Elizabeth S. Anderson-Peacock,
BSc,
DC, DICCP
Birth Trauma
By Elizabeth S.
Anderson-Peacock, BSc, DC, DICCP
Barrie, Ontario, Canada
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
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