Pelvic girdle instability (pain) and Symphysis pubis instability (pain)
You might also be interested in Frequently asked questions about massage and pregnancy which has some practical tips. Shiatsu and massage can help support you if you have pelvic girdle instability. As pelvic girdle instability expresses itself differently for different women your therapist can support you to work out the best approach for you. Pelvic girdle instability may start in the first trimester of pregnancy (when already the tissue starts to soften) or it may not express itself till after birth (if the birth has involved straining the pelvis).
There are many scare stories and myths which exist. Some pregnant women are told that they have to stop doing everything, that they are likely to end up on crutches and may need a Caesarean birth as they will be in so much pain. In my experience, if the condition is evaluated early on, and women follow correct movements and get the correct support, then the symptoms may actually disappear even as the pregnancy progresses. They often can have easy natural vaginal births, if they know what positions to use and are well supported. If a woman ends up on crutches, I see that as a failure of care! Postnatally it may immediately improve, but in other cases it may take some time to disappear.
One key aspect of support with massage and shiatsu is the emotional component of care and relaxation and the whole body/mind approach. Shiatsu uses the meridians and points of Chinese medicine and the Girdle Vessel is a great meridian to support the pelvis but also to integrate an awareness of the whole body.
Testimonial: Shiatsu helps with SPD (pelvic girdle pain)
Note: SPD used to be the “label” and this stands for Symphysis pubis diastasis. This term has largely been replaced by symphysis pubis instability as it is not really a diastasis (separation) which can be measured and which gives an indication of the severity: like diastasis of the recti (abdominal) muscles. Indeed, people have now become aware of the importance of looking at the functioning of the whole pelvis, not just the pubic bone and so tend to refer more to pelvic girdle instability.
“I went to see Hannah Mackay, a Wellmother trained practitioner, with SPD (Pelvic Girdle Pain) in my second pregnancy. I had problems with walking any distance over a few minutes without resting, and was in a lot of discomfort, sitting, standing. The pain and discomfort were causing me a lot of anxiety as I was only half way through my pregnancy and was worrying about being able to look after my two year old and how long I would be able to work into the pregnancy. The day before my first appointment with Hannah I had had a panic attack (my first) which I feel was caused by my increased anxiety levels, caused by the pain.
After my first session, I immediately felt clearer headed and got my sense of ‘self’ back which had become a little bit lost. I wasn’t in anywhere near as much discomfort and felt able to move more easily than before. I had another two sessions after this, both before week 30 – although I still wasn’t able to walk very far for the remainder of my pregnancy, the shiatsu definitely helped me to feel more together both mentally and physically, significantly eased my discomfort and gave me a clear head to plan in spite of and accept my physical limitations. Unfortunately I don’t think that shiatsu for SPD is known about widely, but I recommend it and Hannah to any pregnant women suffering from it I come across. Natalie Q”
What is pelvic girdle instability?
Essentially what it says: pain in the pelvic area. It affects all women differently as there are several causes and different parts of the pelvis may be affected. This means that individual assessment is needed to establish the best way forward. In the past, women have been told to avoid any movements, yet some movements are usually helpful. However it is important to know which ones for your presentation!
In every pregnancy there is a natural increase in the mobility of the pelvis due to the softness of tissue under the influence of pregnancy hormones. This helps create space for your baby. As your baby puts on weight, your pelvis has to work harder. The main joints of the pelvis are the sacro iliac (the two bones at the base of your spine) and the symphysis pubis – pubic bone joint – right in the middle at the front.
For many women, these changes do not cause any discomfort, For others they can experience extreme discomfort which may even begin in the first trimester, as the hormonal changes begin in this trimester. Usually if it begins in the first trimester, it is a sign that the women is hypermobile or that they have a weaker pelvis caused by a previous pregnancy or birth.
What are the symptoms of pelvic girdle instability?
The symptoms are a pain which can be on-going or sudden and felt in the pubis, groin, inside of thighs, either on one side or both. It is frequently accompanied by low back, sacro iliac and pain just above the pubic bone which can be mild or severe . Of course, there are many other things which can cause these symptoms e.g. repetitive kicking from your baby in the womb, stretching of the uterine ligaments. What often helps identify the pelvic girdle weakness is that there is often a more specific symphysis pubis pain or pain in the sacro iliac which has a burning sensation.
What is pelvic girdle instability caused by?
The number of women experiencing pelvic girdle instability is growing. I think that it is caused by modern lifestyles which means we are sat down at desks a lot more, driving around rather than walking. This means that our muscles are less toned/strong and therefore support the whole pelvic girdle less effectively during pregnancy. I also feel that there is a stress link due to women receiving inadequate support in pregnancy. Women who are working outside the home during pregnancy are not always able to rest as much as they need to and the body copes less well with the physical demands of the pregnancy. Additionally women don’t feel that they can ask for support: the society view is women should be able to do everything. Help with carrying shopping or lifting an older child can help reduce the amount of weight bearing.
Women who are hypermobile before pregnancy are more likely to experience issues due to the increase in mobility caused by the hormonal changes in pregnancy. Often, due to their natural flexibility, they are likely to have been gymnasts or ballerinas and may perhaps have done excessive amounts of hip opening exercises while young.
Women who have suffered from any kind of pelvic injury are also more likely to suffer as in these cases there is usually a slight displacement of the pelvis (ie it is assymetrical) which means that the symphysis pubis is placed under an unequal stress on one side.
Women who have weak pelvic floor or abdominal muscles due to previous pregnancies and birth are more likely to experience pain in subsequent pregnancies.
What should I do if I have pelvic girdle instability?
Pain in the pubic bone:
If you suspect that you have any of the symptoms of pain in the pubic bone, then avoid, as much as possible, for one week any movements where you part your legs wider than hip width and also minimise the amount of walking and weight bearing exercise you are doing. When turning in bed at night, try and keep your knees together as much as you can. It is best if you can to turn over by rolling into all fours and then lying on the other side. If you notice a difference, then the chances are you have symphysis pubis laxity, so continue in this way. You need to find the pain free gap ie how much movement you can do without causing pain. For some women this means pretty much keeping your legs together most of the time, especially when changing position. For others, the legs can be a little apart, however not more than hip width. If you notice no difference, then it is probably something else.
Pain in the sacro-iliac joint:
This is a little more complex as some women find certain movements helpful and others not. Again it is wise to observe which movements aggravate and which alleviate the discomfort.
Strengthening your pelvis:
As it is aggravated by poor pregnancy posture then you need to look at how you stand and move. The typical poor posture is excessively hollowing your lower back (hyperlordosis). This means that your abdominal muscles are excessively stretched and this means they give less support to your pelvis. You can correct this by lengthening your lower back: but make sure you do this by using your abdominal muscles and pelvic floor: ie not using your buttock muscles. It is important to do correct pelvic floor exercises as part of the work to strengthen your pelvis. This is essentially engaging your pelvic floor and abdominal muscles together on the out breath and relaxing them on your in breath: following your body’s natural movements.
If you do need to walk distances or have a toddler you can’t avoid picking up much, then you will probably find a belt will help. The one I have found to be best is the Serola belt. I like this because it is simply supporting the joints of your pelvis and not going around your abdominal muscles. The advantages of this are two fold. One: it is more comfortable to wear and two it enables the abdominal muscles to strengthen, along with the pelvic floor. You can also ask your midwife to refer you to an obstetric physiotherapist who can assess and suggest some exercises too as well as prescribing the belt. However, do check that you are seeing an obstetric physiotherapist as not all physios know specifically about pregnancy issues and solutions.
When you are moving some tips are:
getting in and out of the car: put a plastic bag on your seat and slide around, keeping your knees together, to get in and out of the car.
getting up and down from the floor: use support (eg like a chair), move slowly and keep your knees together as much as you can
Correct exercise is important to strengthen your pelvis. Do some back, abdominal and pelvic floor strengthening exercises, to give support to the pelvis. You need to check your recti muscles to check which exercises are appropriate. If the recti muscles are separated then you should not lift your head while you are lying supine. Always turn always to your side to get up: you should be doing this anyway in pregnancy, but remember to keep doing this postnatally. In the second and third trimesters of pregnancy, all fours is a great position to do these exercises as there is less weight going through your pelvis compared with standing. Postnatally don’t use the all fours position until you have stopped bleeding or the scar has recovered after a C-section (4 to 6 weeks is a good guideline). If you have laxity in the symphysis pubis, make sure you are only doing movements which don’t involve moving your hips apart too far (remember the “pain free gap” )and where your knees are close together. A good exercise is the yoga cat stretch. Remember to use your out-breath as you round your back and engage your abdominal muscles and pelvic floor together and your in breath as you lengthen the spine back to the flat back position only. Do not hollow your lower back as this will increase the rounding of the lower back and over stretch the abdominal and pelvic floor muscles. See the picture below where the woman has a flat back.
Your therapist can also do some work with you while you are in all fours.
In pregnancy, if you spend time in all fours, then it will also help your baby position in the anterior position: a more comfortable position for you and one which tends to favour labour. Read this blog for more information.
As stress is also a factor, having some form of bodywork which can relax you, as well as addressing the physical problems is extremely helpful. Shiatsu and massage are excellent. The therapist can include techniques which specifically support this condition by strengthening the area of weakness, structurally and emotionally.
If you follow all this, the chances of having a relatively pain free pregnancy are high. You can not “cure” it, as the amount of relaxin increases until the end of pregnancy and your baby is getting heavier, but you can learn to be relatively pain free by strengthening your pelvis.
What can make pelvic girdle instability worse?
It depends if it is caused by asymmetry or hypermobility/laxity. If it is due to hypermobility, then usually certain types of movement and weight bearing aggravate it. If it is caused by asymmetry, the correct type of movement may help.
What makes symphysis pubis pain (and sometimes sacro-iliac pain) worse are potentially any activities or movements which involve opening and moving the hips i.e. turning from side to side in bed at night, breast stroke swimming (legs), squatting. Walking and all weight bearing activities can aggravate it. The problem is that in its early stages the pain may not be felt while doing these activities, only several hours later so the connection is not always made. Symphysial “clicking” or grinding may be audible and can be felt by the woman. There is a characteristic waddling gait. Some people confuse it with urinary tract infections because of the burning pain, but with UTI’s the pain is more internal.
It can come on gradually in pregnancy, usually in the last trimester with a first pregnancy. It can appear from 20 weeks and usually starts earlier in a second or subsequent pregnancy. It can be caused by labour usually by being in stirrups for extended periods.
How to labour if you have pelvic girdle instability
You can have a vaginal delivery but you must make sure that you labour and ideally deliver if possible in the all fours position, keeping your knees as close together as you can. If possible avoid having an epidural, as this will mask the pain which lets you know if a position is aggravating the movement of the joints. If you need to have an epidural, then make sure that your partner or midwife knows which positions won’t aggravate your condition. If you need to have a forceps or ventouse delivery, again make sure that your partner and midwife can advise the obstetrician on the best position for you. Lying on your back with your legs wide apart is likely to aggravate pelvic girdle instability postnatally. Often being in water is helpful as it gives support to your joints, but obviously you need to be careful how you get in and out of the pool. Discuss it with your midwife. Otherwise you can aggravate the problem and so it remains a problem postnatally.
How to support yourself postnatally if you have pelvic girdle instability
If you have followed all the above advice in pregnancy and labour, you may well find that as soon as you have delivered there is no pain. You still need to be careful to avoid leg abduction movements for 4-6 weeks postnatally and then resume them gradually. In the first 4-6 weeks follow a gentle back/abdominal/pelvic floor strengthening programme. If you can, continue to have some shiatsu or massage from a trained specialist in maternity skills.