Pregnancy Advice

Symphysis Pubis Dysfunction (SPD) / Pelvic Girdle Pain (PGP)

Symphysis Pubis Dysfunction (SPD) also known as Pelvic Girdle Pain (PGP) is not 'one of the normal aches and pains of pregnancy' so don't let anyone, including medical professionals, tell you otherwise. SPD is a very painful condition, causing pain in the groin area, hips, coccyx, thighs, lower back and surrounding areas. It is caused during pregnancy by the production in the body of the hormone Relaxin which softens the ligaments in your pelvis in order to make your baby's passage through your pelvis as easy as possible. Although it is unsure why, some women produce too much of this hormone. This causes the ligaments to soften too much which allows for increased movement in the pelvis. This can lead to a great deal of pain and discomfort.

Throughout this article I will refer to this condition as SPD. The term was officially changed to PGP to fit with the European Guidelines but many sufferers feel the term is too generic and doesn't adequately describe the condition or its implications. For that reason I will continue to refer to this condition as SPD throughout this article.

Symptoms

• Pain in the pubic area and groin (the pubis symphysis) is the most common symptom.
• Many women also suffer from lower back pain in the sacroiliac joints, pain in buttock area (posterior pelvic pain), lower abdomen and hip pain. It can also radiate down the inner thigh.
• It is common to feel a grinding or clicking in the pubic area when walking.
• The pain is often made worse by separating your legs, walking, getting in or out of a car, going up or down stairs or moving around in bed.

Diagnosis

Fortunately more GP’s, midwives and obstetricians are recognising and diagnosing SPD. It is usually diagnosed from your own description of your symptoms. They may also exam you to look at the stability, movement and pain in your pelvic area. Many sufferers walk with a characteristic 'waddling' gait which helps aid diagnoses. Once diagnosed you should be immediately referred to a physiotherapist who has experience dealing with SPD.

Some women do find it a struggle to be taken seriously but it is important you persevere. If your GP or midwife is unhelpful ask to see someone else. Take along information on SPD and explain your symptoms in detail. It is vital you get a fast diagnosis so treatment can start as soon as possible.

Treatment

During pregnancy the influence of hormones and the weight of the growing baby pressing down means a ‘cure’ is often not possible, however much can be done to ease the pain. It is important that the first thing that happens is that the alignment of your pelvis is checked and manipulated if necessary. A physiotherapist can do this but make sure it is one with experience of SPD. Exercises can be given to strengthen the muscles around the joints to offer better support. A support belt can help hold the pelvis together and in more extreme cases crutches or even a wheelchair is necessary to limit painful activities.

Painkillers can be prescribed if the pain is bad but they are limited during pregnancy. A GP will find a suitable medication for the particular patient. Other treatments such as TENS and acupuncture have been found to be beneficial.

In the long term, surgery is sometimes offered in extreme cases where the SPD carries on after the pregnancy but this doesn’t always bring a positive outcome and should be discussed at length with health professionals.

There are many things that can be done to help ease the symptoms by the individual. SPD is not a condition that it is recommended you push so it is important sufferers know there limits and get help where necessary. Here are some other suggestions both during pregnancy and once the baby arrives:

• Plan the day to avoid unnecessary trips up/down the stairs. Use a backpack to carry things down in the morning needed for the day.
• Online shopping might be hard work at first but saves so much time and effort in the long run.
• Have a baby changing station upstairs and downstairs to avoid frequent trips up and down stairs with a baby. If possible have a changing area on a higher surface such as a chest of drawers or a table (making sure not to leave the baby unattended) so you don't have to bend or get yourself back up off the floor.
• A cordless phone or extension means you can keep the phone close by.
• Put a note on the front door telling callers to allow you time to get to the door. It saves you rushing to the door and causing extra pain and means you won't miss deliveries when a postman doesn't wait.
• Cleaning can be difficult. Accept offers of help and allow your standards to adapt to your SPD – the house doesn’t need to be spotless!
• A perching stool in the kitchen can make cooking easier.
• Keep snacks and flasks of drinks upstairs to avoid unnecessary trips.
• Try not to sit in one position for too long as this can cause stiffness and discomfort. Take regular short walks (even just round the room).
• Get a seat you are comfortable in and surround it with all the things you need for the day (phone, book, remote control etc).
• Sitting in bed with your legs straight in front of you can put extra pressure on the Symphysis Pubis joint. A chair is better or sit in bed with a pillow under your knees.
• In bed: Get into bed carefully, sit on the edge of the bed and, keeping you knees together, and lay on your side. Then keeping your knees and legs in line roll onto your back/ side. Keep you knees together at all times.
• Tie a dressing gown cord around your legs to help lift your legs and to keep your legs together at night.
• Satin or Silk Pyjamas make turning over in bed easier. If it is too painful to roll over in bed ask your partner to hold your hips together whilst you roll over as it will avoid the joint slipping or grinding.
• A folded towel or cushion between the legs can help make sure the pelvis is properly in line. A V shaped cushion can be used to support your growing bump at the same time. Full body pillows are also available. Get yourself lots of pillows and cushions to help get you comfortable.
• When dressing sit down to avoid standing on one leg. Slip on shoes reduces the amount of bending you have to do.
• Using a shower to wash may be easier to avoid climbing into the bath. A shower seat will make showering easier.
• If you do use the bath, sit on the edge and swing your legs over together if you can, or step over carefully holding onto something to avoid putting weight on one leg. Use your arms to take a lot of your body weight when coming out of the bath. Try to bath when someone else is in the house so you can get help if you find it difficult getting out.
• To get into the car start by sitting on the seat then lift your legs together into the car. A plastic bag on the seat can help you slide round easier (this can also work in bed).
• A wheat bag or hot watch bottle on the groin area can help ease the pain but don't have it too hot or it could be uncomfortable for the baby. Post pregnancy you can have it as hot as you can stand it.
• Your GP might be able to refer you to an Occupational Therapist who can visit the house and provide items which can make life easier for you such as perching stools, bed rails, toilet frames, etc.

Labour

A birth plan can help you during labour. Write one beforehand explaining briefly what SPD is and how it affects you. (i.e. SPD is pain in the joints of the pelvis caused by pregnancy. I cannot lie on my back or walk without crutches). Measure your pain free gap (taken by lying on your back with your knees bent and measuring, at the knees, how far you can open your legs without pain) this distance should not be exceeded during delivery and should be considered particularly during an epidural or instrumental delivery when you may not have control over your legs. Include your wishes for pain relief both during labour and postnatal.

Different positions for labour and internal examinations should be considered to avoid hip abduction (legs opened too far). These include all fours, lying on left side, or kneeling. If stitching is required the midwife may be able to do this without putting legs into stirrups (lithotomy position). If the lithotomy position is used ensure both legs are moved together and are up for as short a time as possible.

Talk it all through with your partner beforehand so he can help remind people of your needs. It is important both you and your birth partner are fully clued up on the positions that are good, and bad, for the SPD. Don't be bullied into changing positions and make sure your birth partner will stand up for you as you may not be in a position to argue.

There is a separate article which goes into far more detail on labour and birth with SPD/PGP available here.

Once Baby is here

A lot of women notice a difference to the symptoms almost straight away but don’t expect miracles. It takes a long time for your body to get back to normal after having a baby and the pregnancy hormones are floating around up to 6 months after baby is born. Carry on the exercises provided by the physiotherapist even if you are feeling better, it might even be worth carrying on with your physiotherapy sessions for a while to make sure you have full strength and support in your core muscles.

It can be tempting when you are feeling better to push yourself and do everything but it is important to take it slow and steady. Start off with short walks pushing the pram or buggy as the pram will offer you some support, similar to crutches, but start of short and slowly increase the length of the walks. Carry on accepting help, every new mum needs help when they have a newborn - don’t feel like you have to be supermum.

There is a common misconception that breastfeeding increases the recovery time for SPD but there is no evidence based research to back this up. Many women find it is a wonderful way to bond with their baby and is a way to be involved even if mobility is restricted. Make sure you let your GP know you are breastfeeding in case you need pain medication but don't worry, there is plenty of medication that is suitable for use whilst breastfeeding.

If you are bottle feeding plan ahead and make up bottle in advance. A night and day feeding system or even just a travel kettle and jug upstairs to heat bottles can reduce night time trips up and down stairs to collect bottles.

Some women find when their periods return the SPD symptoms recur. This is due to the hormonal changes and pain medication and limiting painful activities can help ease this time.

Many women with SPD also experience Post-natal Depression (PND) because of the physical problems suffered postnatal combined with the changes involved with a new baby. Some new mums subconsciously resent the baby for being the cause of the pain and difficulties. Around 1 in 10 women experience PND and women who have had difficult pregnancies or deliveries are more likely to experience it. It is important to seek help early as it is treatable, explain this to your partner and family so they also know what signs to look out for.

If you have had SPD in one pregnancy it is likely, although not inevitable, that it will reoccur in subsequent pregnancies. If left untreated the symptoms can appear earlier and be more painful so it is important to start actively treating SPD from the start with physiotherapy. It is best to leave further pregnancies until your body has recovered and a gap of 2 – 3 years is usually recommended to reduce likelihood of the SPD flaring up again. Remember the decision to have another baby lays with you and your partner, don't let others opinion alter your decision. For the majority of women - the pain and the problems associated with the SPD subside quickly but the joy of having a child remains and makes the experience worth it.

Written by Maddy Dilley

Advice can be found in the Symphysis Pubis Dysfunction / Pelvic Girdle Pain Forums

For further help contact the pelvic partnership at www.pelvicpartnership.org.uk

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