Pregnancy - SPD- Pelvic Pain

S.P.D - SYMPHYSIS PUBIS DYSFUNCTION

Three large bones constitute an adult’s pelvic girdle, a roughly heart shaped arrangement of bones attached to one another by sturdy ligaments. The three bones are the sacrum, or base of the spine, at either side of this, and connected via the sacro-iliac joints, are two large isometric bones known as the ossa coxae or hip bones. These bones are then connected at the front by a ligament called the symphysis pubis.

Under normal circumstances the ligaments involved in the girdle are not very flexible, but when a woman is pregnant she will produce a hormone known as relaxin which softens them to allow some pelvic movement for the birth. Although there is no universal agreement on the cause of pelvic pain in pregnancy, there are some that believe this hormone to be at the root of it. Difficulties can occur when the ligaments become too loose too soon, and pelvic problems can arise at a time when a woman needs the support of her pelvis more than ever due to her extra load.

Pain in the groin and pubic area, whatever the cause, is usually related to the pelvis not functioning like it should, and is referred to as Symphysis Pubis Dysfunction (SPD). The problem is not necessarily with the symphysis pubis itself, it can often be either or both of the sacro-iliac joints putting undue strain upon it.

DSP - Diastasis Symphysis Pubis

DSP is a related condition which is more extreme but less common,
Although there is always a small gap between the two bones at the symphysis pubis joint, which becomes larger during pregnancy, in some rare cases the symphysis pubis can separate more severely. This condition is known as Diastasis Symphysis Pubis (DSP), and can only be detected by x ray, ultrasound or MRI scan. Medical professionals determine the size of the gap as being that of 10 millimeters or above to indicate DSP, while up to 9 mm is normal for pregnancy and 4-5mm normal for non-pregnancy.

POSSIBLE CAUSES OF SPD

There is no generally recognized reason why SPD occurs. Experts have speculated theories about the causes of SPD. These include misaligned pelvises, previous pelvic problems such as trauma and having had many babies or large babies. In the case of relaxin, some think that certain women may have high hormone levels prior to pregnancy, which relaxin production then adds to and creates the problem. Other sources propose ideas such as certain women having oversensitivity to hormones, or overproduction of them.

ONSET OF SPD

SPD can occur from the 12th week of pregnancy onwards, however it can also be a purely postnatal condition. Some women may suffer from it during and after pregnancy, with every pregnancy or sometimes just the first. The effects of the condition can linger on in some cases, but usually with lessened intensity. It is always wisest to leave a gap of two years, where possible, between pregnancies.

SPD - SYMPTOMS

Pain and tenderness in the area of the symphysis pubis joint can often be accompanied by pain in the hips, lower abdomen and groin. Sometimes the pain can also manifest itself in the inner thighs and in one or both buttocks. Walking and other activities exacerbate the pain. Standing on one leg can be virtually impossible, so activities that rely on this to some degree will increase the pain. Climbing stairs, getting dressed and getting in and out of cars or the bath all involve the use of one leg at a time. Women can also experience pain while trying to move in bed, lifting things, sitting down and getting up. They may also have pain if they try to spread their legs past a certain point. Sometimes there can be a clicking during hip movement felt or even heard. A tendency to shuffle along or waddle may develop as women try to distribute their weight evenly.

TREATMENT OF SPD

Always consult a doctor if in need of any medication to aid with the pain associated with SPD or any other ailment while pregnant. General practitioners and other health care professionals will know which painkillers or anti-inflammatory drugs are suitable for your particular stage of pregnancy. If SPD has started after the birth, or continued from pregnancy you should still see a doctor if you are breastfeeding and in need of medication. Whilst there is no way to actually tighten the affected ligaments when pregnant, the relaxin hormone ceases to be produced after the birth. This should lead to the return of a less erratic pelvic state in the majority of cases.

There are other treatment methods available as well as painkilling drugs. Such treatments include TENS (Transcutaneous Electronic Nerve Stimulation) and pelvic supports. These may be among the types of treatments suggested if you are referred to a physiotherapist.
There are also steps you can take yourself to help with getting around and avoiding painful situations. Such measures include;
• Getting into a car by sitting on the seat first, and then lifting your legs inside. Reverse this procedure for getting out.
• Getting dressed while sitting on a chair rather than standing.
• Always having the knees together firmly when turning over in bed.
• Rest as much as possible. Take the body’s weight off the pelvis when you can. Try to have some daily bed rest.
• Where possible, sit down to do daily tasks like food preparation.
• Avoid lifting.
• Avoid the breaststroke if you go swimming.
• Try to avoid twisting the upper body. Think ahead, turn and face the thing you are doing.
• Avoid straddling positions e.g. sit on a bidet as you would on a toilet.
• Be aware of your body and the way it responds to certain activities. Try to avoid the activities that result in pain. These may be anything from walking long distances to hovering or pushing supermarket trolleys. Avoid sudden jerky movements.
• For those whose pain when climbing stairs is too excruciating to bear, it may well be advisable to go up and down stairs using your bottom, and lifting yourself up or down each stair with your hands. This is fairly easy on the downward journey, but quite difficult going up. Bearing this in mind, it would be best to make sure that you only needed to make one trip up and down the stairs each day, and plan for rest periods (and possibly assistance if this can be safely achieved) on the upward trip.
• Pelvic floor exercises may help in relieving pelvic pain. These exercises (also called Kegel exercises) are designed to help strengthen the hammock-like muscles which support the pelvic organs. Better control over these muscles could help take some of the weight bearing responsibility away from the pelvic girdle and ligaments. Consult a health care professional about pelvic floor exercises with regard to your particular circumstances.

HOW DOES SPD EFFECT MY BIRTH

If you experience SPD it may be a good idea to take account of this in any birth plan you draw up. This could mention such things as;
• Your latest measured pain free gap. The distance that the knees can be parted, while lying down with the knees bent, without experiencing pain. This should be measured for you by your birthing partner close to your due date. Midwives and doctors will then be aware of this and take it into account.
• Any preferred positions for delivery. There are alternative positions to lying on your back during labour, which can offer some relief from pelvic pain. Lying on your side with the upper leg supported by someone is apparently, the best way to minimize strain on the back and pelvis. Another position good for easing pain is a kneeling position with your torso fairly upright over several pillows, beanbags or such. This will allow for gravity to assist in delivery. It is best to do whatever is the most comfortable for you. Squatting positions are best avoided, and the lithotomy position (the on your back, knees bent and raised above the hips, thighs apart position often involving stirrups), while convenient for obstetricians, is not the best position for the pregnant woman and can exacerbate pelvic pain. It is known to, among other things, put pressure on the coccyx, and is thought to be a potential cause of pelvic pain that presents itself postnatally. There are similar issues regarding the use of stirrups if any post partum stitching is required.
• Drugs and pain relief you require. In a birth plan you can specify the type of pain relief you do and do not want. In the case of epidurals and SPD sufferers, special care should be taken by midwives, birthing partners etc to support the back, and observe the restrictions of the pain free gap. While you are under the epidural’s effects you won’t be able to feel the pain.
• Assisted delivery. You could specify a ventouse delivery (uses a suction cap on the baby’s head) instead of forceps, as this can be performed laterally.

Birthing pools can help with pain management, but your particular condition needs to be assessed by the midwife team. Some women with SPD experience difficulty getting in and out of birthing pools.

Some women feel that they cannot face the idea of adding to their pelvic pain by having a vaginal birth, and wish to opt for a caesarean. This should be very carefully discussed with health care professionals, as it is a major operation with its own drawbacks and issues. The condition of SPD does no harm to the baby itself. It is purely a matter of the mother’s pelvic pain.

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About Inner-Vision Ultrasound

Inner-Vision Ultrasound has been set up by a husband and wife team of healthcare professionals, Richard and Catherine Warriner. Richard trained as a sonographer at Leeds in 1996. He worked at Pinderfields hospital Wakefield, Queens Park Hospital Blackburn, Huddersfield Royal Infirmary and Liverpool Womens Hospital as a sonographer before joining General Elecctric as an ultrasound applications specialist. In this role Richard travelled throughout the north of England demonstrating and teaching the latest ultrasound techniques to sonographers and doctors in obstetrics and general ultrasound. It was with his time at GE healthcare that Richard was introduced to the Voluson 730. It is the class leader in 3d/4d technology and as such the only choice for Inner-Vision. Richard has lectured to ultrasound students at the universities of Liverpool, Leeds and Lancaster. Catherine is a Midwife, gaining her degree in Midwifery from Newcastle University in 1996. After working in the north east for a short while after qualification, Catherine returned home to Lancashire and has now worked at Queens Park hospital, Blackburn, for the last eight years. She has been a community midwife, worked in an antenatal clinic and has had extensive experience on the antenatal wards.