OSTEOPATHY AND PREGNANCY By Simone Keddy Osteopathy is a complementary health profession that deals with the physical structure of the body. It looks at the relationship between the structure of the body and the way in which it works. It uses hands on techniques to assess and treat restrictions in the tissues. Osteopathy was founded by an American doctor, Dr Andrew Taylor Still. Three of Dr Still’s children died from meningitis and he was upset that he was not able to do anything to save them.(5) He was a very religious man who believed that God had given us the ability to heal ourselves. He believed that if the structure of the body was moving freely, then we would be able to function well, that is, we would be able to fight infections better, be pain free, have easier births etc. He started a detailed study of the anatomy and biomechanics of the human body, and then developed techniques to resolve any restrictions he identified in patients. This is the origins of Osteopathy. Osteopathic care is wonderful during pregnancy. Not only can it help relieve some of the common symptoms of pregnancy but it can also help the labour and delivery to go smoothly.(3) This happens in two ways. Firstly by ensuring the pelvic mechanics are moving freely thus allowing the birth to progress smoothly. Secondly, by aiding optimal foetal positioning, it aims to encourage the baby to present in a left occiput anterior presentation, which is a physically easier birth for the mother and baby. For a natural delivery to occur, the baby descends into the pelvis to engage. The pelvis must first outflare, that is the pelvis becomes wider at the top than the bottom. This occurs by rotation of the pelvic bones around the hips. It also requires the joints of the pelvis and lumbar spine to be moving freely. For the second stage of labour the pelvis must inflare, that is the reverse, with the lower part opening up and the top of the pelvis getting narrower.(6) Along with this, the sacrum and coccyx must move down and backwards. This aims to create as much space as possible for the baby to be delivered. Osteopaths work throughout the pregnancy to ensure the body is adapting freely to the mechanical changes that occur. They also work to ensure the pelvis is moving freely to allow for the best possible birth outcome. Optimal foetal positioning is gaining importance in good birth outcomes. The majority of babies will be born in either a left occiput anterior (LOA) presentation (where the baby is lying on the left side of the mother and the back of their heads towards the front) or right occiput posterior (ROP) presentation (where the baby lies on the right side of the mother and is born with their face, facing forward).(1,2) It is a mechanically easier birth for a LOA presentation as the face is mostly in contact with muscles, whilst the back of the skull contacts the pubic symphysis. As well, a LOA presentation is desirable as it affords greater protection to the baby’s central nervous system. As the baby descends through the birth canal, it must rotate. In a LOA presentation this rotation occurs around the top of the spinal cord and brain stem. However in a ROP the rotation occurs forward of the brain stem and spinal cord.(6) This means that these tissues have to rotate around the axis, thus putting them at greater risk of injury. ROP presentations are becoming more common in Western societies.(4) This is related to posture and lifestyle. Osteopathic treatment can help the baby to adopt a LOA presentation by working on the muscles and joints around the pelvis and abdomen. Sitting on firmer seats, using footrests and spending time on all fours later in pregnancy, can also aide the baby to adopt a LOA presentation. King et al found that osteopathic treatment during pregnancy had a significant association with labour and delivery outcomes. Women who did not receive osteopathic treatment during pregnancy were 3.76 times more likely to have meconium stained amniotic fluid, and 2.2 times more likely to have a preterm delivery. They were also more likely to have a forceps assisted delivery.(14) Both Whiting (15) and Hart (16) found osteopathic treatment to significantly shorten labour duration. The majority of women will suffer from some pain or discomfort during their pregnancy. The incidence of low back pain during pregnancy is around 50%. (8,11, 13) However, it does not have to be part of pregnancy, osteopathy can help. Kofler found osteopathic treatment provided significant improvement in pain and disability scores in pregnant women, compared to a control group which did not receive treatment.(9) Some of the common symptoms of pregnancy that osteopaths help include: • Low back pain – Pregnancy causes huge adaptations through out the body. The increasing weight and changes in the spinal curves results in an increased loading on the posterior spinal ligaments and joints, causing pain.(7) Previous asymptomatic restrictions in the back can limit the body’s ability to compensation to the changes of pregnancy, thus predisposing to back pain. • Mid thoracic pain – Again changes in the spinal curves and increasing breast size contribute to pain in the mid back. In later pregnancy the baby pushes up in the abdomen causing pressure on the lower ribs. This is also a common cause of mid back pain. • Fluid retention. – Lymph vessels have thin walls which are easily compressed. Several areas are important for good drainage. The diaphragm is a major pump for the lymphatic system, creating pressure gradients to aid the flow of lymph back into the venous system and heart (3) Restrictions of the diaphragm are common in later pregnancy as the baby grows and exerts pressure on it. Posture is important for drainage from the arms and legs. Round shoulders block the lymph vessels aggravating fluid retention in the arms. This can contribute to carpal tunnel syndrome and tendonitis in the shoulder. The position the baby is lying is also important for drainage from the legs. • Pubic symphysis pain – This is very common in pregnancy. Its function is closely related to the joints at the back of the pelvis. Russell et al, report that symphyseal pain is often associated with sacroiliac dysfunction. (17) The pubic symphysis is important in the natural birth mechanics and it needs to be functioning freely for a good birth. • Sciatica – This can be due to the position of the baby or from disc problems. Disc problems can be aggravated in pregnancy as the increasing weight puts more pressure on the disc. It is important that the body has good support and balance to help prevent problems occurring during pregnancy. (Ideally, treatment given before a person becomes pregnant can help resolve any restrictions and address weaknesses, so that they do not become a problem during pregnancy). Osteopathy is safe for all stages of pregnancy. When you visit an osteopath, they will take a case history of your complaint. You will then, usually, be asked to undress to your under clothes. The osteopath will do an examination; this involves performing some basic movements such as bending forward, so the osteopath can assess how the body is moving. They will also palpate the muscles and tissues to identify what is causing the problem. Depending on your problem they may also include orthopaedic and neurological tests. The osteopath will then use a range of manual techniques to address any restriction found. They may also give advice on posture or exercises for you. Osteopathy can help to make your pregnancy and labour go as smoothly as possible. You do not have to have symptoms to see an Osteopath; you can have an assessment to make sure everything is functioning well for the birth. Treatment is also beneficial in the post partum period. Andersson and Ostgaard found 67% of women experienced back pain directly after delivery, with more then half of these still having back pain after several months and 7% still having serious back pain 18 months after delivery.(10) Russell et al, found 33% of women to have backache three months after childbirth.(12) Osteopathic treatment can help aid a quicker and more complete recovery after delivery. (3) A new baby is enough to deal with, you don’t need back pain as well. For an Osteopath in your area, please contact the Australian Osteopath Association on 1800-4-67836 (that’s 1800 -4-osteo). Osteopath, Dr Simone Keddy studied osteopathy at RMIT in Melbourne, graduating in 1996. She worked in Singapore and England, before moving to Brisbane in 2003. Whilst in England, she undertook post graduate studies in “Osteopathy and Obstetrics” which fuelled her passion for providing osteopathic care for pregnant women. (As well as pre-conception and post-partum care). Simone is married and has a cheeky 2 year old son, Noah Tiger. References: 1. Bennett, VR. Brown, LK. (ed.) (2002). Myles Textbook for Midwives. Churchill Livingstone, Philadelphia. 2. Carreiro, JE. (2003). An Osteopathic Approach to Children. Churchill Livingstone, Edinburgh. 3. Kuchera, ML. Kuchera, WA. (1994). Osteopathic Considerations in Systemic Dysfunction. Greyden Press, Ohio. 4. Sutton, J. Scott, P. (1996). Optimal Foetal Positioning. Birth Concepts, New Zealand. 5. Hawkins, P. O’Neill, A. (1990). Osteopathy in Australia. P.I.T. Press, Bundoora. 6. Molinari, R. (2002-3) Lecture Notes Osteopathy and Obstetrics Course. European School of Osteopathy, Kent 7. Molinari,R. (1999) The Biomechanical and Postural Adaptation of the Pregnant Woman. European School of Osteopathy, Kent. 8. Andersson, GB. Haagstad, A. Jansson, PO.Svensson, HO. The relationship of low-back pain to pregnancy and gynaecological factors. Spine August 1990. 9. Kofler, G. (2003) Osteopathy for Back and Pelvic Pain in Pregnancy. Wiener Schule fur Osteopathie, Austria. 10. Andersson, GB. Ostgaard, HC. Postpartum low-back pain. Spine. March 1992 11. Colliton, J. Managing Back Pain During Pregnancy. MedGenMed. 1(2), 1999. 12. Russell, R. Dundas, R. Reynolds, F. Long term backache after childbirth: prospective search for causative factors. British Medical Journal. June 1,1996 v312 n7043 p1384(5). 13. Galleher, C. Functional Changes in Back Muscle Activity Correlate With Pain Intensity and Prediction of Low Back Pain During Pregnancy. (Statistical Data Included). Physical Therapy. July 1999 v79 i7 p711. 14. King, HH. Tettambel, MA. Lockwood, MD. Johnson, KH. Arsenault, DA. Quist, R. Osteopathic Manipulative Treatment in Prenatal Care: A Retrospective Case Control Design Study. Journal of the American Osteopathic Association. Dec 2003, v103 n12 p577-582. 15. Whiting, LM. Can the length of labor be shortened by osteopathic treatment? Journal of the American Osteopathic Association. 1911;11:917-921. 16. Hart, LM. Obstetrical Practice. Journal of the American Osteopathic Association. 1918:609-614. 17. Russell, R. Reynolds, F. Back pain, pregnancy and birth: postpartum pain is most likely to be a continuation of antepartum pain. (Editorial). British Medical Journal. April 12, 1997 v314 n7087 p1062(2).