Pelvic Girdle Pain (formerly called SPD)

What is it?

Pelvic Girdle Pain (PGP) is a general term to describe any pain in the pelvic area related to pregnancy and birth. It was previously known as Symphysis Pubis Dysfunction (SPD) because it was thought to be the result of looseness in the pubic symphysis (pubic joint), caused by the hormones which soften and relax the body’s connective tissue during pregnancy. However, most PGP is now recognised to be caused by an existing asymmetry or difference in movement in and around the pelvic joints, which includes the hips. This imbalance is then aggravated by those normal hormonal changes, creating muscle tensions and pressure on surrounding nerves. (See ‘causes’, below)

Where do you feel it?

Sharp pain, varying in severity, can be felt low down in the front or back of the pelvis, (sacroiliac joints), running down the inner thighs and/or in the lower back, or hips, and sometimes spreading to other areas of the body. It is not to be confused with ‘stitching pains’ above the pubic bone in the lower belly. A clicking or grinding sensation might be heard or felt.

Picture from obtained from here

When do you feel it?

Discomfort can start early in pregnancy as soon as the hormones kick in, or develop later as the increased weight of the baby puts extra strain on the pelvis. It can also occur during birth, or more rarely after the birth of your baby. It can be worse in subsequent pregnancies if it is not recognised and well managed and treated from the start. Pain is commonly felt when turning over in bed, walking up the stairs or standing on one leg. During a day with lots of walking or standing, swimming, driving or shopping, characteristically the pain may not always be felt during the activity, but often builds up as the day goes on.

What are the Causes?

The pain may be related to an underlying problem that has not previously caused pain, or may start after an (often minor) injury during pregnancy or birth. There are many factors which can make it more troublesome including weak ‘core stability’ and pelvic floor muscles, previous injuries, spinal problems, muscle tensions or other structural imbalances. Such underlying conditions, combined with the increasing weight of the growing baby, and softening ligaments, affect the normal transference of weight and movement through the pelvis and hips. The resulting extra stress on the muscles, joints and ligaments, causes pain and stiffness as described above.

Very rarely a more acute and specific form of pelvic pain can develop, known as Diastasis of the Symphysis Pubis (DSP). This is diagnosed by an x-ray which shows up excessive movement, (separation or shearing of more than 1 cm), at the pubic joint.

Care during Pregnancy

As soon as you suspect PGP, go and see your GP OR midwife and insist on a referral to a physiotherapist with experience and training in manually treating PGP this may be an obstetric or other musculoskeletal physiotherapist. NHS waits are long so don’t take “no” for an answer. Don’t be fobbed off by seeing a doctor, or by being told that its just one of those aches and pains of pregnancy. At the very least request a pelvic support belt. If you do not see a physiotherapist within 2 weeks then don’t waste any more time – seek support from the www.pelvicpartnership.org and visit a manual therapist. This may be a private physiotherapist, cranial osteopath or a chiropractor who specialises in pregnancy . S/he will be able to diagnose the condition and, if your pelvis is out of alignment, can help to re-balance it. Most women find this reduces the pain enormously. Many women also find that acupuncture brings relief, as it can relieve pain, but it does not help with joint alignment, so this should be checked first.

If you suffer from severe PGP or DSP, you may also need crutches or possibly a wheelchair and you may be entitled to a disabled parking permit (blue badge), available through the DSS, until you have recovered. If you have had the pain for more than 3 months and expect it to last more than another 6 months, you may also be entitled to Disability Living Allowance. In the meantime follow the list of do’s and don’ts below and pin it to your kitchen wall as a reminder! They are not a definitive list, and may not all apply to you, so try them and use the things that help.

How You can Help Yourself

These basic self-care steps will usually stop the pain from worsening and sometimes stop it altogether: -

• IF SOMETHING HURTS, AVOID DOING IT as it is likely to be aggravating your condition, even if you have been told to do it (e.g. some exercises)

• ASK FOR HELP AS SOON AS YOU DEVELOP PAIN AND FIND A GOOD MANUAL THERAPIST.

• SLEEP WITH A PILLOW OR CUSHION BETWEEN YOUR KNEES

• KEEPYOUR KNEES TOGETHER WHEN ROLLING OVER IN BED

• CLIMB IN AND OUT OF THE CAR AND BED KEEPING YOUR KNEES TOGETHER. You can use a plastic bag on the seat to help you swivel (remove before driving!)

• NO LIFTING IF POSSIBLE - ( teach your toddler to climb in and out of the car, delegate all decorating, shopping and household re-organisation).

• SWIM ON YOUR BACK OR SWIM CRAWL, as wide leg kicks will aggravate the condition.

• TAKE REGULAR REST PERIODS

• AVOID SITTING ON HARD CHAIRS - Take a cushion with you if necessary.

• USE YOUR BIRTH BALL TO SIT ON!

• DO PELVIC FLOOR EXERCISES –minimum 50 a day

• SIT DOWN TO TO GET DRESSED AND TO PUT YOUR KNICKERS AND TROUSERS ON

• TRY TO REDUCE THE NUMBER OF TIMES YOU HAVE TO GO UP AND DOWN STAIRS by planning your day and bringing things down in the morning.

• MEASURE YOUR PAIN FREE GAP BEFORE YOU GO INTO LABOUR AND WRITE IT IN YOUR NOTES.

Yoga and YogaBirth – (Keep your YogaBirth Teacher informed!)

YogaBirth classes combined with modified yoga practice at home can be very beneficial for sufferers of pelvic pain. Combined with yoga breathing exercises it can help in releasing tension, relaxing and structural rebalancing. As soon as your YogaBirth teacher is aware of your condition she will indicate which postures should be avoided and which may be helpful, with appropriate modifications. Generally, you must take care moving in and out of postures and avoid those which are asymmetrical, standing on one leg, wide open or cross-legged. Use the birth ball in class to lean over, sit on or use as a prop for modified Yoga postures. ‘Angry cat’ and pelvic floor exercises practiced every day will strengthen the muscular support around your pelvis.

During the Labour and Birth - (Make sure your birth partner reads this!)

A big statement at the top of your notes and birth plan will let all attendants know you have PGP; make sure doctors and midwives on a new shift read it. Any position which you can get into before you go into labour is likely to be comfortable during labour. You still need to make sure you don’t open your legs too wide. Ensure your knees do not separate more than your “pain-free gap”. This is important especially if you have an epidural as you will have no feeling in your lower half, and the knees can fall open, further damaging the connective tissue. The same applies during vaginal examinations and stitching. Stirrups should be avoided.

The birthing pool is a very good option with PGP (get in by having a stool at the right height next to the pool, and asking your partner to help you swing your legs in, then slide gracefully in – reverse the process to get out). Kneeling, standing and resting in the birth pool are good for first stage. You can also deliver your baby in the pool which allows you excellent movement and pain relief. Positions that may help for delivery out of the pool are all fours because you open your pelvis from behind without separating your legs in the front, or side lying if all fours is not possible.

Post-Natal Recovery

Many women find that the pain and discomfort felt during pregnancy soon go after the birth. However it is important that the first few days and weeks are spent resting as much as possible; still no weight bearing or long strident walks. It is advisable to see your manual therapist as soon as you can after birth to make sure that your pelvic joints are aligned to speed up your recovery. Then start doing appropriate gentle exercise to strengthen your core abdominal and pelvic floor muscles

For a small minority of women the birth worsens the condition, and absolute rest is necessary. Again, manual therapy can help to relieve the pain. For acute pain, do not walk after the birth - ask for a wheelchair. Request help from your midwife, health visitor or social services, especially if you have other children to care for.

For some women the odd niggle will remain when your period is due. If this happens, get your joints rechecked as there may still be some alignment problems which are very treatable.

Breastfeeding will have no impact on the speed at which you recover and many women breastfeed for prolonged periods and make a full recovery while feeding.

Post-natal classes run by YogaBirth teachers include exercises that will help bring everything back into alignment and strengthen the muscular pelvic support. You can also correct poor postural habits, which might have worsened the condition. Alternatively find a Body Control Pilates teacher who understands the problem.

Find your local teacher