Understanding pelvic pain in pregnancy

What is symphysis pubis dysfunction (SPD) ?

While a certain amount of pelvic pain is pretty normal in pregnancy (you're growing a human after all!), Symphysis pubis dysfunction (SPD) is a problem with the pelvis that can signal some deeper issues. Your pelvis is mainly formed of two pubic bones that curve around to make a cradle shape. The pubic bones meet at the front of your pelvis, at a firm joint called the 'symphysis pubis'. 

The joint's connection is made strong by a dense network of tough tissues (ligaments). During or after pregnancy, swelling can make the symphysis pubis joint less stable, causing the condition known as SPD.

SPD is just one type of pregnancy-related pelvic pain. Women can also have pain in the joints that connect the spine to the two halves of the pelvis at the back (sacroiliac joints). Together, these conditions are described as pelvic girdle pain (POGP 2018).

A related but uncommon condition is diastasis symphysis pubis (DSP), in which the gap between the pubic bones widens too far (POGP 2015). The average gap between the bones in a non-pregnant woman is between 4mm and 5mm, and during pregnancy it's normal for this gap to widen by 2mm or 3mm. DSP is diagnosed either by presence of severe pain or with an x-ray showing a gap of 10mm or more in the pubic joint (Bermas 2019).

What causes SPD?

Once you're pregnant, your body has to adapt quickly to all the changes that come with a growing baby. Your body produces a hormone called relaxin, which softens your ligaments to help your baby pass through your pelvis. This means that the joints in your pelvis naturally become more flexible.

Usually, your nerves and muscles are able to adapt and compensate for the greater flexibility in your joints. However, if one side of the pelvis moves more than the other when you walk or move your legs, the area around the symphysis pubis can become inflamed.

SPD can be triggered by:

• The joints in your pelvis moving unevenly
• Changes to the way your muscles work to support your pelvic girdle joints
• One pelvic joint not working properly, resulting in pain in the other joints of your pelvis
  (POGP 2015)

In a few women, the position of the baby may cause the pain (POGP 2018).

You're more likely to develop SPD if:

• You had pelvic girdle pain or pelvic joint pain before you became pregnant
• You've had a previous injury to your pelvis
• You had pelvic girdle pain in a previous pregnancy
• You have a high BMI and were overweight before you became pregnant.
• You have hypermobility (movement beyond the normal range of motion) in all your joints
  (POGP 2015)

When does SPD happen?

SPD can occur at any time during your pregnancy or after giving birth vaginally (POGP 2018). Some women notice it for the first time around the middle of their pregnancy, although it’s common later in pregnancy too (Howell 2012, RCOG 2015).

The symptoms may also come on earlier and progress faster, so it’s important to seek help as soon as possible. It can help if you allow the symptoms from one pregnancy to settle before trying to conceive another child.

What are the symptoms of SPD?

Pain in the pubic area and groin are the most common symptoms. But you may also have the following:

• Pain radiating to the back, hips or legs
• Difficulty walking
• A grinding or clicking sensation in your pelvic area
• Pain down the inside of your thighs or between your legs. It can be made worse by parting your legs, walking, getting in and out of the car, going up or down stairs, or moving around in bed
• Pain that’s worse at night and stops you from sleeping well. Getting up to go to the bathroom in the middle of the night can be especially painful
  (Bermas 2019, POGP 2018, POGP 2015)

How is SPD diagnosed?

Early diagnosis is important in helping you to manage the pain, so be sure to talk to your doctor or midwife.

If you’re having any of the symptoms described above, you should be referred to a physiotherapist who can further assess your symptoms, test the stability, movement and pain in your pelvic joints, and come up with a treatment plan. (POGP 2018, Healthline 2018).

Look for a pelvic health physiotherapist with experience treating pregnant and postpartum women.

How is SPD treated?

Like other pelvic girdle pain, the treatment of SPD will include:

• Exercises to strengthen your tummy, back, hips and pelvic floor muscles to improve the stability of your pelvis and back
• Hands-on treatment of your hips, back or pelvis to correct stiffness or imbalance
• Advice on how to make daily activities less painful (see Self-help Tips below) and how to make the birth of your baby easier. Your prenatal caregiver should help you to write a birth plan which takes into account your SPD symptoms. Most women with SPD and other types of pelvic girdle pain can have a normal vaginal birth
• Acupuncture may help, although there's conflicting evidence that shows it works. Make sure your practitioner is trained and experienced in working with women who are pregnant and in the postpartum period
• Osteopathy and chiropractic therapy may help, but again, make sure you see a registered practitioner who is experienced in treating pregnant and postpartum women
• A pelvic support belt, brace or girdle can provide stability and support, and will give quick relief.
  (Bermas 2019, POGP 2018, HealthLink BC 2017, Walters 2018, RCOG 2015)

Self-help tips for SPD

There are some things you can do yourself to reduce pain, such as gentle stretching to ease the strain on your pelvis. The cat/cow yoga pose might give you some relief. Over-the-counter pain medication can also help. Be sure to speak with your prenatal caregiver to find out which ones are safe during pregnancy and postpartum.

Other tips include:

• Avoid moving your legs apart when your back is slumped or you’re lying down. Take care when getting in and out of the car, bed or bath. If you're lying down, pulling your knees up as far as you can stops your pelvis from moving and makes it easier to part your legs. If you’re sitting, try arching your back and sticking your chest out before parting or moving your legs, as this also helps to stop the pelvis from moving
• Avoid pushing through any pain. If something hurts, don't do it, if possible. If the pain is allowed to flare up, it can take a long time to settle down again
• Move little and often. You may not feel the effects of what you’re doing until later in the day or after you’ve gone to bed
• Rest regularly by sitting on an exercise ball, or by getting down on your hands and knees. This takes the weight of the baby off your pelvis and holds it in a stable position
• Avoid pushing or heavy lifting. Pushing grocery carts can often make your pain worse, so shop online or ask someone to shop for you
• When climbing stairs, go up one step at a time. Step up onto one step with your best leg and then bring your other leg to meet it. Repeat with each step. Only use stairs when you have to.
• Avoid swimming breaststroke and take care with other strokes. You may feel swimming is helping your pain while you’re in the water, but it could make you feel worse when you get out.
• When getting dressed, sit down to pull on your pants and underwear. This helps you to avoid standing on one leg, which can make the pain worse.
  (Bermas 2019, POGP 2018, HealthLink BC 2017, Walters 2018, RCOG 2015, HealthLink 2018)

How soon after I've had my baby will I recover from SPD?

Most women find their symptoms improve after their baby is born, although some still have pain afterwards. You may find that you get pain every month just before your period is due. This is caused by hormones which have a similar effect to the pregnancy hormone, relaxin (POGP 2018).

If you’re still having symptoms of SPD, or develop it for the first time, after the birth of your baby, start or continue with physiotherapy and try these self-help tips:

• When feeding your baby, sit in a firm, comfortable chair that supports your back with your feet flat on the floor
• Change diapers on a surface that is at your waist height
• Carry your baby in front of you rather than on one hip
• Lower the side of the crib when placing your baby in and taking them out
• Kneel by the side of the bath instead of leaning over
• When carrying your baby in a car seat, hold it in front of you, not on your hip. Better yet, use a car seat frame stroller if you have one.
  (RCOG 2015, POGP 2018)

You may need extra help with caring for your baby and your own personal needs during this time. It’s important to talk to your partner and family/friends so they can lend a hand (POGP 2018).

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