The Webster Technique: A Chiropractic Technique
with Obstetric Implications

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

FROM: J Manipulative Physiol Ther 2002 (Jul);   26 (6):   E1—9 ~ FULL TEXT

Pistolese, RA

Richard A. Pistolese, DC, 3201 Ridge Ave, Suite 2, Point Pleasant, NJ 08742-3468


OBJECTIVE:   To survey members of the International Chiropractic Pediatric Association (ICPA); regarding the use of the Webster Technique for managing the musculoskeletal causes of intrauterine constraint, which may necessitate cesarean section.

METHODS:   Surveys were mailed to 1047 US and Canadian members of the ICPA.

RESULTS:   One hundred eighty-seven surveys were returned from 1047 ICPA members, constituting a return rate of 17.86%. Seventy-five responses did not meet the study inclusion criteria and were excluded; 112 surveys (11%) provided the data. Of these 112 surveys, 102 (92%) resulted in resolution of the breech presentation, while 10 (9%) remained unresolved.

CONCLUSION:   The surveyed doctors reported a high rate of success (82%) in relieving the musculoskeletal causes of intrauterine constraint using the Webster Technique. Although the sample size was small, the results suggest that it may be beneficial to perform the Webster Technique in month 8 of pregnancy, when breech presentation is unlikely to spontaneously convert to cephalic presentation and when external cephalic version is not an effective technique. When successful, the Webster Technique avoids the costs and/or risks of external cephalic version, cesarean section, or vaginal trial of breech.In view of these findings, the Webster Technique deserves serious consideration in the health care management of expectant mothers exhibiting adverse fetal presentation.


From the Full-Text Article:

Discussion

The pelvic bowl consists of the two innominate bones, the sacrum and the coccyx, and connective tissues. [66, 67] The sacroiliac joint is described as both diarthrotic and amphiarthrotic [66-68] and moves with rotation around a Y-axis. [69-71] During pregnancy and parturition, the ligaments of the pelvis relax in order to permit a spreading of the bones. [72] Throughout this period the movement of the sacrum is multidirectional for 1 to 3 mm.70 When the sacrum is in a neutral position relative to the right and left innominates, the pelvic bowl has a uniform, symmetrical opening (Fig 1).

Fig. 1. Normal unsubluxated female pelvic bowl. (Model) S to I view. Note symmetry and relative roundness of opening. (Radiograph provided courtesy of Cherie Goble, DC.)

However, when the sacrum is rotated, its position in relationship to the innominates is altered and the normal perimetry of the pelvic bowl is distorted. Due to the unique diarthrotic and amphiarthrotic nature of the sacroiliac joint, as the sacrum rotates the adjacent ilium moves along one axis of motion either posteroinferiorly or anterosuperiorly. [73-75] This movement is denoted by the change in the position of the posterosuperior iliac spine (PSIS).

In addition, the innominates can rotate around a second axis either externally or internally. [74-76] Internal and external rotation of the ilia with respect to the sacrum is characterized by the changed position of the posterosuperior iliac spine either toward or away from the midline.

Figure 1 is a superior to inferior (S to I) radiographic view of a model demonstrating normal pelvic perimetry. Notice the symmetry and relative roundness of the pelvic bowl with respect to the midline. A model was used for the radiography because of the inherent risk associated with the use of radiography during pregnancy. Moreover, radiographs of nonpregnant patients were not used because it is believed that they would not exhibit the 1- to 3-mm multidirectional movement in the sacroiliac joints that occurs in pregnancy and parturition as described by Schafer. [70]

Figure 2 is an S to I radiographic view of a model demonstrating pelvic perimetry when the ilia have rotated posteroinferiorly and anterosuperiorly, as described above.

Fig. 2. PI/anterosuperiorly subluxated female pelvic bowl. (Model) S to I view. Note lack of symmetry and distortion of roundness of opening. Also note difference in space from centerline through pubic symphysis. (Radiograph provided courtesy of Cherie Goble, DC.)

Note the lack of symmetry and distortion of the roundness of the pelvic bowl. Observe also the differences in space from the centerline through the pubic symphysis to each lateral aspect of the pelvic bowl. Figure 3 is an S to I radiographic view of a model demonstrating pelvic perimetry when the ilia have rotated externally and internally, as previously described.

Fig. 3. Ex/In subluxated female pelvic bowl. (Model) S to I view. Note lack of symmetry, and distortion of roundness of the opening. Also note difference in space from centerline through pubic symphysis to right ilium. (Radiograph provided courtesy of Cherie Goble, DC.)

Again, notice the lack of symmetry and distortion of the roundness of the opening. Contrast the difference in space from the centerline through the pubic symphysis to the right ilium as opposed to the left ilium.

There are 3 major ligaments suspending the uterus: the uterosacral, ovarian, and round ligaments. The location of the uterus is dynamically positioned by the stretch of these ligaments.

The uterosacral ligament arises from the posterior wall of the uterus and it inserts on the anterior face of the sacrum at the S2-S3 level. It exerts tension on the cervix in dorsal direction, preventing the body of the uterus from displacing anterior and inferiorly. [63] Uterosacral ligament laxity is almost always associated with uterine prolapse. When the sacrum rotates as described above, it may torque the uterus out of its proper juxtaposition via the change in tension of the uterosacral ligament, resulting in intrauterine constraint.

The low force sacral chiropractic adjustment performed in Step 1 of the Webster Technique is intended to relieve the tension exerted on the uterus due to sacral rotation. Moreover, it is intended to restore the proper perimetry and biomechanics of the pelvic bowl.

The round ligament arises from the fundus of the uterus and proceeds inferolaterally to the labia major, joining up with the inguinal ligament about halfway through its course. [63] The round ligament plays a major role in uterine support as it limits posterior movement of the uterus, thus, maintaining the normal anterior uterine position.

Myofascial trigger points are hyperirritable areas in a muscle or its fascia. The presence of trigger points (myofibrositis) indicates possible nutritional deficiencies to the area resulting from such things as postural and skeletal abnormalities, overloading, fatigue, and/or psychological stress. [77] Myofascial trigger points prevent the full lengthening of a muscle or other fascia and may be latent, eliciting pain only upon palpation. [78] The presence of a myofascial trigger point, as evidenced by a palpable nodule in the area of the round ligament is thought to further torque the uterus out of its proper juxtaposition. This also contributes to the forces of intrauterine constraint.

In the second step of the Webster Technique, the woman's lower abdomen is palpated for nodules, taut bands, edema, adhesions, or tenderness in the area of the round ligament as it passes inferomedially of the anterosuperior iliac spine. Upon location, light effleurage trigger point therapy is performed to release latent or acutely painful muscle nodules. The efficacy of trigger point therapy is well supported by the medical literature and appears in many physical medicine and rehabilitation texts. [77, 79-81] It should be noted that the Webster Technique does not employ the use of cryogenics, electrotherapy, ultrasound, or pharmaceuticals as the effect of these modalities on the developing fetus remains largely undetermined.

Conversely, ECV involves applying pressure to the mother's abdomen in order to turn the fetus in either a forward or a backward somersault to achieve a more vertex presentation. The goal of ECV is to increase the proportion of vertex presentation in fetuses that were formerly in breech position near term. With selective screening, ECV has been reported to be 38.4% to 65% effective. [28, 82-84] External cephalic version before term, at less than 37 weeks, has not been shown to be effective. [83, 85]

The additional use of tocolytic agents during ECV improves the success rate only slightly. [86-88] However, most studies involving tocolysis are not randomized trials, [40] and the benefits of tocolysis remain unproven. [89, 90] Moreover, the safety of tocolytic agents remains controversial at best. [91]

Even with the use of tocolysis, ECV has been associated with abruptio placentae, [84, 92] fetal bradycardia, [88-93] prenatal cranial hemorrhage, [94] umbilical cord prolapse, [33, 95] vaginal bleeding, [84] and even death. [96, 97] While the incidence of serious complication associated with ECV may be low, the potential is present. Currently, the American College of Obstetricians and Gynecologists recommends that ECV only be attempted in settings in which cesarean delivery services are readily available. [90]


Conclusion

The doctors surveyed in this study reported a high rate of success with the Webster Technique (82%). Although the sample size was small, the results suggest that it may be beneficial to perform the Webster Technique in month 8 of pregnancy, when breech presentation is unlikely to spontaneously convert to cephalic presentation31 and when ECV is not effective. [83, 85]

This study has some limitations. The response rate of 17.86% is low, and the 11% response rate is inherently subject to bias. In 59 reported cases, the breech presentation was not confirmed with ultrasound, which introduced the potential for medical misdiagnosis. Furthermore, there was no way to objectively confirm how long after employment of the Webster Technique that the resolution of breech presentation occurred (Question 16). Because this was a retrospective trial, the results are subject to recall bias and, consequently, respondents may have reported more socially desirable results, particularly with respect to selection of cases reported. I attempted to limit self-report bias and recall bias by asking respondents to report the results of all documented cases in which the Webster Technique was used in the previous 6 months, regardless of outcome. However, because I relied on retrospective self-report data, the sample size was small, and there were potential design weaknesses, these results should be tempered with caution. Nonetheless, when successful, the Webster Technique avoids the costs and/or risks of ECV, cesarean section, or vaginal trial of breech. In view of these findings, the Webster Technique deserves serious consideration in the management of expectant mothers exhibiting adverse fetal presentation.

I am not suggesting that chiropractic care is a substitute for prudent, proper obstetric care for the expectant mother. Moreover, not all chiropractors are trained in the performance of the Webster Technique. Currently, the ICPA maintains a database of chiropractors certified in the proper performance of the technique.

The results of this study warrant a larger, more extensive observational study on this promising noninvasive technique. Furthermore, it is suggested that the Webster Technique be further investigated regarding its role in the overall health care of pregnant patients.

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