevents many cesareans that would otherwise happen. This is important because cesarean rates are so high; ECV is quite an effective way to reduce the number of cesareans and probably many cases of resulting abnormal placental attachment.

Astonishingly, though, research shows that ECV is not used that much in many areas, despite its relative success rate and potential for lowering the cesarean rate.

Often, doctors don't even tell people that ECV is an option. They just schedule a cesarean and discourage people from exploring other options. One study from New Zealand estimated that only 26% of eligible patients with breech presentations were referred for ECV.

The situation is even worse if you have had a prior cesarean. For those with a scarred uterus, it's even harder to get an ECV because doctors have been taught that it's too dangerous.

The Controversy

People whose babies are breech and have a history of a prior cesarean are often told that ECV is simply not a choice for them because manipulation done during an ECV might make the uterus rupture along the scar from the prior cesarean.

The problem is that there is no actual proof that this is a substantial risk. No study has found this to be a problem, but just the mere fear of the possibility has led to its denial for this group. Currently, you can still find recommendations online that list prior cesarean (or any prior uterine surgery) as a contraindication to even attempting an ECV.

However, a policy of no External Cephalic Version for people with a prior cesarean is not supported by research.

There are a number of studies, including some very recent studies, that suggest that people with a prior cesarean SHOULD have the option to have an External Version if they want it.

The latest study (Weill 2016) had 158 women in the study group and found no increase in complications in the group with a prior cesarean. The success rate of ECV in this group was good (117/158, or 74%), and only 12 of these patients ended up with a cesarean during labor. That means that using ECV in the prior cesarean group prevented 105 automatic repeat cesareans. The authors summarized their findings this way:

ECV may be successfully performed in patients with a previous caesarean delivery. It is associated with a high success rate, and is not associated with an increase in complications.

Similarly, another recent study (Burgos 2014) found no increased rate of complications in the group with a prior cesarean. The authors concluded:

Uterine scar should not be considered a contraindication and ECV should be offered to women with previous caesarean section with breech presentation at term.

Another study (Abenhaim 2009) also found no increase in complications in those with a prior cesarean who had an ECV. The authors stated:

Concern about procedural success in women with a previous cesarean section is unwarranted and should not deter attempting an external cephalic version.

However, both RCOG (Royal College of Obstetricians and Gynaecologists) and ACOG (American College of Obstetricians and Gynecologists) still hesitate to endorse ECV after prior cesarean. They say that there is not enough research to prove that it is safe. They point out that many of the studies on ECV and prior cesarean are fairly small, which limits their power.

That is a fair point. It's true that most studies have been relatively small and we don't have a huge pool of data to pull from, but taken together the results are quite encouraging.

One older review (Sela 2008) did a search of previous studies to pool the results. They found a total of 124 patients who had an ECV after prior cesarean. They added 42 patients from their own database. Adding in the 36 from the Abenhaim 2009 study, 70 from the Burgos 2014 study, and 158 from the Weill 2016 study, you get a total of 430 patients who have been documented to have an ECV after prior cesarean ─ all without any poor outcomes.

What this means is that there isn't ANY evidence to prove that ECV is unsafe in those with a prior cesarean. While the data pool is still somewhat limited, so far ALL of it supports ECV after prior cesarean.

Yet ACOG's recently revised 2016 guideline on ECV states, "Having had a previous cesarean delivery is not linked with lower rate of success; however, whether it magnifies risk for uterine rupture is not known." They cite only two studies from 1991 and 1998 and state, "Larger studies would be needed to establish the risk of uterine rupture." This ignores all the recent studies on ECV. This cavalier omission will continue to lead many care providers to continue to deny ECV to those with prior cesareans.

Although more research is needed, the bottom line is that the accumulating evidence certainly suggests that an ECV after a prior cesarean is not unduly risky and is a reasonable choice that should be offered to those who want it. 

A more reasonable view of the evidence has led the SOGC (the Canadian version of RCOG and ACOG) to state:

External cephalic version is not contraindicated in women with a previous Caesarean birth.

It's time for ACOG and RCOG to recognize that they are basing their guidelines more on fear than on the latest evidence and update their guidelines accordingly. Bravo to the Canadians for leading the way on this issue.

More research should be done ─ an excellent question is WHY hasn't more been done by now? My best guess is that it reflects the exaggerated fears of the care providers rather than a reasoned response. But given the absence of poor outcomes up till now, research on this topic should be expanded and in the meantime, ECV should be available to those with a prior cesarean.

In addition, it is time for more care providers to offer ECV as an option across the board. This is a sadly underused procedure that could certainly greatly impact cesarean rates and maternal morbidity, both by preventing the first cesarean and lowering the rate of automatic repeat cesareans that follow.


References

External Cephalic Version After Prior Cesarean

Aust N Z J Obstet Gynaecol. 2016 Sep 14. doi: 10.1111/ajo.12527. [Epub ahead of print] The efficacy and safety of external cephalic version after a previous caesarean delivery. Weill Y, Pollack RN. PMID: 27624629

BACKGROUND: External cephalic version (ECV) in the presence of a uterine scar is still considered a relative contraindication despite encouraging studies of the efficacy and safety of this procedure. We present our experience with this patient population, which is the largest cohort published to date. AIMS: To evaluate the efficacy and safety of ECV in the setting of a prior caesarean delivery. MATERIALS AND METHODS: A total of 158 patients with a fetus presenting as breech, who had an unscarred uterus, had an ECV performed. Similarly, 158 patients with a fetus presenting as breech, and who had undergone a prior caesarean delivery also underwent an ECV. Outcomes were compared. RESULTS: ECV was successfully performed in 136/158 (86.1%) patients in the control group. Of these patients, 6/136 (4.4%) delivered by caesarean delivery. In the study group, 117/158 (74.1%) patients had a successful ECV performed. Of these patients, 12/117 (10.3%) delivered by caesarean delivery. There were no significant complications in either of the groups. CONCLUSIONS: ECV may be successfully performed in patients with a previous caesarean delivery. It is associated with a high success rate, and is not associated with an increase in complications.

BJOG. 2014 Jan;121(2):230-5; discussion 235. doi: 10.1111/1471-0528.12487. Epub 2013 Nov 19. Is external cephalic version at term contraindicated in previous caesarean section? A prospective comparative cohort study. Burgos J, Cobos P, Rodríguez L, Osuna C, Centeno MM, Martínez-Astorquiza T, Fernández-Llebrez L. PMID: 24245964

OBJECTIVE: To determine if external cephalic version (ECV) can be performed with safety and efficacy in women with previous caesarean section. DESIGN: Prospective comparative cohort study. SETTING: Cruces University Hospital (Spain). POPULATION: Single pregnancy with breech presentation at term. METHODS: We compared 70 ECV performed in women with previous caesarean section with 387 ECV performed in multiparous women (March 2002 to June 2012). MAIN OUTCOME MEASURES: Success rate, complications of the ECV and caesarean section rate. RESULTS: The success rate of ECV in women after previous caesarean section was 67.1% versus 66.1% in multiparous women (P = 0.87). The logistic regression analysis confirmed this result (odds ratio 0.93, 95% CI 0.52-1.68; P = 0.82) adjusted by the variables associated with success of ECV. There were no complications in the previous caesarean section cohort. The vaginal delivery rate in the previous caesarean section cohort was 52.8% versus 74.9% in the multiparous cohort (P < 0.01). There were no cases of uterine rupture. CONCLUSION: Based on our data, we conclude that complications are uncommon with ECV in women with previous caesarean section, with a success rate comparable to that of multiparous women. Uterine scar should not be considered a contraindication and ECV should be offered to women with previous caesarean section with breech presentation at term.

J Perinat Med. 2009;37(2):156-60. doi: 10.1515/JPM.2009.006. External cephalic version among women with a previous cesarean delivery: report on 36 cases and review of the literature. Abenhaim HA1, Varin J, Boucher M. PMID: 19021458

AIMS: Whether or not women with a previous cesarean section should be considered for an external cephalic version remains unclear. In our study, we sought to examine the relationship between a history of previous cesarean section and outcomes of external cephalic version for pregnancies at 36 completed weeks of gestation or more. METHODS: Data on obstetrical history and on external cephalic version outcomes was obtained from the C.H.U. Sainte-Justine External Cephalic Version Database. Baseline clinical characteristics were compared among women with and without a history of previous cesarean section. We used logistic regression analysis to evaluate the effect of previous cesarean section on success of external cephalic version while adjusting for parity, maternal body mass index, gestational age, estimated fetal weight, and amniotic fluid index. RESULTS: Over a 15-year period, 1425 external cephalic versions were attempted of which 36 (2.5%) were performed on women with a previous cesarean section. Although women with a history of previous cesarean section were more likely to be older and para >2 (38.93% vs. 15.0%), there were no difference in gestational age, estimated fetal weight, and amniotic fluid index. Women with a prior cesarean section had a success rate similar to women without [50.0% vs. 51.6%, adjusted OR: 1.31 (0.48-3.59)]. CONCLUSION: Women with a previous cesarean section who undergo an external cephalic version have similar success rates than do women without. Concern about procedural success in women with a previous cesarean section is unwarranted and should not deter attempting an external cephalic version. 

Eur J Obstet Gynecol Reprod Biol. 2009 Feb;142(2):111-4. doi: 10.1016/j.ejogrb.2008.08.012. Epub 2008 Nov 18. Safety and efficacy of external cephalic version for women with a previous cesarean delivery. Sela HY, Fiegenberg T, Ben-Meir A, Elchalal U, Ezra Y. PMID: 19019528

OBJECTIVE: To evaluate the success and morbidity rates for attempted external cephalic version (ECV) in patients with one previous cesarean delivery (CD) and a breech-presenting fetus at term. STUDY DESIGN: This is a retrospective study of outcomes of ECV at our institution for all women with one previous CD and a breech-presenting fetus at term between January 1997 and June 2005. A literature review was also performed as a Medline search (1966-2006). RESULTS: ECV was attempted for 42 women with a breech-presenting fetus and previous CD. The success rate of ECV was 74.0%, and 84% of women with successful ECV delivered vaginally. All fetal and maternal outcomes were favorable. Only four Medline reports met our inclusion criteria, representing a total of 124 patients and a mean ECV success rate of 76.6%. Thus we assessed 166 cases of attempted ECV and find an average ECV success rate of 76.5% and favorable fetal and maternal outcomes. CONCLUSIONS: Women with a breech-presenting fetus at term and previous CD, who desire a trial of labor, should be counseled regarding the accumulating evidence about the efficacy and apparently safety of this procedure and may be offered an ECV attempt.

Eur J Obstet Gynecol Reprod Biol. 1998 Oct;81(1):65-8. External cephalic version after previous cesarean section: a series of 38 cases. de Meeus JB1, Ellia F, Magnin G. PMID: 9846717

OBJECTIVE: To determine if external cephalic version (ECV) is a reasonable alternative to repeat cesarean section in case of breech presentation. STUDY DESIGN: Retrospective study of 38 women with one previous cesarean section and a breech presentation after 36 weeks of gestational age who have had at least one experience of ECV. Statistics used the Fisher's test with significance when P<0.05. RESULTS: Version attempts were successful in 25 of the 38 women (65.8%). Seventy-six percent of the successful version women went on to have vaginal birth after cesarean section. A total of 19 successful vaginal deliveries occurred (50%). Success rate of ECV was lowered when breech was the indication of the previous cesarean section. The vaginal delivery rate was increased after successful ECV in patients previously vaginally delivered, but this difference did not reached significance (P=0.057). No maternal or neonatal complications occurred. CONCLUSION: ECV is acceptable and effective in women with a prior low transverse uterine scar, when safety criteria are observed.

Int J Gynaecol Obstet. 1994 Apr;45(1):17-20. External cephalic version after previous cesarean section--a clinical dilemma. Schachter M, Kogan S, Blickstein I. PMID: 7913053

OBJECTIVES: To describe our limited experience with external cephalic version from breech to vertex presentation at term, with the use of ritodrine tocolysis, in women who had undergone a previous cesarean delivery. METHODS: Eleven parturients after previous cesarean delivery underwent external version after 36 gestational weeks, utilizing tocolysis with ritodrine, after excluding cases of low-lying placenta, severe oligohydramnion or ruptured membranes. Patients were then followed until delivery and scar examination was carried out after vaginal delivery, or at re-cesarean section, according to mode of delivery. RESULTS: All 11 attempted versions were successful. Six patients subsequently delivered vaginally and five by re-cesareansection. None of the uterine scars showed any signs of dehiscence. Three of the five infants delivered by re-cesarean section weighed over 4000 g, whereas all of the vaginally-delivered infants weighed under 3500 g. CONCLUSIONS: External cephalic version to vertex presentation after previous cesarean section was successful in all 11 carefully selected patients. No untoward effects were noted, and no signs of scar dehiscence were found. The safety and efficacy of this procedure after previous cesarean delivery should be examined further.

Am J Obstet Gynecol. 1991 Aug;165(2):370-2. External cephalic version after previous cesarean section. Flamm BL, Fried MW, Lonky NM, Giles WS. PMID: 1872341

Approximately 100,000 cesarean sections are performed each year in the United States because of breech presentation. Numerous studies have shown that external cephalic version can eliminate the need for many of these operations. However, because of the fear of uterine rupture, these studies have generally excluded patients who have undergone previous cesarean section. To evaluate the validity of this exclusion policy, we studied patients with one or more previous cesarean sections and breach presentations near term. Version attempts were successful in 82% of 56 patients who had undergone a previous cesarean section. Sixty-five percent of the successful version patients went on to have vaginal birth after cesarean section. There were no serious maternal or fetal complications associated with the version attempts. We conclude that external cephalic version is a reasonable option in patients with prior low transverse cesarean section.

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.