Published in Canadian Chiropractor Magazine in April 2020 by Dr. Erik Klein and Dr. Sarah Mickeler of Westendmamas
CHIROPRACTIC and PHYSIOTHERAPY DURING PREGNANCY: THE BASICS OF INTERPROFESSIONAL COLLABORATION.
The beauty of being a chiropractor that works with pregnant patients is that your patient likely has more medical support for this 9 months of her life, than they’ve had on any other occasion. Treating a pregnant patient is an incredible opportunity to not only give the patient top-notch care via interprofessional collaboration with their primary CARE and allied health team, but it’s also a fabulous opportunity for you to establish alliances with that team, if you haven’t already.
WHO ARE THE KEY PLAYERS DURING PREGNANCY?
- Family Physicians (many of them still have delivery rights at hospitals)
- Pelvic Floor Physiotherapists
- Massage Therapists
- Lactation consultants (in the immediate postpartum)
PRIMARY CARE RELATIONSHIPS FOR THE PATIENT
In most provinces in Canada, your patient has a choice of primary care provider (PCP): they may choose a midwife for an uncomplicated pregnancy, or they may opt for an Obstetrician, or, less commonly, their Family Doctor may care for them and deliver their baby. All three routes are covered by our tax dollars. Midwifery services sit outside the usual provincial healthcare coffers, and for this reason, newcomers to Canada, including undocumented immigrants, qualify for midwifery care for free. In Canada in 2017, 10.8% of all births were midwife-led births.
Your patient will see their PCP, on average, once a month during their first and second trimester (up until week 27) on average bi-weekly from weeks 28-36 and usually weekly from weeks 36-40 or 41. That’s roughly 14 visits; more if the patient is a high-risk patient, or if any issues are identified during their pregnancy.
ALLIED CARE RELATIONSHIPS FOR THE PATIENT
In addition to choosing your exceptional chiropractic care, your patient may want or require the services of other allied health professionals (AHP). Each of these professionals is valuable in the lifecycle of your pregnant patient, and while most patients will not require the services of ALL of these professionals, it’s worth knowing what they do. In addition, it’s important to know who does what so that when you go to build relationships with them, you can be well-educated on their scope of practice, and what would be a great referral for them.
If you approach your potential interprofessional collaborator with an attitude of “how can I help you” you will almost always be very well received. Just as we don’t naturally graduate with a full contact list of people to refer our patients to, neither do other AHPs. We are all looking for the best people on our team to help our patients feel their best. By putting the patient first, you will be able to sleep at night, and I can just about guarantee that the patient will refer back to you because of your integrity, and it’s likely that whoever you referred the patient to will, also.
Some readers may be nervous to make these referrals, for fear of “losing the patient”. However, when it’s done right, you will keep the patient, if they need to continue seeing you, and you will likely IMPROVE your relationship with the patient, increasing their trust in you. Put the patient first.
WHO TREATS WHAT?
For the purposes of this article, we will stick to the top 4 services, other than chiropractic, that a pregnant (or immediately postpartum) person may be interested in accessing. Many of us will have access to licensed practitioners in all of these designations in either our own city or in neighbouring ones, but if you don’t, that’s ok. Just do the best job you can with the tools you have.
- Pelvic Floor Physio
- Urinary incontinence and dyspareunia at any time in the patient’s life – during pregnancy, 6 weeks after having a baby, 20 years after having the baby, etc.
- Please remember that any amount of urinary incontinence, even a single drop, is not normal. Common, yes. Normal, no. Any amount of reported incontinence should automatically trigger a referral to a Pelvic Floor Physiotherapist.
- Hip pain
- Pelvic girdle pain
- Labour prep for a vaginal birth
- Many, many other issues
- MASSAGE THERAPIST
- General aches and pains
- Edema/lymphatic drainage
- May do infant massage once the baby is born
- Potentially breast massage postpartum to help with engorgement
- Morning sickness
- Sleep issues
- Cervical ripening, to encourage a more efficient birth
- Natural induction
- Milk supply issues postpartum
- Latch issues
- Blocked ducts, mastitis (mastitis should also be an immediate referral to the doctor as it will require antibiotics)
- Assessments for tongue tie
- Milk supply issues
- Pain with breastfeeding
HOW TO BUILD THOSE RELATIONSHIPS
Now that you know who else your patients may want or need to see during their pregnancies, it’s time to build those relationships. The easiest way to do this is to simply send a clinic note to their PCP and AHPs after their first visit. Make sure to get the written consent of your patient before doing so. If you integrate the consent to share health information with other health care providers into your intake form, simply get their verbal consent to do so.
Make the note short but sweet; get to the point. Lay out who the patient is, when they came in and why, what you found (don’t bore them with the names of orthopedic tests; they don’t know or understand what they are for), what you are planning to do about it, and how you expect the patient to do. Let them know that you love working with pregnant patients (if you do!) and that you would love to work together again soon.
If you have a referral pad, send one. Send some literature about your office (if it’s pregnancy-specific literature, that is). Send that note out within one week of the patient’s first visit.
The note should, at the very least, go to your patient’s PCP. Most PCPs don’t have a built-in network of alternative care providers that they already work with, so you sending a note to them will let them know that you do this work, and they will likely remember your name because you took the time to send them a well-written, logical, patient-centered note. In addition, it opens the lines of communication between you and them. It will help the patient, because when the patient says “I’ve been seeing my chiropractor for x-y-z” the PCP will be able to say “oh yes, I got their note. They seem to know what they’re doing. Is that going well for you?”. This is good for everyone – you and the patient.
The same goes for any AHPs that you may send the note to. If, for example, the patient is seeing a pelvic floor physio (or any other allied health professional), send them a note, with the patient’s consent. Let them know what you’re doing and that you’re open to chatting with them if they feel the need to do so. Remember that our services are complementary – seeing one practitioner does not negate the need to see another. The patient can see a pelvic floor physio for their pelvic girdle pain, and ALSO see a chiropractor. Well all do slightly different things, and we all have value for the patient. By framing it as “I want to help my patient feel their very best” you can’t lose.
WHAT IF YOUR PATIENT ISN’T SEEING OTHER HEALTH CARE PROVIDERS?
If your patient isn’t already under the care of an AHP, you have an opportunity to build community relationships so that you have an adequate referral network for those patients that require referrals. Google “pelvic floor physios near me” or “pregnancy massage near me” or whatnot, and figure out who is doing that work. Give them a call and ask if they would be open to meeting. When you meet them, let them know that you work with pregnant patients and that you would like to get to know what kind of work they do so that you can refer to them when the time comes. Like everyone else, they likely don’t have a large network of people to refer to, and they will remember you when their patient says that they have a complaint. This is good for you, them, and the patient.
If you would like to work with more midwives, go meet them! Set up a meeting, ask if they would allow you to come chat about what you do during their practice meetings, and go put your face in front of them. Sponsor an ice cream social (or something similar) in your office for local health professionals to come by and get to know you and your clinic. If they know who you are and what you do, they are more likely to refer to you to help their client feel their best.
PUT THE PATIENT FIRST
No matter what, remember to put the patient first. No one person can be everything to everyone. Many chiropractors are exceptionally skilled, but you will be hard-pressed to help a patient with their baby’s latching issues, pelvic floor issues, or to help with a natural induction. If you do not feel comfortable treating pregnant people because you do not have enough experience with them, either take advanced evidence-based training for working with pregnant patients, and/or seek out the chiropractors in your network that are comfortable working with them. Interprofessional collaboration is so important during a patient’s pregnancy – by putting the patient first, you will be able to comfortably make the referrals that will help the patient feel their very best during and after their pregnancy.
The original published article can be found here –> Canadian Chiropractor