CASE STUDY
Successful Clinical Outcomes Confirmed via Ultrasound
in a Patient with Placenta Previa and Breech Fetal
Presentation with Chiropractic Care
John Edwards, D.C.1 & Joel Alcantara, D.C.2
Abstract
Objective: To describe the care of a pregnant patient medically diagnosed with a breeched fetus and placenta previa.
Clinical Features: The patient is a 32 year old multi-parous woman in her 32nd week of pregnancy. She was referred for
chiropractic care by her midwife and obstetrician after ultrasound imaging confirmed breech fetal positioning and
placenta previa. The consensus by both birthing professionals was that vaginal birth was unlikely.
Intervention and Outcome: The patient was cared for with a combination of Diversified Technique and Webster
Technique with successful outcomes. Comparative ultrasound imaging confirmed the breeched fetus assumed a vertex
position with the placenta migrating to more than 3 cm away from the os of the cervix.
Conclusion: This case report provides supporting evidence on the effectiveness of chiropractic as described in the care of
a pregnant woman.
Keywords: Placenta previa, chiropractic, subluxation, pregnancy
Introduction
In the United States, approximately 6 million pregnancies
occur yearly resulting in 4,058,000 live births with 875,000
women experiencing one or more complications resulting in
1,995,840 pregnancy losses.1 Fetal and neonatal losses may
have serious long-term consequences for a woman2 such as
depression, anxiety, irritability, excess fatigue, sleep disorders
and concentration difficulties and post-traumatic stress
syndrome to list a few.3-4 Given this clinical scenario, there is
a need to provide healthcare interventions that prevent or
address these pregnancy and post-partum related
comorbidities and complications.
1.
2.
Private Practice of Chiropractic, Cape Coral, FL
Research Director, International Chiropractic Pediatric
Association, Media, PA & Chair of Pediatric Research,
Life Chiropractic College West, Hayward, CA
Placenta Previa
In the realm of alternative therapies, the prevalence rate of use
by pregnant women range from 1 to 87 percent.5 Motivation
and condition of use have been established to address a
specific symptom or condition and to promote health and
wellbeing.5-6
Of the practitioner-based alternative therapies, chiropractic
care is popular and highly utilized by women during
pregnancy, particularly when one considers the prevalence of
MSK pain conditions in this patient population and the
effectiveness of chiropractic to address it.7 However, despite
the high uptake of chiropractic during pregnancy, the research
has been described only as “emergent.” 8 To contribute to
evidence-informed practice, we describe the chiropractic care
J. Pediatric, Maternal & Family Health - March 13, 2014 3
of a pregnant patient with placenta previa and breech fetal
presentation with successful outcomes.
Case Report
times, and upon re-examination of the Webster analysis, both
heels evenly approximated the ischial tuberosities. The patient
was instructed to lay prone and low-force myofascial and
trigger point releases were performed on both the left round
ligament and right psoas muscle .
History
Outcomes
A 32 year old multi-parous woman presented for chiropractic
care in her 32nd week pregnancy. She was referred for
chiropractic care by her midwife and obstetrician after
ultrasound imaging confirmed both breech fetal positioning
and placenta previa. There was a consensus by both birthing
professionals that since the placenta was partially obstructing
the cervical os, it would not be possible to attempt a vaginal
birth. The patient had delivered her three previous children
without complication or intervention at a local birthing center
specializing in water birth. She suffered no significant trauma
since her last delivery 3 years earlier, but had a history of 3-4
months of chiropractic care following a motor vehicle accident
4 years prior to her first pregnancy.
Examination
A systems review revealed mild asthma in the winter months
and vital signs within normal ranges for pregnancy. A spinal
alignment analysis was performed using the PostureScreen
Mobile software (Trinity, FL, USA; 2011) for the iPhone 3G
with data points selected on both eyes, mid lip, jugular notch,
bilateral acromio-clavicular joints, ASIS, and mid talus on the
frontal view and the external auditory meatus, the cervicothoracic spine junction, trochanter, mid-knee and lateral
malleolus on the profile view.
The patient’s alignment demonstrated a 0.40 0 left lateral head
shift from the midline with a 2.50 tilt inferiorly to the left, a
0.520 left rib cage shift, and a 4.40 hip tilt inferiorly to the left
(see Figure 1). From the profile (see Figure 2), the patient
demonstrated a 1.27 inch head shift forward from the midline,
a 1.17 inch shift backward of the shoulder, a 1.41” forward
trochanter shift and a 0.53” forward knee shift. Cervical,
thoracic, and lumbar ranges of motion (ROM) were within
normal limits and both George’s Test for vertebrobasilar
artery insufficiency and Kemp’s Test for lumbar and sacroiliac joint pain were negative.
Static palpation revealed spasms on the left lateral aspect of C1
with restricted left lateral bending at the segment and a short
right arm on the supine psoas tension test.
Intervention
The patient was instructed to lay prone on two specially
prepared memory foam pillows to perform the prone exam,
which revealed a positive right Webster sign for sacro-iliac
involvement, with the left heel approximating the ischial
tuberosity on flexion and the right remaining several inches
away. After adjusting the sacrum prone three times utilizing a
pelvic drop, the re-assessment of the Webster analysis showed
both legs gave equal resistance to flexion, but neither would
approximate the ischial tuberosities.
The next lumbar segment above the sacrum was adjusted as a
PR utilizing a Diversified drop-table technique repeated 3
4
J. Pediatric, Maternal & Family Health - March 13, 2014
The patient was attended a total of 9 visits over the course of
three weeks and provided at-home exercises including pelvic
tilts and mobilizations. She was also instructed to spend 10-15
minutes daily crawling on her hands and knees. Throughout
the course of treatment there were inconsistent findings using
the Webster sacral analysis.
Of the 9 visits, 5 times the patient demonstrated a right
resistant leg on 5 occasions and on the left 4 times. Three of
those visits required a left-to-right diversified adjustment to
the lowest lumbar segment to allow the heels to approximate
the ischial tuberosities, and two of them required a right-to-left
line of drive of that lowest segment. The psoas sign that
appeared on the right at the initial examination changed to the
left for the next three visits before re-testing normalized, and
on four occasions the left round ligament was indicated as
dysfunctional and on three occasions the right one was
“tighter”, and twice they were both equally dysfunctional
At the 5th visit the patient felt as if her baby had turned
transverse, and she began to take the supplement Pulsitilla and
spending time in her swimming pool for exercise and leisure.
The patient reported on the 6th visit that she felt the baby move
more when she ate or drank something cold than when she
took the herbs. At the 8th visit the patient reported feeling the
baby had moved low and to her right, and on the following
visit she reported that on the two previous nights, she felt that
her baby had moved up into her ribs and back down again.
Following her 10th chiropractic visit, she was scheduled with
her obstetrician for ultrasound imaging. The imaging
confirmed her reports of fetal movements and that her baby
had moved into the vertex position with the placenta migrating
to more than 3 cm away from the os of the cervix. Both the
obstetrician and midwife confirmed the results and the patient
was “cleared” to deliver vaginally.
A comparative spinal alignment examination demonstrated her
head had shifted 0.130 left with a 3.30 clockwise tilt, a 0.130
counter-clockwise shoulder tilt, a 0.470 left shift of the ribcage
and her left hip rotation had reduced to 2.00. Spinal alignment
had improved closer to the midline for all of the markers in the
coronal plane. Forward head carriage had reduced to 1.14”,
shoulders had improved to 0.77” back, hips were shifted
0.74”, and knees were 0.34” forward.
The patient attended 3 more chiropractic visits before her
contractions began, and on visit 12, she reported her
contractions had occurred regularly at 10 minutes apart. A
final pre-natal spinal alignment examination, the findings were
similar as previously described with a 0.440 left head shift and
3.40 left tilt, with no significant shifts or rotations in the
shoulders or ribcage.
The patient’s hip had shifted left 0.17” but the analysis did not
Placenta Previa
detect any pelvic rotation. The profile view had changed all
markers forward of the plane line. The forward head carriage
reduced to 0.45” and her shoulders had moved to 0.32”
forward. Her trochanter was calculated to be 1.11” forward
and the knees 0.37” relative to the midline.
The patient delivered a healthy baby in the water at the
birthing center without complication. Two weeks postpartum, she returned for 6 visits over a four-week time span,
initially complaining of a focal sharp pain in the left abdomen
which resolved after the first adjustment and psoas release.
Subsequent visits addressed mild right sacroiliac joint pain
which completely resolved after the fifth visit.
A post-partum spinal analysis examination demonstrated a
2.80 left head tilt, a 0.530 left shoulder shift, and a 0.67” shift
of the hips left from the midline. The patient’s head anterior
carriage increased to 1.35” forward and shoulders shifted to
0.27” back, with an increase in the anterior displacement of
the hips to 1.83” and the knees to 1.14” backward from the
calculated center of gravity.
Discussion
There are many interesting and clinically relevant issues for
discussion in the case report presented. In the interest of
brevity, we will focus on three aspects of the case: the comanagement of the patient characterized as integrative
medicine, patient’s breeched fetus and diagnosis of placenta
previa.
Medical plurism (i.e., the use of both conventional and
alternative therapies) is well established. In the case report
presented, the attending chiropractor has an established
professional relationship and works closely with midwives and
medical physicians situated within a birthing center. The
patient attended chiropractic care on the advice of her
obstetrician and midwife.
Interestingly, referrals to alternative practitioners during
pregnancy have been found to be more likely to be midwifeled than obstetrician-led and obstetricians appear more
cautious and skeptical than midwives about CAM use for
women in their care.9 To examine the health service utilization
among pregnant women for both conventional and alternative
therapy, Steele and colleagues10 surveyed 1835 women and
found that the consultation with alternative practitioners only
involved certain conditions such as neck pain and sciatica.
Women consulted both CAM practitioners and conventional
maternity health professionals (i.e., obstetricians, midwives
and GPs) for back pain and gestational diabetes. Women who
had more frequent visits to a midwife were more likely to have
consulted with an acupuncturist or a doula than those visiting
midwives less frequently for their pregnancy care.
Steele and colleagues10 concluded that their study findings
emphasize the need for a considered and collaborative
approach to interactions between pregnant women,
conventional maternity health providers and alternative
practitioners to accommodate appropriate information
transferral and coordinated maternity care.
Placenta Previa
Adams and colleagues11 performed an integrative review of
the literature to determine the attitudes and behaviors of
maternity care professionals towards alternative therapies
during pregnancy. A total of 21 papers covering 19 studies
were identified. Findings from these studies were extracted,
grouped and examined according to three key themes:
'prevalence of practice, recommendation and referral',
'attitudes and views' and 'professionalism and professional
identity'. The authors asserted that there is a need for greater
respect and cooperation between conventional and alternative
practitioners as well as communication between all maternity
care practitioners and their patients about the use of alternative
therapies.
Münstedt and colleagues12 explored the clinical indications for
using CAM in obstetrics. The authors sent out a questionnaire
to delineate who provided the alternative therapy (i.e.,
midwife or physician). The authors found that alternative
therapies were widely offered despite perceived lack of
evidence of effectiveness or information on adverse
consequences. Although obstetricians are responsible for
patient care, decisions to provide alternative therapy were
largely taken by midwives, and the midwives' belief in the
methods' effectiveness as well as patient demand.
There is a long history of collaboration between midwives and
chiropractors in the care of pregnant women. In a survey of
midwives, Mullin and colleagues13 found that midwives were
aware that chiropractors worked with "birthing professionals"
and attended to patients with both musculoskeletal and nonmusculoskeletal disorders. A vast majority indicated a positive
personal and professional clinical experience with chiropractic
and that chiropractic was safe for pregnant patients and
children.
Allaire and colleagues14, surveyed North Carolina midwives
on the use of herbal and other CAM therapies and found that
53% of midwives would recommend chiropractic to their
clients. Bayles15, in a survey on the use, recommendation, and
referral of Texas midwives also reported that chiropractic was
the most popular for the care of pregnancy-related MSK
complaints.
In most deliveries near term, the fetus presents by the head,
with the best fit into the lower pelvis in the occipito-anterior
position. For the patient presented, ultrasound imaging
determined that her pregnancy was breeched. The most
common fetal malpresentation; the buttocks, not the head, is at
the lower pole of the uterus and is termed breech from the old
English word brec—breeches or buttocks).16 Approximately
3% to 4% of all pregnancies reach term with the fetus in
breech presentation.17-18
Before 28 weeks of gestation, approximately 25-30% of all
fetuses will present as breech. At 34 weeks of gestation, 7-8%
of babies are breech19 with 50% of these breeched fetuses
turning by themselves to head down by 38 weeks.20 Frank
breech is the most common type of presentation and occurs in
about 60% of breech births.21
Single or double footling account for 35% of breech births and
is a common presentation for pre-term fetuses. The remaining
breech presentations involve complete breech presentations.19
J. Pediatric, Maternal & Family Health - March 13, 2014 5
A baby is more likely to turn from breech to head down if the
mother has previously given birth. Perinatal morbidity and
mortality with breech presentation have been estimated to be
three times more likely when compared to fetuses with vertex
presentation for vaginal delivery.22 Maternal complications
include preterm gestation, abnormalities in amniotic fluid
volume, uterine anomalies, placenta previa and multifetal
gestations while examples of fetal complications include
hydrocephalus, anencephaly, and other conditions that impair
fetal movement.21
In terms of delivery, vaginal delivery babies presenting as
breech is associated with increased neonatal mortality
compared with Cesarean delivery while Cesarean delivery is
associated with maternal morbidity compared with the vaginal
delivery.23 As such, planned Caesareans is the choice of
birthing. However, planned Caesarean section compared with
planned vaginal birth reduced perinatal or neonatal death or
serious neonatal morbidity for the singleton breech baby at
term, at the expense of somewhat increased maternal
morbidity.
As a result of the pregnancy-related morbidities such as low
back pain and risks involved with medical procedures for
breech pregnancies, expectant mothers turn to alternative
therapies for care.24 Of the various practitioner-based
alternative therapies, chiropractic is popular for both pregnant
and non-pregnant women.5, 25
Chiropractic Care
In a practice-based research network, Alcantara and
colleagues26 characterized the chiropractic care of pregnant
women and found the use of the Webster Technique as very
common and possibly reflects the uniqueness of this technique
in the care of pregnant patients. The authors further
commented that this observation may also indicate the need
for expertise and specialization of this type of care. In a
similar setting (i.e., PBRN), Alcantara et al.27 examined the
effectiveness of the Webster technique based on a
convenience sample of 81 pregnant women presenting for
chiropractic care with fetal malposition and malpresentation.
The investigators found that previous or concurrent care
included external cephalic version, slant board, acupuncture,
moxabustion, homeopathy and various forms of exercises.
Based on 63 of the 81 subjects, the authors found that 70% of
the subjects with abnormal fetal pregnancies reported a
correction to the vertex position, indicating possible
effectiveness of the Webster Technique in influencing positive
outcomes.
Before we commence further, we wish to emphasize in these
discussions that the theoretical and clinical framework of the
Webster Technique is not to “turn” the breeched fetus as in
external cephalic version. Rather it is to address lumbopelvic
subluxations to allow for a more optimal environment for the
fetus with positive outcomes for the baby for a natural
childbirth.28
In the case report presented, an examination of the impact of
chiropractic adjustments on the patient’s prenatal spinal
alignment suggests a reduction on the absolute difference of
6
J. Pediatric, Maternal & Family Health - March 13, 2014
the ribcage and hip shifts from midline, a reduction in pelvic
rotation, and an improvement in the distance the head,
shoulder, and knee were positioned anterior or posterior from
midline. Furthermore, the patient was able to maintain the
improvements in absolute difference between head and
shoulder and shoulder and hip positioning in the sagittal plane
after her delivery compared to her initial presentation.
Based on the attending chiropractors in the care of pregnant
women, he was of the clinical opinion that during pregnancy
the body experiences a rapid change in the distribution of
mass over a short time frame, so it’s reasonable to expect the
postural righting systems to take some time to adapt. The
postnatal postural examination findings partially support this
presumption with the landmarks as described retreating further
from the midline when compared to the examination
immediately before delivery. However, the chiropractor was
of the opinion that the postural examination also suggest that
the chiropractic adjustments left some lasting impact on the
patient’s postural alignment, considering head shift, rib cage
shift, hip tilt, shoulder translation and the absolute differences
between sagittal head and shoulder and shoulder and hip
differences maintained their improvement compared to the
initial exam.
The medical literature is aware that maternal posture may
influence fetal position and many postural techniques have
been used to promote cephalic version. A recent review by
Hofmeyr and Kulier29 assessed the effects of postural
management of breech presentation on measures of pregnancy
outcome. The investigators evaluated procedures in which the
mother rests with her pelvis elevated. These included the
knee-chest position, and a supine position with the pelvis
elevated with a wedge-shaped cushion.
The authors found 6 studies (i.e., randomised and quasirandomised trials comparing postural management with pelvic
elevation for breech presentation, with a control group)
involving a total of 417 women. The rates for non-cephalic
births, Caesarean section and Apgar scores below 7 at one
minute, regardless of whether ECV was attempted or not, were
similar between the intervention and control groups. The
authors concluded (as in a similar review in 200030) that there
is insufficient evidence from well-controlled trials to support
the use of postural management for breech presentation. We
would add that the conclusion by Hofmeyr and colleagues29 is
perhaps premature given that the chiropractic approach to
posture has not been investigated.
Further on the perspective of postural and more importantly
for the unique aspect of this case is the presenting diagnosis of
placenta previa. According to the attending chiropractor, two
major postural alignment changes stand out between the initial
exam and the one following the confirmation ultrasound.
There was a 54.6% drop in coronal hip tilt and the absolute
difference between sagittal shoulder and hip translation
improved 41.5% closer to the line of gravity.
These changes suggest a combination of the chiropractic
adjustments, trigger point releases and exercises may have
created a structural and neurological environment favorable to
allowing the placenta to migrate (as well as the breeched
fetus). Placenta previa is a potentially severe obstetric
Placenta Previa
complication where the placenta lies within the lower segment
of the uterus, presenting an obstruction to the cervix and thus
to delivery.31 The overall prevalence of placenta previa was
5.2 per 1000 pregnancies. Evidence of regional variation
exists with prevalence highest among Asian studies (i.e., 12.2
per 1000 pregnancies) and lower among studies from Europe
(i.e., 3.6 per 1000 pregnancies), North America (i.e.,2.9 per
1000 pregnancies) and Sub-Saharan Africa (i.e., 2.7 per 1000
pregnancies). The prevalence of major placenta previa has
been placed at 4.3 per 1000 pregnancies.31
References
Risk factors for placenta previa include prior cesarean
delivery, pregnancy termination, intrauterine surgery,
smoking, multifetal gestation, increasing parity, and maternal
age. The diagnostic modality of choice for placenta previa is
transvaginal ultrasonography, and women with a complete
placenta previa should be delivered by cesarean. Unlike the
case report presented, small studies suggest that, when the
placenta to cervical os distance is greater than 2 cm, women
may safely have a vaginal delivery.32
4.
In 1980, Wiles commented that SMT is relatively
contraindicated in the third trimester but if performed
judiciously and with precautions, SMT may be performed at
this late stage of pregnancy.33 The author continues with the
admonition that certain absolute contraindications exist during
pregnancy that include excessive vaginal bleeding (at any time
during pregnancy), premature labour, placenta previa, placenta
abruptio, ectopic pregnancy, and ruptured amniotic
membranes without labour. We take issue with this
recommendation by Wiles without supporting evidence.
Borggren34 and Zerdecki35 shares similar sentiments as Wiles.
This case report provides a dissenting view and we
recommend further investigations on the contraindications to
chiropractic care in pregnancy.
7.
In closing, we wish to provide the usual caveats with case
reports. Due to lacking a control group, the effects of
spontaneous remission and natural history, subjective
validation, and expectations for clinical resolution on the part
of the patient, inferences on claims of cause and effect must be
examined with caution with generalizability avoided.
Conversely, case reports describe the clinical encounter from
examination and evaluation, to diagnosis and prognosis, the
intervention and outcome in the care of the patients and as in
the case presented, challenge notions and unsubstantiated
claims about patient care.
1.
2.
3.
5.
6.
8.
9.
10.
11.
12.
Conclusion
This case report provides supporting evidence that women
with breech pregnancies and/or placenta previa may benefit
from chiropractic care. We encourage further research on the
benefits of chiropractic care in this patient population.
13.
Acknowledgement
14.
We are grateful to Annette Osenga and Barbara DelliGatti at
the Life West College library for their assistance with our
literature review.
15.
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Mogos MF, August EM, Salinas-Miranda AA, Sultan
DH, Salihu HM. A systematic review of quality of
life measures in pregnant and postpartum mothers.
Appl Res Qual Life 2013;8(2): 219–250.
Franche RL, Mikail SF. The impact of perinatal loss
on adjustment to subsequent pregnancy. Soc Sci
Med 1999;48(11):1613-23.
Horowitz M. Stress response syndromes. Character
style and dynamic psychotherapy. Arch Gen
Psychiatry 1974;31(6):768-81.
Mason S, Rowlands A. Post-traumatic stress disorder.
J Accid Emerg Med. 1997;14(6):387-91.
Adams J, Lui CW, Sibbrit D, Broom A, Wardle J,
Homer C, Beck S. Women’s use of complementary
and alternative medicine during pregnancy: a critical
review of the literature. Birth 2009;36:3: 237
Wang S, DeZinno P, Fermo L, et al. Complementary
and alterna- tive medicine for low-back pain in
pregnancy: A cross-sectional survey. J Altern
Complement Med 2005;11(3):459–464.
Wade C, Chao M, Kronenberg F, Cushman L,
Kalmuss D. Medical pluralism among American
women: results of a national survey. Journal of
Women’s Health 2008; 17(5):829-840
Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans
MW. Chiropractic care for nonmusculoskeletal
conditions: a systematic review with implications for
whole systems esearch. J Altern Complement Med
2007;13(5):491-512.
Hall HG, Griffiths DL, McKenna LG. Keeping
childbearing safe: midwives’ influence on women’s
use of complementary and alternative medicine. Int J
Nurs Pract 2013;19(4):437-43.
Steel A, Adams J, Sibbritt D, Broom A, Gallois C,
Frawley J. Utilisation of complementary and
alternative medicine (CAM) practitioners within
maternity care provision: results from a nationally
representative cohort study of 1,835 pregnant
women. BMC Pregnancy Childbirth. 2012;12:146.
Adams J, Lui C-W, Sibbritt D, Broom A, Wardle J,
Homer C. Attitudes and referral practices of
maternity care professionals with regard to
complementary and alternative medicine: an
integrative review. J Adv Nurs. 2011;67(3):472-83
Münstedt K, Brenken A, Kalder M. Clinical
indications and perceived effectiveness of
complementary and alternative medicine in
departments of obstetrics in Germany: a
questionnaire study. Eur J Obstet Gynecol Reprod
Biol. 2009;146(1):50-4.
Mullin L, Alcantara J, Barton D, Dever L. Attitudes
and views on chiropractic: a survey of United States
midwives.
Complement
Ther
Clin
Pract.
2011;17(3):135-40
Allaire AD, Moos MK, Wells SR. Complementary
and alternative medicine in pregnancy: a survey of
North Carolina certified nurse-midwives. Obstet
Gynecol 2000;95:19-23
Bayles BP. Herbal and other complementary
medicine use by Texas midwives. J Midwifery
Womens Health 2007;52:473-478.
J. Pediatric, Maternal & Family Health - March 13, 2014 7
16. Chamberlain G, Steer P. ABC of labour care: unusual
presentations and positions and multiple pregnancy.
BMJ. 1999;318(7192):1192-4.
17. Hickok DE, Gordon DC, Milberg JA, Williams MA,
Daling JR. The frequency of breech presentation by
gestational age at birth: a large population-based
study. Am J Obstet Gynecol. 1992; 166:851-52.
18. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED,
Saigai S, Willan AR. Planned caesarian section
versus planned vaginal birth for breech presentation
at term: a randomized multi- centre trial. Lancet
2000;356:1375 – 83.
19. Williams JW, Cunningham FG, eds. Williams
Obstetrics. New York. Appleton & Lange, 1996.
20. Cohain JS. Turning breech babies after 34 weeks: the
if, how, & when of turning breech babies. Midwifery
Today Int Midwife 2007; 83:18-9, 65.
21. Yamamura Y, Ramin KD, Ramin SM. Trial of
vaginal breech delivery: current role. Clin Obstet
Gynecol 2007;50: 526-36.
22. Demol S, Bashiri A, Furman B, Maymon E, ShohamVardi I, Mazor M. Breech presentation is a risk factor
for intrapartum and neonatal death in preterm
delivery. Eur J Obstet Gynecol Reprod Biol. 2000;
93:47-51.
23. Demirci O, Tuğrul AS, Turgut A, Ceylan S, Eren S.
Pregnancy outcomes by mode of delivery among
breech
births.
Arch
Gynecol
Obstet.
2012;285(2):297-303.
24. Anderson FW, Johnson CT. Complementary and
alternative medicine in obstetrics.Int J Gynaecol
Obstet. 2005;91(2):116-24.
25. Barnes PM, Bloom B, Nahin RL. Complementary
and alternative medicine use among adults and
children: United States, 2007. Natl Health Stat Report
2009;12:1-23.
26. Alcantara J, Ohm J, Kunz K, Alcantara JD, Alcantara
J. The characterisation and response to care of
pregnant patients receiving chiropractic care within a
practice-based research network. Chiropr J Aust.
2012;42(2):60-67.
27. Alcantara J, Ohm J, Kunz D. The Webster
Technique: Results from a practice-based research
network study. J Pediatr Matern & Fam Health Chiropr. 2012 Win;2012(1):16-21.
28. Ohm J, Alcantara J. The Webster Technique:
Definition, application and implications. J Pediatr
Matern & Fam Health – Chiropr 2012
Spr;2012(2):49-53.
29. Hofmeyr GJ, Kulier R. Cephalic version by postural
management for breech presentation. Cochrame
Database Syst Rev 2012 Oct 17;10:CD000051.
30. Hofmeyr GJ, Kulier R. Cephalic version by postural
management for breech presentation. Cochrane
Database Syst Rev. 2000;(3):CD000051.
31. Cresswell JA, Ronsmans C, Calvert C, Filippi V.
Prevalence of placenta praevia by world region: a
systematic review and meta-analysis.Trop Med Int
Health. 2013;18(6):712-24.
32. Oyelese Y, Smulian JC. Placenta previa, placenta
accreta, and vasa previa. Obstet Gynecol.
2006;107(4):927-41.
8
J. Pediatric, Maternal & Family Health - March 13, 2014
33. Wiles M. Gynecology and obstetrics in chiropractic.
JCCA: J Can Chiropr Assoc 1980;24(2): 163-166.
34. Borggren CL. Pregnancy and chiropractic: a narrative
review of the literature. J Chiropr Med 2007; 6(2):704.
Placenta Previa
Figures
Figure 1. Anteroposterior postural examination of the patient.
Figure 2. Lateral postural examination of the patient.
Placenta Previa
J. Pediatric, Maternal & Family Health - March 13, 2014 9