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Dynamic Chiropractic
July 13, 1998, Volume 16, Issue 15

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Birth Trauma


by Elizabeth S. Anderson-Peacock, BSc, DC, DICCP

Birth is a normal biological process. It does not require management as a disease, but even a seemingly "uneventful" birth is stressful and traumatic for the mother and neonate. Pregnancy and birth have special significance for the chiropractor, as often the mother and child are exposed to harmful routine practices for which scientific investigation is poorly documented, or often not assessed for long-term effects on the fetus and the mother. With respect to the infant, the longer undetected dysfunction is allowed to continue in the developing nervous system and spine, the greater the potential to affect the patient.

The following areas are important to address during pregnancy and birth to detect potential sources of fetal intrauterine stress prior to labor, stressing the passage of the fetus during labor, and management at the time of birth.

As subluxations are caused by trauma (micro or macro), chemical stress or toxicity and autosuggestion, it is important to evaluate exposure of the infant in these areas.

Exposure through maternal habits such as alcohol is well-documented with effects on brain growth and development, facial and cranial abnormalities, growth retardation, and fetal alcohol syndrome in as many as 3/1000 to 6/1000 births.1,2 Smoking is another insidious toxin. Whether the mother smokes or lives in a smoke-filled environment, the fetus is the receiver of the second-hand smoke. Evidence suggests lowered birth weight, increased prematurity, and an increased incidence of such problems as cleft lip/palate and limb reduction malformations.3

It has been my experience that many women take over-the-counter prescriptions without questioning their safety. The thinking is that since it is not prescribed, it will do little harm. It is important to educate all mothers that there is no drug which is 100 percent safe for the fetus as no one can clinically know the effects of all medications on a particular fetus.

Certain types of medications are well known to cause problems for the developing fetus. It might be recommended for mothers to read the fine print in a CPS, PDR or a safety data sheet. Again, remind the mother that the effects of medications are accentuated in the fetus. The safety of most prescription drugs have not bee studied or established in the fetus. The fetal effects will vary depending on the dosage, duration and time during gestation in which they were taken. It is well-documented that in the adult population, properly prescribed medications are the fourth leading cause of death in the United States. Only 10 percent of adverse reactions are estimated to be reported.4,5 as amniocentesis and chorionic villi sampling. The type of preferred procedure varies depending on where you reside in the country. The rate of fetal spontaneous abortion through these procedures is 0.5 percent and 1.5 percent respectively.6

The Lancet reported in January 1998 that early prenatal testing increased the rates of abortions and birth defects. The routine use of ultrasound has caused some concern expressed in the research.7,8 In a NEJM paper, the use of ultrasound did not change the perinatal outcome in 15,151 low-risk pregnancies.9 Ultrasound has been found to be associated with delayed speech and dyslexia in children.10,11

In animal science research, equivalent amounts of ultrasound have been shown to cause frank demyelination in rats, cell growth pattern defects, long-term DNA effects and genetic changes.12,13,14

Electronic fetal monitoring has not undergone rigorous scientific study even though it is used in over 90 percent of hospitals. In one review, EFM has been shown not to change the incidence of neurological trauma and has increased the number of cesarean sections four-fold.15

Forceps and vacuum extraction are traumatic. Improperly applied location or pressure, practitioner inexperience and error can lead to trauma. Often, there is already difficulty with the delivery when their application is employed. Peripheral, phrenic and brachial plexus, dural tears and traction injuries are not uncommon.16-23

Internal fetal monitoring is by its nature traumatic, as sensors are attached in utero to the fetal skull to monitor the emerging infant's health status. Scalp abscess has been noted in as high as 5.4 percent and hemorrhaging in 44 percent.24

Episiotomies were performed in 61.9 percent of the deliveries in 1987. Two randomized studies have demonstrated no benefit for its routine use. Women who had midline episiotomies have been shown to have nearly 50 times more severe lacerations, and women who had mediolateral episiotomies were nearly eight times more likely to have severe lacerations than women who did not have one.25

A change in birth position was associated with a reduction in the need for episiotomy due to increased pelvic outlet size, greater relaxation of the perineal region and psoas relaxation.26,27

The use of epidurals has been shown to prolong labor by 1.3 hours and cause fever in the mother, which is then treated by antibiotics in both the mother and neonate.28

Prior to labor, the history of trauma to the mother is of importance. Older research performed on animals demonstrated abnormal gestation in mammals who had subluxations induced at the in sustaining pregnancy to full gestation.29

Squatting or kneeling postures are associated with more favorable neonatal outcomes. Home deliveries have been found to reduce neonatal stress, labor dystocia, meconium staining, maternal infection and postpartum hemorrhage.30-33

A June 1998 study published in the Journal of Epidemiology and Community Health compared 3.9 million vaginal births delivered by midwives and physicians. A 19 percent reduction in infant mortality rate was reported by the midwives when compared to similar births attended by physicians. It was also found that neonatal mortality in the first 28 days was 33 percent lower if delivered by nurse midwives. The risk of delivering low birth weight babies was 31 percent lower among the midwives.

The ability for the sacrum and coccyx to move posteriorly during labor has integral importance to the labor and birth with passage of the fetus. Those with sacralization of L5 or a fused coccyx, congenital or traumatic anomaly of the pelvis may experience greater difficulty with delivery as the pelvis is less mobile.

The birth posture chosen has an influence on the stress of delivery. Cross-cultural evaluation has been performed on women with squatting, which has been shown to increase the diameter of the pelvic outlet, allow gravity to work with the delivery, free the movement of the sacrum, and allows the mother to bear down using the thighs and legs for resistance and deliver with less trauma than those who lay in a supine or semi-recumbent position.30-33

Maternal fitness and expectations will also have an impact on the mother's strength and endurance for delivery. A well-integrated nervous system with strong muscles working together and appropriately will aid in the rhythm established through the second stage of labor. A mother prepared through birth coaches (i.e., Bradley method or Doulas) and birthing techniques will have a prepared mental attitude for birth. In a report on the Bradley method, 96 percent of births are unmedicated, whereas only one percent of Lamaze prepared births were unmedicated.34

The maternal pelvis size and type (android, anthropoid, platypelloid) will have an effect on the birth canal size and shape and the forces encountered on the emerging head and spine. Gynecoid is the most favorable pelvis present in approximately half of females. The fetus should be in a longitudinal, vertex and flexed position. Neonates who are breech have a greater incidence of congenital hip dislocation, club foot and scoliosis, and are more likely to have cervicothoracic spinal trauma.20-24

In the event of twins, there will be a decrease in the available fetal moveable space, which increases the likelihood of malpresentation. Club foot and bent pinnae are examples of asymmetrical forces on the fetus, the greater the potential for aberrant growth and asymmetrical and damaging effects.

Observe or inquire regarding the neonatal head shape as an indicator of birth stress. The presence of cephalohematoma, caput succedaneum and ecchymosis are indicators of trauma. Large fetuses (or a small maternal pelvis) increase the chance for cephalopelvic disproportion and/or shoulder dystocia, which causes considerable stress to the fetus and can lead to increased traction injuries to the fetal brachial plexus, dural tears, phrenic nerve damage, clavicular fractures and spinal cord injuries.

Inquire regarding the neonatal presentation and duration of both the first and second stage of labor. This will provide valuable information of neonatal birth stresses during passage. Once labor begins, different forces are applied to the fetus through uterine contractions. An unfavorable lie or disorganized uterine contractions will stress the fetus, especially as the piston-like movement of the uterus meets resistance from the fetus meeting the pelvic floor. Should the fetus be in a brow or deflexed presentation, it will encounter stress to the forehead/face, abnormal head molding and cervical spine hyperextension trauma.

Birth trauma is estimated to be between the sixth to tenth leading cause of infant mortality in the U.S. It is under reported and often misdiagnosed.35,36,37

The implications to chiropractors are obvious if we wish to encourage patients to deal with the birth process with the least amount of interference to be proactive and informed. It also should encourage the wellness-oriented pediatric chiropractor to evaluate all pregnancies and children subsequent to birth. The long-term implications of birth are not fully known. However, birth history is significant, as demonstrated in a published report which compared types of suicides to birth trauma stress and postulated the effect due to imprinting. Of the adult suicides studied, those individuals who experienced suffocation deaths had a history of birth asphyxiation; those who died through violent mechanical death experienced mechanical birth trauma; and those who experienced drug addiction were associated with mothers who had opiate or barbiturate administration during labor.38

References

  1. Larroque B, et al. Moderate prenatal alcohol exposure and psychomotor development at preschool age. Amer J of Public Health Dec 1995; vol. 85(12):1654-1660.
  2. Russell M, et al. Detecting risk drinking during pregnancy: a comparison of four screening questionnaires. Amer J of Public Health Oct 1996; vol. 86(10):1435-1439.
  3. Kallin K. Maternal smoking during pregnancy and limb reduction 87(1):29-32.
  4. Lazarou J, et al. Incidence of drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA April 15, 1998; vol. 279(15):1200-1205.
  5. Adverse drug reactions common among outpatients but rarely reported. Reuters, Chicago, May 4, 1998.
  6. Miller, Callender. Obstetrics Illustrated, 4th edition. Churchill Livingstone, 1994; p. 106-115.
  7. Haire D. Fetal effects of ultrasound: a growing controversy. Journal of Nurse Midwifery July/Aug 1994; vol. 29(4):241-246.
  8. Taylor KJW. A prudent approach to ultrasound imaging of the fetus and newborn. Birth Dec 1990; vol. 17(4):218-222.
  9. Ewigman BG, et al. Effect of prenatal screening on perinatal outcome. New England Journal of Medicine Sept. 16, 1993; vol. 329(12):822-827.
  10. Campbell JD, et al. Case control study of prenatal ultrasoundography exposure in children with delayed speech. Can Med Assoc J 1993; vol. 149(10):1435-1440.
  11. Stark CR, et al. Short and long term risks after exposure to diagnostic ultrasound in utero. Obstet Gynec 1984; vol. 63(2):194-200.
  12. Ellisman MH, et al. Diagnostic levels of ultrasound may disrupt myelination exp. Neuro 1987; vol. 98(1):78-92.
  13. Liebeskind D, et al. Sister chromatid exchanges in human lymphocytes after exposure to diagnostic ultrasound. Science 1979; vol. 205(4412):1273-1275.
  14. Liebeskind D, et al. Diagnostic ultrasound: effects on the DNA and growth patterns of animal cells. Radiology 1979; vol. 131(1):177-184.
  15. Pelka F. Electronic fetal monitoring. Mothering Fall 1992;71-75.
  16. Teng FY, Sayre JW. Vacuum extraction: does duration predict scalp injury? Obstet Gynecol 1997; vol. 89(2):281-285.
  17. Hickey K, McKenna P. Skull fracture caused by vacuum extraction. Obstet Gynecol 1996; vol. 88(4, part 2):671-673.
  18. Ross MG. Skull fracture caused by vacuum extraction. Obstet Gynecol 1997; vol. 89(2):3
  19. fetal macrosomia and method of delivery. Obstet Gynecolo 986; vol. 68(6):784-788.
  20. Byers RK. Spinal cord injuries during birth. Dev Med Child Neurol 1975; vol. 17(1):103-110.
  21. Painter MJ, Bergman I. Obstetrical trauma to the neonatal central and peripheral nervous system. Seminars in Perinatology Jan 1982; vol. 6(1):89-104.
  22. Abroms IF, et al. Cervical cord injuries secondary to hyperextension of the head in breech presentations. Obstetrics and Gynecol March 1973; vol. 41(3):369-378.
  23. Fielding JW. Cervical spine injuries in children. Fractures and Dislocations; Pediatric Fractures, vol. 3, 2nd edition. Philadelphia, J.B. Lippincott, p. 422-427.
  24. Curran JS. Birth associated injury. Clinics in Perinatology Feb. 1981; vol. 8(1):111-127.
  25. Shiona P, et al. Midline episiotomies: more harm than good? Episiotomy and lacerations. Obstet and Gynecol May 1990; vol. 75(5):765-770.
  26. Paciornik M. Commentary: arguments against episiotomy and in favor of squatting for birth. Birth 1990;17(2):104-105.
  27. Borgatta L, et al. Association of episiotomy and delivery position with deep perineal laceration during spontaneous delivery in nulliparous women. Am J Obstet Gynecol 1989;160(2):294-297.
  28. Lieberman E, et al. Epidural analgesia, intrapartum fever and neonatal sepsis evaluation. Pediatrics 1997;99(3):415-419.
  29. Burns L. Vertebral lesions and the course of pregnancy in animals. J Am Osteop Assoc Nov 1993, vol. XXIII(3):155-157.
  30. Gastaldo TD. Labor posture. Birth 1992;19(4):230.
  31. Gardosi J, Hutson N. Randomized controlled trial of squatting in the second stage of labor. Lancet July 8, 1989;74-77.
  32. Gardosi J, Sylvester S. Alternative positions in the second stage of labor: a randomized controlled trial. Br J Obstret Gynec 1989;6(11):1290-1296.
  33. Mehl LE. Home delivery research today -- a review. Women's Health 1976;1(5):3-11.
  34. McCutcheon-Rosegg S. Natural Childbirth the Bradley Way. 1984; New York, Penguin Books, p. 7-13. musculoskeletal injuries stemming from birth trauma. JMPT 1993; vol. 16(8):537-543.
  35. Faix RG, Donn SM. Immediated management of the traumatized infant. Clinics in Perinatology 1983; vol. 10(2):487-505.
  36. Dickman CA, et al. Pediatric spinal trauma: vertebral column and spinal cord injuries in children. Pediatric Neurosci 1989; vol. 15:237-256.
  37. Jacobson B, et al. Perinatal origin of adult self-destructive behavior. Acta Psychiatr Scand 1987; vol. 76:364-371.

Elizabeth Anderson-Peacock, BSc, DC, DICCP
Barrie, Ontario, Canada

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Dynamic Chiropractic
July 13, 1998, Volume 16, Issue 15

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