Symphysis Pubis Dysfunction and Pregnancy

What are the signs & symptoms of Symphysis Pubis Dysfunction?

Symphysis Pubis Dysfunction (SPD) is described as a discomfort in the pelvic area that most commonly occurs during pregnancy. It is also commonly referred to as ‘pubic symphysis dysfunction’ or ‘pelvic girdle pain’. Symphysis Pubis Dysfunction occurs when the ligaments that keep your pelvis aligned become too relaxed as a result of the hormone ‘relaxin’. This hormone is vital in the lead up to childbirth, it allows increased joint mobility, allowing the pelvis to loosen up so that the child can pass through the birthing canal during labour. This loosening also means that joints can become more unbalanced and mobile than they usually would be, leading to pain and discomfort.

Typically, the majority of the pain experienced during SPD is in the central pubic area but it can radiate to the upper thighs and perineum (area between the anus and vulva) and across 1 or both sides of your back. It is often described as an ache but can also be a sharp shooting or stabbing pain or a deep muscle pain. The pain tends to worsen with walking and doing one-legged weight-bearing activities such as getting dressed, turning over in bed and getting in and out of a car and is usually relieved by rest.

Symphysis Pubis Dysfunction is most often seen in pregnancy, mostly in the second and third trimester and is diagnosed in 1 in every 300 pregnancies (Owens, Pearson and Mason, 2002). It can happen for no apparent reason during pregnancy although it is linked to previous pelvic damage, weight and position of the baby, previous history of SPD in prior pregnancies, being overweight and having a physically demanding job.

However it can also occur as a result of diastasis recti ( this is the separation of the rectus abdominis muscle), previous surgery or fracture of the pelvis, after an injury with legs in hyper-abduction (seen in gymnastics and horse-riding) and following a prostatectomy.

Symphysis Pubis Dysfunction is normally diagnosed through a thorough case history and physical examination. An early diagnosis is important to reduce any longer-term problems and allow as much intervention to occur in the early stages.

Although it’s diagnosed symptomatically, the only way to confirm diastasis and separation of the pubic bones is via MRI or X-Ray. This isn’t often done unless symptoms continue postpartum due to risk of ionising radiation on the baby.

In the interim, ultrasonography can be safely used to measure the distance between the bones using electronic callipers. In most women this is 4-5mm. This increases 2-3mm in the final trimester, however this is often increased in those with SPD. A gap of 10mm or more indicates diastasis of the symphysis pubis (or symphyseal separation), which tends to cause more serious pain and needs to be taken into consideration when creating a birthing plan.

With treatment, symptoms can be managed however most have to adjust their activities for the remainder of the pregnancy in order to avoid any pain-provoking movements.

For most, pain relieves within 2-6 weeks after childbirth due to the decrease in the hormone relaxin production and the reduction in pressure on the pelvis. If pain persists at your 6 week check-up, speak to your GP.

The earlier a diagnosis can be made, the better. This will allow you to keep pain to a minimum and avoid longer-term discomfort. It is recommended to seek help from your GP or physical therapist for SPD if it occurs.

Self-care

• You can apply a heating pad or ice pack to the area. Don’t leave this on for longer than 7 minutes at a time. You can safely cycle the pack on/off for every 10 minutes.
• Avoid triggers: sit down to get dressed, avoid heavy lifting and pushing
• Be as active as possible (within your limits!). It’s important to avoid sitting or standing for long periods of time. Many find swimming comfortable as it is a non weight bearing exercise. Sometimes breaststroke can be aggravating so be careful about which strokes you chose to do.
• Some may find it useful to place a band around your legs slightly less than what normally brings on the pain to avoid moving into the painful ranges.
• Wear flat, supportive footwear.
• Avoid crossing your legs.
• Try and get help with household chores and shopping from your partner, family or friends.
• When turning in bed, try keeping your knees together while squeezing your buttocks. You may find it useful to have a small pillow between your legs.
  (Pelvic pain in pregnancy, 2021)

Manual Therapy
A manual therapist such as a physiotherapist or osteopath will take a full case history and conduct a thorough examination in order to exclude any other issues. Once a diagnosis of SPD is made, treatment will be tailored to you. It tends to consist of manual therapy to ensure that the pelvis, hip and spine are moving as efficiently as they can and any compensatory mechanisms are addressed. It is important to stabilise the pelvis as much as possible, so for this you will often be given exercises to strengthen your pelvic floor, back and hip muscles.

Appropriate exercise
As with self care, it is important to keep moving, however this needs to be done in your pain-free movement. An osteopath or physiotherapist will often prescribe exercises that can help. In addition to this, you may find Clinical Pilates can be beneficial in assisting with SPD. Some of the Osteopaths and Physiotherapists at bodytonic clinic are also trained in this and can advise you whether they feel Clinical Pilates may be of benefit for you.

Medication
Pain medication can be taken to help with the discomfort you are receiving, however it is best to speak to your GP or local pharmacist about this.

Alternative Therapies

• Although not proven to be effective, many find some relief with:
• TENS machines
• Acupuncture
• Meditation
• Complementary therapies such as massage and reflexology

Walking Aids and Support Bands
In more severe cases, it may be necessary to use crutches or a pelvic support belt to assist with easing your symptoms.

It is important to speak to your midwife about your diagnosis of SPD. It should be established what distance between your legs is your pain-free range of movement. During child-birth it is suggested that you shouldn’t exceed this distance and use of stirrups and forceps should be avoided as they can strain the ligaments further. It is also recommended that those with SPD give birth in an upright position (kneeling, on all fours or standing) or consider a water birth (Jain, Eedarapalli, Jamjute and Sawdy, 2006).

There is no definitive way to prevent SPD from occuring during pregnancy. It is possible to minimise the risk by maintaining a moderate body weight and seeing an experienced therapist to ensure that your body is best adapted to the physical stresses of pregnancy.

Kegels

• Squeeze your pelvic muscles up and in, hold for 10 seconds then relax completely before repeating this 10 times.
• Think about tightening the pelvic muscles as if you were trying to stop urinating.
• Do not hold your breath or tighten the abdominals, buttocks or thigh muscles; only the pelvic floor should be recruited.

Pelvic Tilt

• Lie on your back with your knees bent,
• Imagine pulling your belly button inward and activate your pelvic floor muscles slightly.
• Tilt your pelvis by flattening your back to the ground whilst breathing normally.
• Return to the initial position.
• Tilt your pelvis in the opposite direction by slightly arching your back.
• Return to neutral and repeat 10 times.
• Make sure you return to neutral between repetitions to keep the movements separate.

Overhead Reach

• Lie on your back with your knees bent, legs hip width apart, neck long, and shoulders drawn down away from your ears.
• Float your arms above your head, with your palms facing away from you, while exhaling
• Inhale and hold
• Exhale and lower both arms overhead, keeping the rib cage soft (if you feel the ribcage starting to lift then don’t progress further).
• Circle your arms out and down while inhaling to finish with your hands over your shoulders. As if you are drawing a capital ‘D’.
• Repeat this for 1 minute in a controlled manner.

Exercise has a positive effect if it is done correctly. Exercising incorrectly can also cause or worsen SPD or further injury, so make sure you have great technique and if needed gain advice from a personal trainer, 1-2-1 Pilates teacher or a physical therapist such as an osteopath or physiotherapist.

It is useful for your GP and midwife to be aware of a diagnosis in SPD due to the implications in your birthing plan.

SPD itself is not a medical emergency however, if you experience any pain while urinating, pins and needles/numbness in your legs speak to your GP or midwife. If you experience vaginal bleeding, fever, severe stomach or low back pain or any swelling in your legs call your midwife, GP or hospital immediately.

• Jain, S., Eedarapalli, P., Jamjute, P. and Sawdy, R., 2006. Symphysis pubis dysfunction: a practical approach to management. The Obstetrician & Gynaecologist, 8(3), pp.153-158.
• Owens, K., Pearson, A. and Mason, G., 2002. Symphysis pubis dysfunction—a cause of significant obstetric morbidity. European Journal of Obstetrics & Gynecology and Reproductive Biology, 105(2), pp.143-146.
• NHS Website