Prenatal and perinatal chiropractic care

Prenatal and perinatal chiropractic care is a specialized field within the chiropractic profession focused on the diagnosis, management, and prevention of neuro-musculoskeletal disorders affecting women during pregnancy and the postpartum period. Its significance stems from the profound physiological and biomechanical changes that occur during gestation. A primary factor is the increased production of the hormone relaxin, which causes systemic ligamentous laxity to facilitate childbirth but can also reduce the stability of the pelvis and other joints, contributing to pain and dysfunction ¹. This hormonal effect, combined with an enlarging uterus, weight gain, and a shifting center of gravity, frequently leads to complaints such as low back pain, pelvic girdle pain, and sacroiliac joint dysfunction. The management of these conditions forms the core of this specialty.

Chiropractic care for this population utilizes manual therapies, including spinal and pelvic adjustments, soft tissue work, and therapeutic exercises, to address biomechanical imbalances, alleviate pain, and improve function. The approach is supported by a growing body of research. A 2014 prospective cohort study by Peterson et al., published in Chiropractic & Manual Therapies, followed 115 pregnant women receiving chiropractic treatment for low back pain and found that a high proportion of patients reported clinically relevant improvement ². Regarding safety, a 2021 systematic review by Weis et al. in the Journal of the Canadian Chiropractic Association, which served as an update to a 2014 review, analyzed available literature on spinal manipulative therapy in pregnant and postpartum populations. The authors found limited evidence of adverse events, concluding that most reported incidents were minor and transient, such as temporary soreness ³. This aligns with the broader acceptance of complementary therapies for pregnancy-related back pain, for which the American College of Obstetricians and Gynecologists (ACOG) suggests that exercises, physical therapy, and other approaches may be helpful ⁴.

This article provides a detailed examination of prenatal and perinatal chiropractic care. It will outline the historical context of this specialty within the chiropractic profession, a history generally chronicled in works like Walter R. Rhodes's The official history of chiropractic in Texas ⁵. The article details the specific diagnostic procedures and treatment modifications employed, such as the use of specialized pillows with abdominal cut-outs or tables with breakaway pieces that allow for comfortable prone positioning ⁶. It also discusses specific methodologies and concepts, such as the Webster Technique, which has been a focus of practitioners like Jeanne Ohm ⁷. The evidence base for the treatment of specific conditions will be analyzed, alongside a review of established safety guidelines, contraindications, and the nature of interprofessional collaboration with obstetricians, midwives, and other healthcare providers involved in perinatal patient management.

Definition and overview

Prenatal and perinatal chiropractic care is a specialized field focused on the diagnosis, treatment, and management of neuro-musculoskeletal conditions in pregnant and postpartum individuals. The scope of care encompasses the entire duration of pregnancy (prenatal) and the period following childbirth, typically the first year (perinatal or postpartum). The practice is grounded in the foundational principles of chiropractic, a profession with a history documented by figures such as D.⁸ D. Palmer ⁸ and historians like Walter R. Rhodes ⁵, but adapted specifically to the anatomical and physiological changes of the childbearing year. The primary objective is to address musculoskeletal complaints and optimize biomechanical function of the spine and pelvis, not to treat obstetric conditions.

The principal goals of this specialized care are the reduction of pregnancy-related pain and the improvement of biomechanical function, particularly within the pelvis. During pregnancy, the body undergoes significant changes driven by hormones and the physical demands of a growing fetus. The hormone relaxin, for instance, is released to prepare the pelvis for childbirth but causes systemic ligamentous laxity ¹. This increased flexibility can lead to instability and misalignment in the sacroiliac joints and lumbar spine, contributing to common conditions such as low back pain, pelvic girdle pain, and sciatica ¹. A 2014 prospective cohort study by Peterson et al. published in Chiropractic & Manual Therapies documented that a high proportion of pregnant patients receiving chiropractic treatment for low back pain reported clinically relevant improvements ². This aligns with recommendations from organizations such as the American College of Obstetricians and Gynecologists (ACOG), which suggest that complementary therapies may be helpful for managing back pain during pregnancy ⁴.

To accommodate the physical changes of a pregnant patient, chiropractors employ specific practice modifications. Standard adjusting techniques, as outlined in historical texts like F. P. DeGiacomo's Textbook of chiropractic technique, are adapted for safety and patient comfort. Common modifications include the use of specialized pregnancy pillows, which have cut-outs for the abdomen and breasts, and chiropractic tables equipped with a breakaway abdominal piece ⁶. These tools allow the patient to lie in a prone (face-down) position without applying pressure to the abdomen, facilitating assessment and treatment of the posterior spinal and pelvic structures ⁶.

The safety of spinal manipulative therapy during pregnancy is a key consideration. A 2021 systematic review by Weis et al. in the Journal of the Canadian Chiropractic Association evaluated the existing literature and found limited evidence of adverse events associated with chiropractic care for pregnant and postpartum populations ³. The review, which served as an update to a 2014 review by Stuber and Wynd, concluded that most reported adverse events were minor and transient, such as temporary muscle soreness ³. Practitioners are trained to avoid contraindicated techniques, such as those that apply direct pressure to the abdomen, and to screen for red flags that would require referral to an obstetrician or other medical specialist. The care is intended to be a supportive component of a patient's broader perinatal healthcare team.

Historical development

The practice of providing chiropractic care to pregnant patients extends back to the profession's origins. From its inception in 1895, chiropractic was presented by its founder, D. D. Palmer, as a health system for the entire family, with an emphasis on restoring nervous system function to benefit overall health ⁸. Early chiropractic literature, such as the historical accounts compiled by David D. Palmer, suggests that practitioners treated a wide range of patient populations, including pregnant women, as part of a general family practice ⁹. In these early decades, care for obstetric patients was not a distinct specialty but was integrated into the broader chiropractic principle of correcting vertebral subluxations to enhance the body's innate healing capabilities ¹⁰. The focus was on maintaining spinal alignment to support the body through the physiological changes of pregnancy, with the belief that this would contribute to a more comfortable gestation and an easier birth process ⁹.

Throughout the mid-20th century, as the chiropractic profession fought for licensure and defined its scope of practice in various states, the care of pregnant patients continued, albeit often without specific codification ⁵¹¹. Regional histories from states like Texas and Wisconsin document the work of chiropractors who served their communities as primary contact health providers, which included managing the musculoskeletal complaints of expectant mothers ⁵¹¹. However, specific techniques tailored exclusively for the pregnant population were not yet widely systematized or taught as a separate curriculum within chiropractic colleges. The approach remained largely based on modifying standard adjusting techniques on a case by case basis.

A significant shift toward formalization and specialization occurred in the latter part of ahe 20th century. Textbooks published in the 1970s and 1980s began to dedicate sections to the topic of obstetric care. F. P. DeGiacomo's 1981 Textbook of chiropractic technique, for instance, was among the publications that started to outline specific patient positioning and adjustment modifications for pregnancy. This period saw the development and adoption of specialized equipment, such as adjusting tables with breakaway abdominal pieces and pregnancy pillows, to allow for safer and more comfortable prone adjustments ⁶. Concurrently, specific techniques began to emerge. The most notable of these is the Webster Technique, a sacral analysis and adjusting protocol developed by Larry Webster, D.C. Its stated goal is to reduce the effects of sacral subluxation and sacroiliac joint dysfunction. This, in turn, is thought to improve neuro-biomechanical function in the pelvis. Proponents and educators, such as Jeanne Ohm, D.C., later advanced the teaching and certification for this technique through postgraduate organizations, solidifying perinatal care as a distinct area of focus within the chiropractic profession ⁷.

Biomechanical and physiological rationale

The rationale for prenatal chiropractic care is founded on the significant biomechanical and physiological adaptations the human body undergoes during pregnancy. A primary driver of these changes is the hormone relaxin, which circulates at elevated levels throughout gestation. Its principal function is to increase the laxity of connective tissues, particularly the ligaments of the pelvic girdle, to facilitate parturition ¹. This systemic ligamentous laxity can, however, lead to hypermobility and mechanical instability in weight-bearing joints, most notably the sacroiliac joints and the pubic symphysis ¹. This inherent instability is often compounded by other pregnancy-related adaptations, including an average weight gain of 11 to 16 kilograms, a progressive anterior shift in the center of gravity, and a compensatory increase in lumbar lordosis. These shifts alter posture and gait, placing additional mechanical stress on the spine and pelvis. Research published in the American Journal of Obstetrics & Gynecology has documented these postural accommodations and their correlation with musculoskeletal discomfort ¹².

Chiropractic intervention is aimed at addressing the resulting joint dysfunction that can arise from these physiological and postural demands. The focus is not on the state of pregnancy itself, but on the management of its musculoskeletal sequelae. Chiropractors assess the spine and pelvis for areas of abnormal or restricted joint motion, muscular imbalance, and nerve irritation. Special attention is given to the sacroiliac joints, which are particularly susceptible to dysfunction due to the effects of relaxin ¹. The work of researchers such as Bernard and Sdr in the Journal of Manipulative and Physiological Therapeutics has explored the complex biomechanics of the sacroiliac joint, providing a basis for understanding how its dysfunction can generate localized and referred pain patterns ¹³. Through the application of specific, modified spinal manipulative therapy, or adjustments, practitioners seek to restore proper motion to hypomobile joints, reduce mechanical strain, and alleviate associated pain.

The application of these principles is supported by clinical research and contextualized by recommendations from medical organizations. A 2014 prospective cohort study published by Peterson et al. in Chiropractic & Manual Therapies investigated outcomes for 115 pregnant patients receiving chiropractic care for low back or pelvic pain. The study found that a high proportion of patients reported clinically relevant improvements on numerical pain scales and disability questionnaires ². Regarding safety, a 2021 systematic review by Weis et al. updated a prior 2014 review and analyzed the available literature on adverse events. The authors concluded that there was limited evidence of such events following spinal manipulation for pregnant and postpartum populations, with the majority of reported events being minor and transient, such as temporary local soreness ³. This aligns with guidance from organizations like the American College of Obstetricians and Gynecologists (ACOG), which suggests that complementary therapies may be a helpful component of managing back pain during pregnancy ⁴.

The Webster technique

The Webster technique is a specific chiropractic sacral analysis and diversified adjustment developed by Larry Webster, D.C., in the latter half of the 20th century. It has become one of the most recognized techniques within the subspecialty of prenatal and perinatal chiropractic care. The International Chiropractic Pediatric Association (ICPA), an organization long promoted by figures such as the late Jeanne Ohm, D.C., defines the technique's purpose as the analysis and correction of sacroiliac (SI) joint dysfunction ⁷. Its application is theoretically grounded in the significant physiological and biomechanical changes a pregnant person's body undergoes. During pregnancy, hormonal changes, including the release of relaxin, lead to increased ligamentous laxity throughout the body, which can make the pelvic girdle and SI joints more susceptible to misalignment and dysfunction ¹.

The Webster analysis is performed with the patient in a prone position, using specialized pillows or chiropractic tables with abdominal cut-outs to ensure comfort and safety ⁶. The practitioner assesses for potential SI joint dysfunction by performing a specific leg-flexion test, checking for asymmetry or resistance in leg movement, which is interpreted as an indicator of sacral subluxation or fixation. The corrective procedure involves two primary steps. First, a gentle, low-force adjustment is applied to the sacrum to restore its normal motion. Second, the practitioner applies a sustained, gentle pressure to a corresponding point on the abdomen, typically targeting the round ligament or associated soft tissues to release tension.

A common misconception is that the Webster technique is an obstetric "breech-turning" technique. Proponents explicitly state that it is not an obstetric procedure and that practitioners do not attempt to physically move the fetus ⁷. Instead, the stated goal is to improve the neuro-biomechanical function of the pelvis. The theoretical mechanism is that by correcting sacral dysfunction and reducing related soft tissue tension, uterine constraint may be lessened. This restoration of pelvic balance may, in turn, provide more room for the fetus to move into an optimal, vertex position for birth ⁷.

The clinical use of the Webster technique has been documented primarily through case reports and series, which form the lower tiers of the evidence hierarchy. For example, a 2012 case report published in the Journal of Manipulative and Physiological Therapeutics described the resolution of chronic sacroiliac joint pain in a pregnant patient following a course of care that included the Webster technique ¹³. A 2019 case series described the outcomes for five pregnant women with musculoskeletal complaints and breech presentations who received chiropractic care that included the Webster technique, resulting in resolution of the breech presentations and reductions in pain. ¹⁴. As with many named techniques in the field, which proliferated during a period of professional development documented in works like Textbook of chiropractic technique, its teaching and certification are standardized through postgraduate education programs.

Evidence and research

The scientific literature on prenatal and perinatal chiropractic care centers primarily on the efficacy of managing common musculoskeletal complaints and the safety of the therapeutic procedures involved. Research has sought to address the prevalent issue of back and pelvic pain during pregnancy, which is often attributed to biomechanical and hormonal changes, such as increased ligamentous laxity caused by the hormone relaxin ¹. The American College of Obstetricians and Gynecologists (ACOG) acknowledges that complementary therapies may be helpful for managing pregnancy-related back pain, placing chiropractic care within a broader context of nonpharmacologic pain management strategies ⁴.

In terms of efficacy, a significant prospective cohort study published in 2014 by Peterson et al. in Chiropractic & Manual Therapies investigated outcomes for pregnant patients seeking chiropractic care for low back pain ². The study found that a high proportion of these patients, 85% at the end of care, reported clinically relevant improvement in their pain levels. It is a feature of this study's design that it was a prospective cohort study observing outcomes within a chiropractic setting, not a randomized controlled trial comparing chiropractic treatment to standard obstetric care alone ². Other research includes a 2012 case report in the Journal of Pediatric, Maternal & Family Health by Jeanne Ohm, which discussed chiropractic care during a breech presentation ⁷. Case reports published in the Journal of Manipulative and Physiological Therapeutics have also described positive outcomes, including the resolution of sacroiliac joint pain and dysfunction in pregnant patients ¹³¹⁴.

The safety of spinal manipulative therapy (SMT) for pregnant and postpartum populations has been evaluated in systematic reviews. A 2021 systematic review by Weis et al., published in the Journal of the Canadian Chiropractic Association, provided an update to a previous 2014 review on the topic ³. This review analyzed the available literature, which included case reports and other observational studies ¹³¹²¹⁴, to assess the risk of adverse events associated with SMT during this period. The authors found that the evidence for adverse events following SMT in pregnant or postpartum patients was limited ³. The majority of adverse events that were reported in the literature were characterized as minor and transient, such as temporary muscle soreness. This low risk profile is supported by the standard clinical application of modified adjusting procedures for pregnant patients. These modifications include the use of specialized pregnancy pillows with abdominal and breast cut-outs or chiropractic tables designed with a breakaway abdominal piece, both of which allow the patient to lie in a comfortable prone position without applying pressure to the abdomen ⁶. These adaptations are considered standard practice and are taught in postgraduate programs and texts on chiropractic technique.

Clinical applications and practice

The clinical application of prenatal chiropractic care primarily addresses the common biomechanical complaints that arise during pregnancy. Low back pain (LBP) and pelvic girdle pain (PGP), including sacroiliac joint pain, are the most frequent reasons for pregnant patients to seek chiropractic services. The physiological basis for these conditions is partly attributed to the endocrine system; the hormone relaxin, which increases significantly during gestation to prepare the pelvis for childbirth, results in systemic ligamentous laxity ¹. This increased flexibility can lead to joint instability, particularly in the weight-bearing joints of the pelvis and lumbar spine, predisposing the patient to pain and dysfunction. The American College of Obstetricians and Gynecologists (ACOG) acknowledges that non-pharmacologic interventions such as physical therapy and complementary therapies may be beneficial for managing pregnancy-related back pain ⁴.

Evidence guiding the use of chiropractic care for these conditions includes a 2014 prospective cohort study by Peterson et al. published in Chiropractic & Manual Therapies. The study followed pregnant patients with LBP and found that a high proportion reported clinically significant improvement following a course of chiropractic treatment ². While this was not a randomized controlled trial comparing the intervention to standard obstetric care alone, its findings support the application of chiropractic methods for this population. Research by Bernard and Sadr in the Journal of Manipulative and Physiological Therapeutics has also explored the biomechanical changes in the pelvis during pregnancy, providing a rationale for manual assessment and treatment of sacroiliac and pubic symphysis dysfunction ¹³.

The process of care begins with a thorough patient assessment. This includes a detailed history covering the current pregnancy, previous pregnancies, and any pre-existing health conditions. The physical examination is modified to ensure patient safety and comfort. Orthopedic and neurological tests are performed with the patient in seated or side-lying positions to avoid compression of the vena cava, which can occur in the supine position. The chiropractic examination focuses on static and motion palpation of the spine and pelvis to identify areas of segmental joint dysfunction.

Treatment planning is individualized based on the assessment findings. The plan outlines the recommended frequency of visits and the specific techniques to be used. Adjusting techniques are modified from standard procedures to accommodate the patient's changing body. In addition to specialized tables and pillows, chiropractors use low-force and low-amplitude thrusts. Side-posture adjustments are commonly employed for the lumbar spine and pelvis. Specific protocols, such as those promoted by practitioners like Jeanne Ohm, focus on establishing pelvic balance through targeted analysis and adjustments of the sacrum and surrounding soft tissues ⁷. Consistent communication with the patient’s obstetrician or midwife is a standard component of co-managing the patient's musculoskeletal health throughout the pregnancy.

Significance and professional context

Prenatal chiropractic care operates as a complementary healthcare modality focused on the diagnosis and management of musculoskeletal conditions that commonly arise during pregnancy. The physiological changes of gestation, particularly the release of the hormone relaxin, lead to increased ligamentous laxity throughout the body ¹. This laxity, while necessary for childbirth, can contribute to biomechanical stress, pelvic instability, and pain in the low back and sacroiliac joints, conditions reported by a significant percentage of pregnant individuals. Chiropractic care aims to address these neuromuscular complaints through manual therapies, positioning it as a supportive service alongside standard obstetric management.

The relationship between chiropractic and conventional obstetric care is characterized by a growing trend toward integration and collaborative management. Leading medical organizations now recognize the burden of musculoskeletal pain in pregnancy and the value of non-pharmacological interventions. The American College of Obstetricians and Gynecologists (ACOG), for example, includes complementary therapies in its suggestions for managing back pain, alongside physical therapy and exercise ⁴. This creates a framework for interprofessional collaboration where chiropractors communicate with a patient's primary obstetric provider to ensure coordinated and safe care. This modern, integrated approach contrasts with the historical division between chiropractic and allopathic medicine, a separation detailed in historical accounts such as Walter R. Rhodes's The official history of chiropractic in Texas ⁵.

The evidence supporting the use of chiropractic care during pregnancy is based primarily on observational studies and systematic reviews of safety. A 2014 prospective cohort study by Peterson et al. in Chiropractic & Manual Therapies found that a high proportion of pregnant patients with low back pain reported clinically relevant improvement with a course of chiropractic treatment ². It is important to contextualize this finding by noting the study's design was not a randomized controlled trial and lacked a non-chiropractic control group, thus precluding definitive conclusions on efficacy compared to other treatments or no treatment ². Regarding safety, a 2021 systematic review by Weis et al. provided an update to a 2014 review by Stuber and Wynd, concluding that there is limited evidence of serious adverse events following spinal manipulative therapy in pregnant populations ³. The majority of reported events were minor and self-limiting, such as temporary localized soreness ³. Other case series and cohort studies have also indicated a favorable safety profile ¹³, ¹⁴.

Despite positive patient-reported outcomes and a good safety profile, a significant limitation is the absence of large-scale randomized controlled trials to firmly establish clinical efficacy. The profession has addressed the specific needs of this population through increased specialization. While the practice's origins, documented in texts like D. D. Palmer's The Chiropractor, were built on a general theory of health ⁸, contemporary chiropractic includes postgraduate certifications in areas like pediatrics and perinatal care. This advanced training provides clinicians with expertise in modified adjusting techniques, such as the use of specialized tables and pillows, and specific assessment protocols to accommodate the anatomical and physiological changes of pregnancy ⁶. The primary significance of this specialized care lies in its role in managing symptoms to improve patient comfort and physical function during a period of profound bodily change.

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