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Pelvic Pain

16 Aug

I totally agree with the advice recommended here.  I was at the stage where I couldn’t walk as my pelvis was so incredibly painful (about 26 weeks along).  After 7 visits to a chiro, I was pain free.  (Get extras cover from health insurance, it’s worth it just for going to the chiro while pregnant)

http://www.plus-size-pregnancy.org/pubicpain.htm

Pelvic Pain (Symphysis Pubis Dysfunction)

 

by KMom
Copyright © 2001-2003 KMom@Vireday.Com. All rights reserved.
Last updated:  April 2003

DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider.
CONTENTS

One problem that many pregnant women complain about is pubic pain.  Yet doctors and midwives often dismiss this pain as either ‘inconsequential’, ‘unfixable’, or ‘just one of those pregnancy discomforts that have to be endured’.  Occasionally, some uninformed doctors have even erroneously told women that such pubic pain means that they would need an elective cesarean section in order not to permanently damage that area during birth, or as a result of prior damage to the area.
Yet none of this is true.  Pubic pain in pregnancy is certainly not ‘inconsequential’;  Kmom knows from experience that it can be very difficult to deal with.  Although many doctors and midwives do not know what causes it or how to fix it, many women are able to get improvement or relief with chiropractic treatment or osteopathic manipulation.  It is not something that you ‘just have to live with’.  And although extra care should be taken during labor and birth in order to prevent trauma, it absolutely does NOT mean that you ‘have’ to have a cesarean!


This purpose of this FAQ is to discuss what causes pelvic/pubic pain, what some of the symptoms are, possible causes, hints for coping with pubic pain, how to prevent further trauma during birth, what kinds of treatments are available, and women’s experiences with these treatments.

Anatomy and Structure
Your pelvis is a kind of a circular bone that goes all around and almost meets in the middle in front.  The two sides do not quite touch; there is a small gap between them connected by fibrocartilaginous tissue reinforced by several ligaments.  This area is called the Pubic Symphysis.  This is important for helping your pubic bone to move freely, stabilizing the pelvis while allowing a good range of motion.  [An illustration of the pelvis can be found at http://omie.med.jhmi.edu/weblec/templatev1/lec11.html.]


The Pubic Symphysis and the Sacro-Iliac joints (in the back of the pelvis) are especially important during pregnancy, as their flexibility allows the bones to move freely and to expand to help a baby fit through more easily during birth.  In fact, the pregnancy hormones relaxin and progesterone help the ligaments of your body to loosen and be even MORE flexible than before, so that there is plenty of ‘give’ and lots of room for the baby to slip right through.
Because of these hormones, it is normal for there to be some extra looseness and pelvic pressure in pregnancy.  This is good—it means your body is getting ready for birth! It’s loosening up to give you maximum space and flexibility, and to help make things easy for you and your baby.


However, in some women, either because of excessive levels of hormones, extra sensitivity to hormones, or a pelvis that is out of alignment, this area is extra lax or there is extra pressure on the joint.  In 1870, Snelling described this condition:  “The affection appears to consist of a relaxation of the pelvic articulations, becoming apparent suddenly after parturition, or gradually during pregnancy; and permitting of a degree of mobility of the pelvic bones which effectually hinders locomotion, and gives rise to the most peculiar, distressing and alarming sensations.

Simply put, significant pubic pain is caused by the pelvic girdle area not working they way it should, probably because of hormones, misalignment of the pelvis, or an interaction of the two.

Although not every provider has a name for this condition, it is most commonly called Symphysis Pubis Dysfunction (or SPD), especially in Britain.  Other names for it include:

  • pubic shear  (osteopathic term)
  • symphyseal separation
  • pubic symphysis separation
  • separated symphysis
  • pelvic girdle relaxation of pregnancy
  • pelvic joint syndrome.

Diastasis Symphysis Pubis (DSP) is the name for the problem in its most severe form (where the pubic symphysis actually separates severely or tears).   For ease of use, in this FAQ the ‘milder’ form will be referred to as SPD.

Symptoms
The symptoms of SPD vary from person to person, but almost all women who have it experience substantial pubic pain.  Tenderness and pain down low in the front is common, but often this pain feels as if it’s inside.  The pubic area is generally very tender to the touch; many moms find it painful when the doctor or midwife pushes down on the pubic bone while measuring the uterus (fundal height).


Any activity that involves lifting one leg at a time or parting the legs tends to be particularly painful. Lifting the leg to put on clothes, getting out of a car, bending over, sitting down or getting up, walking up stairs, standing on one leg, lifting heavy objects, and walking in general tend to be difficult at times. Many women report that moving or turning over in bed is  especially excruciating.  One woman wrote, “There were days that I didn’t think I was going to be able to get out of bed and actually had to roll out of bed and onto the floor to be able to do so!” [See her story below.]


Many movements become difficult when the pubic symphysis area is affected.  Although the greatest pain is associated with movements of lifting one leg or parting the legs, some women experience a ‘freezing’, where they get up out of bed and find it hard to get their bodies moving right away–the hip bone seems stuck in place and won’t move at first.  Or they describe having to wait for it to ‘pop into place’ before being able to walk.  The range of hip movement is usually affected, and abduction of the hips especially painful.


Many women also report sciatica (pain that shoots down the buttocks and leg) when pubic pain is present.  SPD can also also be associated with bladder dysfunction, especially when going from lying down (or squatting) to a standing position.  Some women also feel a ‘clicking’ when they walk or shift just ‘so’, or lots of pressure down low near the pubic area.
Many women with SPD also report very strong round ligament pain (pulling or tearing feelings in the abdomen when rolling over, moving suddenly, sneezing, coughing, getting up, etc.).  Some chiropractors feel that round ligament pain can be an early symptom of SPD problems, and indicate the need for adjustments.  Other providers consider round ligament pain normal, part of the body adjusting to the growing uterus.  If experienced with pubic and/or low back pain, it probably is associated with the SPD.


Onset of Pain and Duration
Pubic pain often comes on early in pregnancy, even as early as 12 weeks. One mother reports that she had it at 17 weeks.  She says:

When I woke up [from my nap] I could hardly move.  It took me forever to walk into the next room.  Felt like my hips/pelvis were glued together or something.  Already this baby feels sooo heavy inside me, like lots of pressure.  I’ve gained 4 lbs. so far, what’s the deal?  At night when I wake up to go to the bathroom, sometimes I can’t move my legs/hips at all, and sometimes things have to ‘pop’ back into place.  I think, what if there is a fire and I died ‘cuz I’m too slow!…I thought this problem in my 1st pregnancy was from gaining so much/swelling and it got worse and worse and stayed till over 3 months postpartum.” 

Indeed, although pubic pain often does go away after pregnancy, many women find that it sticks around afterward, usually diminished but still present.  If treatment to resolve any underlying causes is not done, long-term pain usually sticks around.  Anecdotally, this often seems to be associated with long-term low back pain or reduced flexibility in the hips.  Even worse, if the mother is mishandled during the birth, the pubic symphysis can separate even more or be permanently damaged.  This is called Diastasis Symphysis Pubis (diastasis means gap or separation).


Summary
To summarize, SPD is the mild form of this problem.  Its symptoms often include one or more of the following:

  • pubic pain
  • pubic tenderness to the touch; having the fundal height measured may be uncomfortable
  • lower back pain, especially in the sacro-iliac area
  • difficulty/pain rolling over in bed
  • difficulty/pain with stairs, getting in and out of cars, sitting down or getting up, putting on clothes, bending, lifting, standing on one foot, lifting heavy objects, etc.
  • sciatica (pain in buttocks and down the leg)
  • “clicking” in the pelvis when walking
  • waddling gait
  • difficulty getting started walking, especially after sleep
  • feeling like hip is out of place or has to pop into place before walking
  • bladder dysfunction (temporary incontinence at change in position)
  • knee pain or pain in other areas can sometimes also be a side-effect of pelvis problems
  • some chiropractors feel that round ligament pain (sharp tearing or pulling sensations in the abdomen) can be related to SPD

Cause
No one knows why SPD occurs for sure, or why it happens in some women and not in others.  Some ethnic groups report a high incidence, especially Scandinavian women and perhaps Black women.   Other risk factors may include having lots of kids, having had large babies, pre-existing problems with this joint, past pelvic or back pain, or past trauma (car accident, obstetric trauma, etc.) that may have damaged the pelvic girdle area.   It also seems logical that women who have broken or injured their pelvis in the past would probably be prone to this problem.


Some sources view SPD simply as a result of pregnancy hormones.  As noted, the pregnancy hormones relaxin and progesterone tend to loosen the ligaments of the body in preparation for birth.  One theory is that some women have high levels of hormones before pregnancy, and then additional pregnancy horm
ones cause excessive relaxation of ligaments, especially in the pelvis.


Another theory is that some women manufacture excessive levels of relaxin during pregnancy, causing pelvic laxity.  However, although still popular, this theory seems to have been disproven by recent research. Another theory is that women whose joints are especially flexible before pregnancy may be more susceptible to the effect of hormones, or that some women’s bodies are just more affected by hormones than others.  Traditional medical sources tend to view the problem of pelvic/pubic pain (when they acknowledge it at all) as simply a hormone problem.


A different theory holds that the problem is structural instead, and usually results from a misalignment of the pelvis.  In this view, if the pelvis gets out of alignment, the bones don’t line up correctly in front, and this puts a lot of extra pressure on that pubic symphysis cartilage.  If the two sides are not aligned, it restricts full range of motion, pulling on the connecting pubic symphysis, and making it quite painful.  The more out of alignment it is, the more painful this area becomes.  It also tends to affect the back, especially in the sacroiliac area, since the pelvis and back are interconnected and work as a unit.  And since many areas are affected by back problems, pain can also extend to other areas too.


Kmom’s personal opinion is that this condition is probably primarily a problem of misalignment, although hormone levels and sensitivity to hormones may also play a role.  In her opinion, the first line of SPD treatment should probably address the possibility of misalignment.  Others may not agree.  But whatever the cause, SPD is certainly annoying and painful to deal with, and Kmom knows this from personal experience!

Implications for Malpositions and Cesareans
One of the most interesting side-effects of a misalignment of the pelvic bones is that anecdotally, it often seems associated with malpositions of the baby, including:

  • breech (feet or butt-first)
  • occiput posterior (head-down but facing the mother’s stomach instead of her back)
  • asynclitic (head tilted to one side so that the parietal bones presents first instead of the crown)
  • compound (hand or arm by face)

All of these malpositions tend to cause more difficult labors, with greater pain and often great difficulty in dilation or descent of the baby.  There is a high rate of operative intervention when malpositions are present, including lots of forceps in vaginal births, and many cesareans as well.  In fact, research shows that only a small percentage of babies with persistent malpositions actually are born spontaneously and without interventions.  (See the FAQ on Malpositions on this website for further information and references.)
As noted on the website of the Australian Osteopathic Association:

The descent of the baby through the pelvis is determined by factors such as ligament laxity, hormonal control, uterine contraction, gravity and position of the baby.  If the mother’s pelvis is mechanically unstable or is lacking mobility, it may interfere with the baby’s passage through the birth canal.  

Unfortunately, very few doctors in recent years have paid much attention to malpositions (except to do cesareans for breech).  Only in the midwifery, osteopathic, and chiropractic communities have these positions received much attention, and then only recently.  Interest is now just beginning to re-surface in the obstetric community, but is very limited in mainstream obstetric journals as of now.


There is little scientific data to show that pelvic misalignment is associated with malpositions because traditional medicine does not recognize misalignment as a problem or research it, nor do they take the idea of “pelvic misalignment” seriously.  Really, they barely take the idea of non-breech malpositions seriously! Therefore, it cannot be stated from an evidence-based point of view that pelvic alignment is associated with fetal malpositions or difficult labors, or that re-aligning the pelvis would prevent malpositions, prevent cesareans, or lessen the incidence of difficult labors.
Obviously, research into this issue is very important, but quite unlikely to occur anytime soon. The funding and interest is simply not there in the traditional medical community.  This lack of data does not prove or disprove the misalignment theory; it simply has not been researched in the traditional scientific manner.  Chiropractors, on the other hand, have seen in their own practices for years that women with misaligned backs and pelvises tended to have more malpositioned babies.  There are some limited case series studies on this available in chiropractic research journals, but even this is not very well-documented.


The first really significant work was done by Dr. Larry Webster, founder of the International Chiropractic Pediatric Association.  He found that simply by realigning the pelvis and releasing the soft tissues, most breech babies turned head-down within a few treatments.  It is important to emphasize that he did NOT manually turn the baby in any way, but simply realigned the mother’s pelvis and ‘released’ the ligaments supporting the uterus.  The baby then was not “constrained” anymore from assuming the best possible position, and so usually quickly turned vertex.


Dr. Webster taught this “Webster In-Utero Constraint Technique” to many other chiropractors.  Success rates depend on the skill of the practitioner, but usually are documented at about 80% or more in turning the breech baby.  This is much higher than the success rates for manually turning the baby with the often-rough procedure known as a “External Cephalic Version”.  ECV success rates generally run anywhere from 40-65% or so, whereas the Webster Technique successfully turns 80% or so, at least in the data available so far.


Thus, it seems likely that many cases of breech babies are quite probably associated with pelvic misalignment, and that treatment to re-align the pelvis may help many breech babies turn head-down.  However, proof of this is limited to anecdotal evidence, lectures and articles from Dr. Webster, a few small case series, and surveys about chiropractors’ experience with the Webster Technique. Not overwhelming evidence by any means, but all we have at this point.  Yet it may be women’s best bet in preventing malpositions and relieving pelvic pain.


The Webster Technique also has a variant that can be used with babies that are head-down but facing the wrong way (posterior).  Although little formal data exists on this, anecdotally many women and midwives have reported this to be helpful for non-breech malpositions as well.  Thus, it is quite likely that in many cases, pelvic misalignment is often accompanied by baby malposition of varying types, not just breech presentations, and treatment may help resolve such malpositions.


Anecdotal evidence also suggests that many women who have had past cesareans for non-progressive labor or “Cephalo-Pelvic Disproportion” (supposedly, baby too big or pelvis too small) actually may have had malpositioned babies.  It’s not that the baby was too big or the mom’s pelvis too small, it’s that the baby’s position did not permit it to go through easily, causing it to get “stuck.”  These women (one of whom is Kmom!) often report that if they get regular chiropractic care in subsequent pregnancies, they frequently go on to have a Vaginal Birth After Cesarean because the baby malposition is prevented or is more easily resolved.  They also regularly report that their pubic symphysis pain decreases significantly with treatment.


So although little concrete scientific data exists from mainstream studies (largely because it has not been studied), and although anecdotal evidence has to be treated with caution, women with misaligned pelvises often seem to experience pelvic pain/SPD, and possibly a higher rate of malpositioned babies.   It seems logical (though unproven) that treatment to help re-align the pelvis may help lessen pelvic pain, and may also prevent or correct a fetal malposition.


Although not every women with SPD experiences a malpositioned baby, it does seem to be very common in this group. Since baby malpositions commonly lead to lots of interventions like epidurals and forceps that tend to worsen pubic pain and may even damage the pubic symphysis permanently, checking for misalignments and working carefully to avoid/treat baby malpositions may be important to avoiding long-term pain or permanent pubic symphysis damage.  This is a fascinating area that is just beginning to be researched but has potentially far-reaching implications.

Tips for Coping with Pubic Symphysis Pain
Although the best idea may be to resolve chronic SPD pain through realigning the pelvis girdle and soft tissues,  most women have at least some residual pubic and low back pain stick around for pregnancy and the early postpartum weeks because of hormones.  Therefore, tips for coping with pubic pain tend to be a focus of many SPD websites.  Many of the suggestions include:

  • Use a pillow between your legs when sleeping; body pillows are a great investment!
  • Use a pillow under your ‘bump’ (pregnancy tummy) when sleeping
  • Keep your legs and hips as parallel/symmetrical as possible when moving or turning in bed
  • Some women also find it helpful to have their partners stabilize their hips and hold them ‘together’ when rolling over in bed or otherwise adjusting position
  • Some women report a waterbed mattress to be helpful
  • Silk/satin sheets and nighties may make it easier to turn over in bed
  • Swimming may help relieve pressure on the joint (many sites recommend avoiding breaststroke but Kmom did not find it to be a problem at all for her; see what works for you)
  • Deep water aerobics or deep water running may be helpful as well (there are flotation devices to help you stay afloat easily during this; you do not need to know how to swim in order to do this)
  • Keep your legs close together and move symmetrically (other sources recommend a very small gap between the legs with symmetrical movement)
  • When standing, stand symmetrically, with your weight evenly distributed through both legs
  • Sit down to get dressed, especially when putting on underwear or pants
  • Avoid ‘straddle’ movements
  • Swing your legs together as a unit when getting in and out of cars; use plastics or something smooth and slippery (like a garbage bag) on the car seat to help you enter car backwards and then turn your legs as a unit
  • An ice pack may feel soothing and help reduce inflammation in the pubic area; painkillers may also help
  • Move slowly and without sudden movements
  • If sex is uncomfortable for you, use lots of pillows under your knees, or try other positions
  • If bending over to pick up objects is difficult, there are devices available that can help with this
  • Really severe cases may need crutches, although these should probably only be used as a last resort
  • Sciatica may be helped by stretching the hamstring muscles with a stirrup around your foot (long piece of rope, two neck ties tied together, etc.)  See the Elizabeth Noble book for directions (resources)
  • Back pain can often be helped by resting backwards over a large gymnastic or ‘birth’ ball (see resources)
  • Some women report that pelvic binders/maternity support belts are helpful for pelvic pain; brands in the U.S. include Prenatal Cradle or BabyHugger or the Reenie Belt.  However, if the pelvic bones are really misaligned, some women report more pain with these.  Listen to your body on whether to use these

Many sites also recommend a lot of bed rest, but Kmom has to disagree with this for most women.  In Kmom’s experience, her pain levels were much worse when she was inactive.  Inactivity may lead to atrophy, and regular exercise is helpful in the prevention of many common pregnancy problems. Although the first 5-10 minutes of activity were uncomfortable for Kmom, she always felt much better after that, and usually returned from her walks feeling much less fatigued and in less pain overall than if she had not walked at all or had stopped partway through.  It’s possible that in very severe cases, bedrest may be the best option, but Kmom would encourage most women to stay reasonably active as long as they use caution and listen to their bodies.


Other tips that don’t usually appear on SPD websites but which have helped Kmom cope include pelvic rocks, a  lumbar pillow against the back when sitting, and very strong massage/counterpressure against the lower back.   Pelvic rocks (getting on all fours and then slowly tilting the angle of the pelvis back and forth) are  general recommended exercises for all pregnant women, plus they help promote good birth positions for baby.  They can also help ease tight low back muscles.  It is usually recommended to do 2-3 sets of 40 of these throughout the day.  You can also do them sitting or standing against a wall, but on all fours is often most comfortabl and has the added effect of helping the baby’s position, which may be important with SPD.


Lumbar pillows are very helpful to many pregnant women.  They are available at many car stores, but if you cannot find one, try a small neck pillow (elongated like a tube), rolled up towel, or tube sock filled with rice or flax seeds.  Put it behind your back when sitting, wherever it feels best; for some women this is down low in the small of the back, for some it is even lower against the sacrum, and for others it feels best up high in the middle of the back.  Socks or pillows filled with rice or flax have the advantage of being able to be warmed in the microwave before using, which can feel really nice!


Massage of the lower back or strong counterpressure in that area feels really great to some women.  Some women like it just to the sides of their spine (helps loosen the muscles there), and some like it really low and farther out (there are trigger points there).  Others like it all up and down on either side of the spine.  See what feels best to you and go from there.  If your partner’s hands get tired (this is a tough place to massage!), try a rolling pin, tennis ball, or other hard object there.  For women who like extra hard pressure on this spot, try getting on your hands and knees and arch your back a bit, then have your partner put his elbow against the area that feels best, lean his weight on it, and rub around in small circles.  For others who like more gentle pressure, hand or finger pressure may be more than enough.


Although it’s possible to ‘deal with the pain’ or use these tips to help you cope with pelvic pain, these ideas only address the SYMPTOMS of the problem, not the root cause of it.  If the source of your pain is purely hormonal, then addressing the symptoms is about all you can do until the baby is born and your hormones start to change.  However, if the problem is in the misalignment of the bones creating stress on the joints, only fixing this misalignment can really help resolve the problem, and simply having the baby won’t change much.   It may make sense to at least get an evaluation of your pelvic area and back to see if there’s a problem.  Then you can choose whether to try any treatment or not.

Possible Treatments There are many treatment approaches available for SPD, although most websites have information primarily on traditional medical approaches.  However, there are a number of other alternatives.  Unfortunately, randomized trials examining the efficacy of different modes of treatment for SPD do not seem to exist.  Obviously, Kmom’s opinion is that chiropractic care is the best approach, since that was her experience and she knows a number of other women who have benefited from it as well.  However, she makes no absolute recommendations to others as to what their best course of treatment would be, merely passes on her experience of what worked best for her.  Each person must decide what treatment would be best for their situation.


Don’t give up easily in your search for effective treatment, however.  Because the problem of pubic pain is so underacknowledged even in ‘alternative’ health care fields, women often have to search long and hard to find real help.  Expect it to take a while to find effective help, and keep looking for a new provider if the one you’re seeing does not take this problem seriously or cannot help.  Be willing to try different treatment modalities, and be persistent—it took Kmom five years before she found help!

Traditional Approach
It is often extremely difficult to get the traditional medical community (especially the obstetric community!) to take pubic pain/SPD seriously.  They often simply ascribe pubic pain to the ‘normal aches and pains of pregnancy’ and brush it off as no big deal.  They often believe that no real physical therapy or treatment is possible while pregnant and that it is just a matter of waiting it out.


Even when traditional practitioners take your pain seriously, the treatment recommended by most traditional providers is very conservative.  Bedrest, painkillers, and anti-inflammatories are the typical recommendations.  Some may also recommend wearing a maternity support garment or belt, such as the Prenatal Cradle, Reenie Belt,  or Baby Hugger.  For severe pain, some may recommend using crutches or a wheelchair as well.  Again, this tends to treat only the symptoms, since they believe the cause to be hormonal, ending only with birth.


In Britain, they have made some strides in recognizing SPD as a legitimate problem, but they often refer women to an ‘obstetric physiotherapist’.  Some women report being told that the physiotherapy needed should not be done on a pregnant woman and the physiotherapist would not treat them.  Other physiotherapists would treat pregnant women; sometimes it was helpful, but many women report that it was not.  Many of the treatments recommended tend to be very traditional (bedrest, crutches, painkillers) and not very effective.


Postpartum, if the pain does not disappear or if the pubic symphysis is damaged due to obstetric mishandling, traditional medical treatment in Britain sometimes includes surgery to put a plate over the affected joint or to induce scarring over it in order to ‘stabilize’ it, or injecting a steroid directly into the pubic symphysis.  Very invasive treatments indeed, and ones that involve a great deal of recovery time.

Chiropractic Chiropractic care aims to realign the pelvis, the back, and all affected areas through the use of manual adjustments.  Many women with pelvic pain anecdotally report the greatest improvement from chiropractic or osteopathic treatment.  Yet the majority of women on SPD websites apparently have not tried chiropractic care, and SPD organizations seem to be reluctant to promote chiropractic care as a possible treatment.  Many people still see it as “too alternative” to actively promote.
If the cause of SPD lies in pelvic misalignment, then only chiropractic or osteopathic manipulation will really address the root cause of the problem instead of addressing only the symptoms.  There is no solid proof of this, but anecdotally, it does seem to be the most promising approach.


The following information is designed to help women be more comfortable considering the possibility of chiropractic care, and to answer some of their concerns about chiropractic care.  Be aware that like doctors, chiropractors vary in quality, and sometimes you have to see more than one to find the right one for your needs, and of course, it’s also possible that chiropractic care may not be the right mode of care for you.


Different Types of Chiropractic Care
There are different schools of chiropractic technique.  Some adjust with quick sudden movements, while others adjust only with gentle, almost imperceptible movement.  Kmom has experienced both styles, and while she would have thought she would have preferred the gentler style, she didn’t really find much relief from it.  When she finally found the chiropractor who helped turn her baby, that chiropractor’s style was the more sudden and forceful kind.  It wasn’t painful, but it was definitely startling!  However, within an hour amazing changes began to happen, and Kmom’s pain level was definitely MUCH improved.


So while you think you might favor one style over the other, try to keep an open mind.  It may be that one style helps you more than the other style, or that if you go for treatment only late in pregnancy, the ‘gentler’ style of treatment won’t have enough time to work.  If you find the idea of the stronger style of adjusting scary, be sure to tell the chiropractor ahead of time so they will know to take extra time to help you understand what will happen and help you relax into the adjustment instead of resisting it.  That helps things considerably.


Finding a Chiropractor Familiar with Webster’s In-Utero Constraint Technique
It is important to find a chiropractor that is well-trained in the treatment of pregnant women.  Although most chiropractors receive some training in this while in school, some receive advanced post-grad training and are true specialists for pregnant women, babies, and children.  In addition, many specially trained chiropractors will know the Webster Technique (which can turn malpositioned babies), something many other chiropractors are not familiar with.  However, it is not always easy to find people with this training.


If you can, it’s best to find someone who specializes in “pediatric chiropractics.” One possible way to find one is to check the website at www.icpa4kids.com and see if there is a specialist listed in your area.  If there is not, you can email info@icpa4kids.com or call 1-800-670-5437 and ask if there’s one in your area. They have an extensive file of many chiropractors who are not listed on the site itself.


Another excellent resource is the International Chiropractic Association (ICA). Call and ask for the Council on Chiropractic Pediatrics (1-800-423-4690).  They also have an extensive list of people trained in this technique and many others.  It is not always easy to get through to this group, but their training is extensive and extremely detailed, so this is an excellent place to start.


If there’s no one listed in your area through either of these groups, start cold calling all the chiropractors in your area to find one who knows the Webster Technique.  If there is no one in your immediate area that knows the Webster Technique, see if there is one within a few hours.  In Kmom’s opinion, it is definitely worth driving some distance in order to find someone specially qualified.  It’s better to drive a little than to endure the continuing pain of SPD, risk a long and difficult labor with a malpositioned baby, or possibly a cesarean because of a breech baby!  So don’t be afraid to go outside your usual range of driving.


If there is truly no chiropractor in your area trained in Webster’s Technique, try to find someone who has extensive experience and/or extra training with pregnant women.  Some women have found that even though they didn’t have the specific “Webster’s Technique” done, they were able to get some pain relief from SPD, and sometimes their babies even turned. Webster’s is the most effective treatment, so you should search long and hard for that before choosing someone else.  BUT if you cannot find one trained in Webster’s, a chiropractor with experience in treating pregnant women may be better than no treatment at all.


Whatever chiropractor you see, it seems to be very important to have them not only evaluate the back and the sacroiliac joints, but also to evaluate and adjust the pubic symphysis directly, something many chiropractors omit, even those trained in Webster’s Technique.  Be sure they check and treat the pubic symphysis too!  And if possible, they might want to try a “diaphragmatic release,” a “Xiphoid Process Release,” and Cranial Sacral Therapy as well (see below).


What Is An Adjustment Like for Pregnant Women?
Many women who have never seen a chiropractor before are understandably anxious about what an adjustment is like, and especially how it is done during pregnancy.  A chiropractic adjustment during pregnancy usually involves the mom lying on her stomach on a pregnancy cushion that has an indentation designed to protect and cradle the baby.  Baby is perfectly fine as long as mom is on this cushion. Some chiropractors have a table that is specially designed for pregnant women.


The adjustment usually takes place on a special chiropractor’s table called a ‘drop table’ (with the pregnancy cushion on top).  Alternatively, the woman may also lie on her back for some adjustments as well.  Parts of the drop table are able to be tilted up slightly, at an angle to the rest of the table.  When the chiropractor does an adjustment, the tilted part of the table drops a bit.  The adjustment plus that small drop (usually not very jarring) is often enough to realign the part of the body being worked on. Not all chiropractors use a drop table, but it’s often a good tool with pregnant women because of limited ability to do other maneuvers. Other techniques that may or may not be used involve wrapping your arms around yourself like a pretzel while they adjust your back, leaning your hips/feet to one side, as well as other techniques that depend on the chiropractor’s training and background.


Some (but not all) chiropractors also believe in working with the soft tissues (i.e. ligaments, etc.) that surround the joints.  They feel that if these soft tissues are not also ‘released’, then their tension may slowly pull the bones out of place again.  This is probably an important part of treatment, one that should not be neglected if at all possible.  Don’t just get a spine or pelvic adjustment; also ask for soft tissue work. A ‘diaphragmatic release’ or a “xiphoid process release” has also been noted to help turn some babies even when the chiropractor did not know Webster’s Technique.  [Kmom is not familiar with what either of these processes involve, but they are not reported to be traumatic at all.]


Another excellent treatment is called “Cranial Sacral Therapy” (CST).  (It may have other names outside the US.)  Kmom found CST highly effective too.  If your chiropractor does not do soft tissue work or CST, you may want to supplement your treatment with someone else who can do these things (see www.upledger.com for CST practitioners in your area).


Is Chiropractic Care Really Necessary?
Is chiropractic treatment absolutely necessary to give birth?  Of course not; women were having babies long before chiropractic treatment was invented. Your body knows what to do, and although misalignments might make labor harder or more inclined to malposition, it certainly is not an automatic sentence to a cesarean.  Some women with SPD do have vaginal births (see below).  There are too many variables in birth to say with certainty that SPD will cause problems.  But because such a high percentage of women with SPD anecdotally seem to have malpositions and/or difficult births, it seems sensible to err on the side of treatment if you are experiencing significant discomfort.


What if you are experiencing some pain and discomfort, but not crippling amounts?  Must any degree of SPD automatically be treated?  Most chiropractors believe that any level of pain and discomfort indicate a need for treatment, and that this is your body’s “early warning system” to tell you that something is wrong and needs fixing.  Some degree of pelvic laxity is probably normal in pregnancy, but most chiropractors do not believe that pain, even minimal pain, is normal. From their point of view, it is better for women with mild SPD to get treatment in order to prevent the problem from becoming more severe later on and impacting birth. However, it is not absolutely required.


Some women are understandably reluctant to try chiropractic care, something that is still on the fringes of mainstream medicine, and which, frankly, needs more scientifically rigorous study.  Other women do not have the money or insurance to pay for chiropractic care, or cannot find a suitable provider near their home.  As a result, some women elect to just live with mild to moderate SPD and only get treatment if things become severe.  Kmom’s personal opinion is that it’s better to be treated, even with only mild discomfort, just in case.  But if you really feel that treatment is something you cannot or prefer not to do, this is of course your choice.


Some women with SPD do manage to get through pregnancy reasonably well and still have a normal birth.  Chiropractic care is not a strict necessity for every woman, though probably a reasonable precaution.  If you do not get treatment, keep in mind that you are probably at increased risk for pubic symphysis damage from birth so your providers should be aware of potential SPD problems ahead of time.  They should watch for malpositions, stalled labor, and should be especially careful about maternal positioning during labor and birth (see below).  These moms  should also plan to avoid labor interventions in order to save strain on the area, and to preferably labor unmedicated so they can be more aware of any possible strain on the area.  Hopefully, with care, you will be able to prevent or minimize any problems.


Postpartum, women with mild untreated SPD may find that their pain seems to go away within a few weeks.  Sometimes it is slightly worse right after birth but given time, resolves on its own. Here again, chiropractic care can be helpful but is not absolutely required.  However, these women should be aware that the misalignment is probably still there at least minimally even once the pain ceases, and they should be conscious of the continuing potential for further damage from accidents or falls.  If they show symptoms of problems in the future, they might want to again consider treatment.


What Is a Typical Appointment Like?
A chiropractor will feel down your back to see if there are any subluxations (misaligned parts).  They may also test range of motion on you in certain joints.  In addition, chiropractors trained in Webster’s Technique will test you for pelvic alignment.  The results are sometimes referred to as someone being “Webster Positive” or “Webster Negative.”


To find out if you are Webster positive or negative, you lie down on your stomach while your chiropractor gently pushes your feet towards your bottom.  If one leg reaches further than the other, this means you are “positive” and could use the Webster.  If your feet are even, then your legs are equal in length, and you are “Webster negative” and don’t need Webster’s Technique.  Note that they are not talking about really big leg-length differences (which are unlikely) but rather about small and subtle differences between leg lengths.  These indicate a pelvis that is out of alignment. Chiropractors will not do automatically do Webster’s Technique on anyone; they test first to be sure it is needed.


The Webster Technique is difficult for a non-chiropractor to explain adequately.  (An technical description of it can be found in Anne Freye’s book, Holistic Midwifery.)  The following description relates Kmom’s experience receiving Webster’s Technique and then Cranial Sacral Therapy (at 36-38 weeks), but please note that since Kmom is not a chiropractor, these are only her impressions, which may not be completely accurate technically.  Also note that the full version of Kmom’s story is in the section on Women’s Stories.

First, the chiropractor watched me walk; she remarked on how ‘off’ my gait was.  Then she took a history and we discussed my concerns extensively.  Afterwards, she put me on my stomach on the pregnancy cushions on a drop table.  She felt along my back to see how the joints were moving and to identify problem areas.  Then she took my legs and bent them upwards at the knees towards my hips to see if they were the same length.  (She was looking for subtle differences.)  She found that one leg was indeed longer than the other, indicating that the pelvic area was out of synch.  

After checking several different things, she raised one small section of the drop table, the area under my hips.  She identified the area that needed adjusting, asked me to take a deep breath in, then exhale deeply.  During that exhale, she pushed sharply and strongly on that part of my low back/pelvis, and the table section under my hips dropped a bit at the same time.  I wasn’t quite sure what to expect and was really nervous about seeing this type of chiropractor, so I was pretty startled by that drop to say the least.  But it didn’t hurt; it was definitely jarring but mostly it just startled me.  She apologized and said that I was so far out of synch that she needed to use more of a drop than she usually used. Afterwards, she also put her hands on my abdomen at various points to help “release” the uterine ligaments and other supporting tissues.

It’s hard to remember if she adjusted anything else that day.  Some sources say that you should not have any other adjustments done after Webster’s Technique is initially done.  I can’t recall exactly everything that we did.  I do remember clearly that she did finish up with soft tissue work (very gentle and non-invasive) and Cranial Sacral Therapy (which puts the weight of about a nickel on your head and sacral areas).  At other visits, I know for sure she worked extensively on my Sacro-Iliac joints, my middle back, and to a lesser extent, my neck. As is common with chiropractors, she never checked the pubic symphysis joint, however.

When I walked to the check-out desk after the first visit, I  have to say I felt very foolish for being willing to try such a weird maneuver. As I wrote out the check, I felt like I had probably wasted my money.  I was pretty emotional.  My husband took me out to lunch afterwards to comfort me, and suddenly about an hour after the appointment, I noticed that my pain was gone and I was feeling terrific!  It was weird how it took about an hour to “register” on me. All of a sudden I felt so good I felt like getting up and dancing around the room!   I don’t know if it was because the baby had suddenly turned or what.  Whatever it was, it was just an awesome feeling, and I slept better that night than I had in a long time.

My first visit to that chiropractor was about 45 minutes or so, while subsequent visits were about 15 minutes or so, give or take.  After the first visit, the baby turned to the best birth position for the first time in pregnancy. The progress was really quite remarkable.  I should note that I wasn’t entirely pain-free afterwards, and since tissues tend to revert back to previous patterns, I eventually started to feel things go back again.  But I felt so much better than I had before, it was like night and day!

I had visits once or twice a week for 2+ weeks before the baby was born.  Each time I would feel so much better!  I  just wished I had found her earlier in the pregnancy so I could have gotten some relief then and more fully resolved everything before the birth! I don’t think we were able to fully resolve every alignment issue I had in that amount of time, but it sure helped!

For the birth itself, I did have another malposition, though one more easily resolved than previously.  However, I fell twice the day I went into labor, which could explain the malposition. It was a very rainy day, and I slipped and started falling.  I saved myself from falling badly, but I could feel a big constriction in the PS area all of a sudden.  Then later on, I was sitting on a stool and unexpectedly tipped backwards, landing on my tailbone and sacrum.  I certainly felt that!

The labor stalled about 5 cm, and became very painful for a while, probably indicating a malposition.  I definitely had some pubic pain and major back pain during labor.  However, the malposition resolved when I shifted my hips ‘just so’, and the baby was born shortly afterwards.  I noticed that I made no progress when pushing in the “usual” position (hunched forward in a “C” with legs drawn back), but when I was able to arch my back REALLY strongly, the baby slipped right under the pubic bone and was born shortly thereafter.  Instead of 5 hours of pushing (as with my previous child), this one was born in 12 minutes of pushing.  It was short, intense, and wonderful.

I had a normal vaginal birth after two previous cesareans for malpositions (believe me, the recovery was MUCH easier), and I give my chiropractic treatment a lot of credit for helping me with that.  And I did NOT sustain any permanent damage to the pubic symphysis area from giving birth vaginally! It was a great experience overall.

Postpartum, my chiropractor only treats the babies and not the postpartum mommies, so I did not get any follow-up care after the birth.  The baby did have some significant colic (not unusual in malpositioned babies) so we took him in for Cranial Sacral Therapy.  I was very dubious about taking a baby to a chiropractor (and my husband was even more doubtful!), but after having experienced for myself how very gentle it was, we decided to try it.  It had remarkable results, and REALLY helped the colic.
Postpartum, eventually my pain came back, especially the back pain.   I saw an associate of my chiropractor, and we worked on improving my back.  While the treatments did help, sometimes they had the side effect of causing hip pain and restriction.  What we didn’t realize was that the pubic bone was out of alignment and that was affecting everything else.  It took us some time to figure out the problem, but eventually we tried doing a pubic bone adjustment.  This had not been done for me in pregnancy; it’s often not part of a routine check.  But it seemed to be one of the main sources of problems for me.

In a PS adjustment, they use a drop table raised under the pelvis.  The client puts her own hand over the pubic bone (so the chiropractor is not directly touching you ‘there’), and they do a quick adjustment, just like on the back.  The raised area of the drop table drops down, giving extra ‘oomph’ to the adjustment.
I won’t lie to you.  A pubic symphysis adjustment definitely stings.  The back adjustments never hurt me at all, but this joint does  sometimes ‘sting’ when adjusted.  It’s not bad and goes away quickly (or I’d never do it!), but women should know that this adjustment is a little harder than the others, especially if the pubic bone is way out of alignment.  To me, it was better to have a little sting now then months of discomfort, but it was definitely not as easy as the back adjustments. Harder, but worth it.

Of all the adjustments we’ve done, I’d say this pubic bone adjustment is the one that’s given me the most help.  It also eliminated the hip discomfort and restriction I’d previously experienced from treatment.  We are still working on the soft tissue angle; my recent adjustments have not included the ligaments and such, and probably should.  But it is AMAZING how much the chiropractic care has helped!  I’m not 100% pain-free at all times, but I am MUCH better.  The difficulty we still have is in maintaining the adjustment long-term.  We are still working on this.

One of the important points of my story, though, is the importance of keeping up the search for the right treatment modality and the right provider; see below for the story of how long I actually had to search to find these treatments that helped!

Caveats: It’s important to know that just as with any health field, there are good and not-so-good chiropractors.  Some are extremely well-trained and know exactly what they are doing; some do not.  Most are ethical health providers, but just as with doctors, there are some quacks out there who are just looking to make a quick buck.  Be cautious when selecting a chiropractor, and don’t be afraid to switch if needed.


The Importance of Perseverance
Not every style or treatment plan works for every patient; some women have to see multiple chiropractors before they find one that really finds the key that resolves the problem.  If the first chiropractor you see doesn’t seem to change your pain levels, consider trying another.  Kmom briefly saw 2 different chiropractors and 1 osteopath before she finally found the best approach for her (see her story below), and even now still is experimenting with treatment to find out what works best and what doesn’t.


Remember that there are different “schools” of chiropractic training and tradition too.  If you go to one chiropractor, you may get one form of treatment, and if you go to another, you may get a totally different approach.  That’s why sometimes you have to search to find the approach that’s right for you, and if you are not getting optimal results with one, why trying another approach may help.


Of course, if you are unhappy with your course of treatment, it can be discontinued at any time.  Don’t feel tied to any one provider.  In fact, if you feel you are no longer making progress with one provider, it may be that trying a new chiropractor will bring fresh new perspective on your situation. Just as with doctors, YOU are the employer, and you can “let go” your employee at any time.


Have Realistic Expectations
It’s important to have realistic expectations going in to a chiropractor.  Some people expect to have one adjustment and be forever free from pain or a recurrence of the problem.  In reality, it usually takes multiple treatments (one criticism of chiropractic care), and sometimes it is a challenge to find all the sources of problems.  Chiropractors are not miracle workers.  Making a significant change can take time.


While many women find total relief of pubic pain with treatment, others find it greatly diminished but not gone entirely. A really significant case of misalignment which has been around for years often takes quite a while to resolve, and some women struggle with chronic alignment problems all their lives.  Many need periodic treatment to keep things working well, and if you later experience any falls, car accidents, or other trauma to the area, you may need intensive treatment again.  A short-term course of treatment may not always completely fulfill your needs. On the other hand, sometimes a short-term course of treatment is all that is needed.


The key is not to expect a miracle cure or a permanent total ‘fix,’ but to look for significant improvement in range of motion, pain levels, activity levels, and comfort. Although it is only human to look for a cure, any improvement is helpful, and hopefully long-term treatment can significantly reduce your discomfort. Don’t be afraid to continue to look for additional help if needed, but keep your expectations realistic.

Osteopathic Osteopaths also work with realigning the bones, ligaments, and soft tissues of the body but the philosophy and methods are slightly different.  Osteopaths are trained in traditional medicine as well as the musculoskeletal system, but they tend to place more emphasis on preventive medicine, in looking at the body as an interconnected system, and often use osteopathic manipulation and other ‘non-traditional’ therapies.  They use the initials “D.O.” after their names instead of “M.D.”, but because their training does include traditional medicine, many go on to become pediatricians, OBs, etc. as well.


Although trained in osteopathic manipulations, many D.O.’s have gone very mainstream and no longer do manipulations, may do some only on a limited basis, or may not have much training in manipulation at all.  Simply going to any D.O. will not guarantee that they can help you resolve this problem; you may need to search to find one that truly knows about manipulation and resolving pelvic issues.  You may need what is sometimes called a “classical osteopath.”


At the International Cesarean Awareness Network Conference in April 2001, Kmom saw a presentation by Dr. Anita Showalter, a D.O. who is also an OB/GYN.  Among other things, she mentioned the problem of ‘pubic shear‘, where a misalignment of the pelvis causes one side to be higher than the other, resulting in tension and discomfort in the pubic symphysis joint area.  A search for ‘pubic shear’ online brings up this technical definition from an osteopathy website:

  • Inferior pubic shear (inferior pubis): a somatic dysfunction in which one side of the pubic symphysis is inferior to the contralateral side as the result of a shearing in the saggital plane.
  • Superior pubic shear (superior pubis) reciprocal of inferior pubis.

At a follow-up after the conference, Dr. Showalter elaborated a bit more, explaining how pubic shear happens and what can be done to help.  The following is a summary (from memory!) of her information; please be aware that because it is done from memory, it’s possible there are errors.  It’s also possible that Kmom may have misinterpreted or misunderstood parts of the information, so insert caveats.  Be sure to consult an osteopath familiar with this problem for further information or any treatment advice!


As Kmom understood it, pubic shear is where the two pubic bones are not exactly parallel (in the same plane) in front; one is higher than the other.  This creates lots of extra pressure on the cartilage and ligaments in the area, because they are being stretched and pulled on in a way they were not designed for.  Pregnancy hormones exacerbate this problem.  Hip movement can be restricted, movements that involve lifting one leg higher than the other are particularly painful, and problems in this area can affect other areas, such as the sacro-iliac area, etc.


Dr. Showalter also showed Kmom and others a manipulation that she says helps many women with this problem (and it was nothing like the Webster’s Technique Kmom had gotten previously!).  Because it’s hard to describe accurately, because people might hurt themselves doing it wrong, and because it is important to consult an expert before trying treatments like this, Kmom will not recount here exactly what this manipulation entailed.  However, she will give a basic description so women understand that it really was not very interventive at al, but please don’t try this based on this summary!


It involved the woman lying on her back, having one knee drawn up (which knee depends on which side is out of alignment), and a D.O. or partner using gentle pressure on the opposite side of the pubic bone (towards the hip) while simultaneously pushing down the knee towards the foot until the heel slides down and the leg is stretched out on the ground like the other leg  (it’s trickier than that, but that’s the basic idea).  Doing follow-up with the soft tissues may also be helpful.


Several women tried this with Dr. Showalter, and reported that it felt good.  Kmom tried it but did not feel much difference, although since she was not pregnant at the time and had already had chiropractic adjustments, there may not have been much to affect!  So finding an osteopath that knows how to help ‘pubic shear’ may be another option for treatment.
When told that some doctors have told pregnant women that an elective c/s would be necessary to prevent permanent pubic symphysis damage, Dr. Showalter expressed great dismay.  She was also upset at how many women are told that this pain is normal to pregnancy, and that the only fix is to take some Tylenol and wait for birth.  She felt that treatment was very important, and reinforced that back or pelvic misalignment can increase the chances for malposition of the baby.


When asked about permanent pelvic damage from this condition, she felt that in rare and extreme cases, the pubic symphysis can be torn or separate, but usually only by foolish actions on the part of doctors, nurses, or labor helpers.  She said that virtually every case she’s ever heard of has occurred when the woman had an epidural, was on her back, and had her legs flexed back too strongly by well-meaning but over-enthusiastic personnel.  The epidural prevented the woman from feeling the pain at the time, so nobody knew to stop.  Thus the woman was injured during birth and no one realized it until later.


One intriguing note written online by British osteopath Steve Pike observes that not enough attention is paid to the soft tissues when treating this problem.  He feels that the ‘clicking’ problem many SPD women note may be related to a tendon problem instead of a bone problem.  He writes at www.kamish.com/dsp/_disc2/0000008b.htm:

I have successfully treated several patients with symphysis pubis dysfunction.  It always amazes me that the muscles, ligaments, and connective tissues are virtually ignored in the discussion and treatment of this condition, all attention being focussed on the symphysis pubis joint and the sacroiliac joints.  Yet the soft tissues are what binds the whole pelvis together and provide support and locomotion.  Treatment of the soft tissues using osteopathic massage techniques almost always improves the condition–sometimes dramatically.  I would add that the “clicking” often noticed by sufferers during walking, often does not come from the pubic symphysis at all but from the tendon of the psoas muscle—an indication that this muscle is tight and needs treatment.  

One British woman, Lia Hattersley, wrote about her experience with SPD and osteopathy at www.guardian.co.uk/health/story/0,3605,724347,00.html. The pain was so bad prenatally that she ended up in a wheelchair at times.  Postpartum, she found Quentin Shaw, a “classical osteopath” who is a senior lecturer at Surrey Institute of Osteopathic Medicine.  She says, “After one treatment I was able to walk and my crutches became obsolete.”


Her article recounts her whole experience, the lack of help she experienced from traditional treatments, the reluctance of medical authorities to consider alternative care such as chiropractic or osteopathic treatment, and the stories of a few other women also helped by alternative treatments. She ends her article with a call for more access and openness to these choices within the British medical system.


In summary, osteopathic treatment may be another option for women suffering pubic symphysis pain.  Osteopaths may be a little easier to find than chiropractors who know the Webster Technique, but not all osteopaths still practice ‘osteopathic manipulation’ techniques.  Many no longer use manipulations, and of those who still do, not all are equally trained.  It may be necessary to find a “classical” osteopath, especially one who specializes in pelvic problems.  Treatment may also take longer.


Again, be open to the fact that you may need to try several different practitioners or treatment modalities before finding what works best for YOU.  If one osteopath does not seem to help you, don’t assume that none can.  Be willing to try several different ones.  The quality of osteopaths, like chiropractors, seems to vary widely.  You want one that regularly uses manipulations in their practice, and if possible, one that specializes in pelvic treatment.

Other Alternatives
A.  Polarity Therapy – Elizabeth Noble, a physical therapist and birth activist, wrote about pubic pain a bit in her book, Essential Exercises for the Childbearing Year. She describes polarity therapy for pubic symphysis pain this way on page 219:

Lying on your side, a partner places all five finger tips firmly at the union of your pubic bones, and the other hand rests flat on your sacrum.  The hands should remain still on these two points until warmth, tingling, vibration, pulsing or other evidence of your body’s electric field can be felt equally in your partner’s both hands.  Usually only one to two treatments is necessary.  I have successfully used polarity balancing to treat painful PS laxity for fifteen years. 

Kmom tried this with her husband and had no success with it; perhaps it was not done correctly.  Kmom knows little about ‘polarity therapy’ but tends to be dubious so far.  However, it’s certainly unlikely to do harm to try it.  Noble has many excellent ideas and exercises in her book, and does have some ideas for sacro-iliac pain as well, so this book probably is worth looking into for other issues.


B.  TENS – Some women report that TENS (Transcutaneous Electronic Nerve Stimulation) has helped improve their pain.


C.  Pressure Points – One mother with SPD reported that using pressure points seemed to improve her pain levels.  Here is what she wrote about it:

“If you can’t [see a chiropractor], I will tell you of an exercise you can do at home to help relieve some of the pain yourself!  First, I know you are going to say, ‘Yeah, right, you’ve got to be kidding’ but you have pressure points right on the top, corners and sides of your pubic symphysis bone [the pelvis]. Basically, lie down flat on your back (or as close to it as you can get!) and wherever you are feeling pain, take your fingers or thumbs and press on those point for about 10-20 second at each point and do this once or twice a day.  It will hurt like hell at first but it will actually feel a lot better once you do it.  It’s even better if you can get someone else like your husband to do it because they will exert a little more pressure than you will let yourself do!  Just grin and bear the pain and I promise you that the pain will subside somewhat—maybe not all the way, but it worked wonders for me!
“You can also have microcurrent therapy done on these spots (has to be done in the chiro’s office) but it also works!  It is amazing that my pain is almost gone, especially considering the amount of pain I was in…although I do still have some bad days where overuse and lots of activity give me pain….all I have to do now is do the pressure points and the pain is relieved….LIKE MAGIC!!”  

D.  Movement/Strengthening Therapies – Several women have reported on other websites that movement and strengthening therapies like the Alexander Technique and Pilates have helped them postpartum. The Alexander Technique is supposed to help retrain you into more efficient and better muscle usage. Pilates is supposed to work on strengthening the core muscle areas (abs, back, etc.).  However, some women report that Pilates actually worsened their back pain in the long run.


E. Acupuncture – Acupuncture has also been reported to help pain levels.  It does not resolve pelvic misalignment, but it has been used successfully to treat many different types of pain.  Some acupuncturists are reluctant to work with pregnant women; seek someone who is very well-trained and experienced in working with pregnant women, even if you are postpartum.


F.  Homeopathy – Some women report improvement in pain with the use of the homeopathic remedy, Kali Carb, 30c.  However, homeopathy is very much based on an individual’s personal circumstances, personality, and needs, and you would need an individual consultation to know what remedy would work best for you.  Many scientists are highly dubious of the value and efficacy of homeopathy; but there are also many devotees worldwide who swear it has been helpful.


G. Herbs – In Cora’s story, below, she recounts the use of herbs to help reduce her levels of pain, reputedly by helping to repair internal tears.  Again, herbal treatment should be done only by a specialist in herbs, since over the counter herbs tend to vary widely in quality and strength, and because so many considerations must be balanced in treatment.

The great herbalist Susan Weed recommended (about 3 weeks ago) Teasel tincture, which is for “internal tears that are hard to get at,” and comfrey infusion (the other name for Comfrey is Knit Bone).  Within 3 days of taking the Teasel (15 drops 3x a day) I started seeing improvement.  Now I am 31 weeks and feeling almost no pain at all and can move more quickly and efficiently than I could at 18 weeks when the baby was so much smaller.  I am amazed and thrilled that these remedies are working so incredibly well and thought that other women should know about them.  

H.  Pelvic Support – A maternity support belt can offer extra support and firm pressure, which many women seem to find helpful.  However, please note that if the pelvic bones are not in the ‘right place’, some women find that a maternity support belt can make the pain worse.  One physical therapist at http://pregnancytoday.com wrote:

If the pelvic ring, which includes your pubic bones and sacroiliac joints, is not lined up symmetrically, using the reenie belt will just increase the pain.  This is because it serves to compress the front and back joints of the pelvis which are out of position…I recommend…a physical therapist in your area that specializes in treating pregnant women. The therapist can evaluate your problem carefully, and, if need be, provide hands-on treatment to restore normal joint alignment. Once you achieve that, the reenie belt can do its job of keeping the pelvis in alignment and will not be painful. 

Planning for Birth
Certain common obstetric interventions tend to make Symphysis Pubic Dysfunction pain worse, and may even lead to ligament damage or severe separation of the joint, causing true Diastasis Symphysis Pubis.  Therefore, it is vitally important that your doctor or midwife understand and believe in the existence of SPD and realize its implications for birth.  The following ideas (taken from a number of sources) are supposed to help maximize your comfort and help the normal birth process, while also minimizing the risk for pubic symphysis-related trauma.

  1. Be extremely careful of birth positioning.  Certain positions are better than others.  Avoid stirrups!
  2. Be sure your labor assistants and providers know all about SPD, what movements can hurt or damage you, and what your comfortable range of motion is
  3. Avoid most common labor interventions, as these often cause pubic symphysis strain/damage
  4. Avoid an epidural if at all possible, as this often is associated with more severe damage
  5. Use a ‘narrow gap’ between the legs for any routine procedures that can’t be avoided
  6. Hire a birth attendant that is familiar with and can help resolve baby malpositions



Specifically, you might want to consider the following:
1.  Be extremely careful of birth positioning.  Certain positions are better than others.  Avoid stirrups!

  • Don’t give birth on your back – Many cases of pubic symphysis injury occur in this position
  • Don’t give birth semi-sitting – This tends to force the baby’s head against the pubic symphysis, putting pressure on it to ‘give’ more.  It also prevents the coccyx/tailbone and sacrum from moving out of the way during birth, and thus the only joint available with any ‘give’ to it would be the pubic symphysis, which puts it at greater risk for damage
  • Don’t use stirrups – This widens the gap between the legs and strains the pubic symphysis
  • Use ‘alternative’ birth positions – These include standing, kneeling, and all fours in particular.  You may have to search for a provider that is comfortable using these positions throughout labor.  Some doctors will ‘permit’ women to use alternative positions until just before baby’s head crowns, but often want the woman back in the traditional stirrups or semi-sitting position for crowning of the head and delivery of the shoulders.  However, crowning and birth of the shoulders is the most critical time for prevent pubic symphysis damage, so really look for a doctor or midwife that is willing to ‘let’ a woman be in whatever position feels best to her for birth.  If you must be in a more ‘traditional’ position because of other concerns, try side-lying as this takes the pressure off of the pubic symphysis and allows the coccyx and sacrum to move somewhat.  Otherwise, all-fours or leaning back over a birth ball may be best
  • Listen to your body – Your body usually will tell you what position you need to take in order to help baby out while avoiding damage to your joint.  This may be contrary to what your nurses or provider are telling you, but give preference to the positions that feel best to you. For example, sitting forward in a “C” is the position promoted in most hospitals, but Kmom found arching the back to be most helpful.  This helped her baby move under the pubic arch and be born rapidly, while in the traditional “C” semi-sitting position, there was no descent of the baby and great pain instead.  Other women with pubic pain have reported that arching the back during pushing was helpful too.  Use the position your body tells you to!

2.   Be sure your labor assistants and providers know all about SPD, what movements can hurt or damage you, and what your comfortable range of motion is

  • Hire a birth attendant that takes SPD seriously – Many providers do not really believe that SPD really exists or that it is a serious concern for birth.  Little mainstream literature exists on it, so you may have trouble convincing some providers that it is anything more than the normal aches and pains of pregnancy.  If they do not really understand the concerns of SPD, they will not be as careful at the birth
  • Hire a birth attendant that rarely uses interventions like stirrups, forceps, etc. – If these interventions are not part of your caregiver’s normal procedures, chances are good that you’ll avoid them.  If your provider often uses these procedures, chances are they will have a hard time avoiding them, even when they know that they need to be avoided
  • Consider giving birth in a non-hospital facility or at home – This might help lessen chances of damaging interventions, since stirrups, forceps, and other routine interventions are done less in these settings
  • Educate your birth attendant, coaches, and other helpers about SPD – Raise the awareness of SPD problems with your attendants and helpers so they can help you avoid problems during the birth.  Be sure to especially discuss with them the importance of a ‘narrow gap’, avoiding interventions whenever possible, and how to avoid placing extra strain on the pubic symphysis area

3.  Avoid most common labor interventions, as these often cause pubic symphysis strain/damage

  • Avoid the use of forceps or vacuum extractor – These may necessitate opening the legs wider than the pubic symphysis can safely tolerate
  • Don’t pull your knees back too far – This puts a great deal of strain on the pubic symphysis joint.  Be sure to let your nurses, doula, or labor coach know not to do this!
  • Don’t put your legs on your attendant’s hips – Again, this strains the pubic symphysis joint
  • Minimize or avoid vaginal exams – Positions for vaginal exams tends to strain the pubic symphysis joint.  Do as few vaginal exams as possible (most are not necessary anyhow) so there is less frequent strain, and use as small a leg gap as possible if a vaginal exam must be done
  • Avoid an induction if possible – Induction contractions are often abnormally strong and difficult to handle without an epidural to help, and this increases your chances of other harmful interventions
  • Avoid breaking the waters early – Since malpositions may be more common with SPD, it is probably sensible to avoid breaking the waters artificially during labor.  If baby is malpositioned and the waters are broken, then baby often moves down in that malposition, cannot turn, and gets ‘stuck’, necessitating a c-section. If labor stalls around 4-7 cm or so in a woman with SPD, then baby malposition should be suspected, breaking the waters avoided, and changing maternal posture utilized to help baby turn

4.  Avoid an epidural if at all possible, as this often is associated with more severe damage

  • Avoid an epidural so you can tell if damage is imminent – Once your feelings are deadened, you may not be able to tell if they force your legs too strongly, and this is when many tears or severe separations occur
  • Avoid an epidural to lower the chances for forceps, vacuum extractor, and stirrups – Stirrups are standard procedure in many hospitals with epidurals, and stirrups increase the chances of damage.  In addition, one side-effect of epidurals is to strongly increase your chances of needing forceps or vacuum extractor during pushing, which also necessitate a wider leg position and increase the chance for pubic symphysis damage
  • Consider hiring a doula (professional labor support) – A doula can often help you cope with labor without having to have an epidural; she can also help you remember to remind caregivers to avoid a wide gap.  Research shows that need for epidurals and other pain relief methods is much lower with a doula present

5.  Use a ‘narrow gap’ position between the legs for any routine procedures that can’t be avoided

  • Use a string to measure ahead of time the widest comfortable position for your legs – Have your coaches use that in labor to remind nurses and other attendants of the widest position that is wise
  • Use a ‘narrow gap’ only – If vaginal exams is truly necessary or if any stitching is needed afterwards, be sure to remind the providers to use a ‘narrow gap’ only

6.  Hire a birth attendant that is familiar with and can help resolve baby malpositions

  • Research and understand the signs of a baby malposition – Baby malpositions may be more common in women with misaligned pelvises and pubic pain, and this can cause a more painful, difficult labor.  Understanding the issues and knowing the symptoms may be very important in avoiding such a labor
  • Understand how to prevent malposition or turn a malposition during labor – There are things that can be done to help avoid a malpositioned baby or even to help turn one during labor.  Educate yourself more about this so that you can be proactive about prevention at home and pass on the info to your provider
  • Hire a birth attendant that takes malpositions seriously and knows how to help them – Most doctors and many midwives do not really understand baby malpositions and how they can affect labor and birth.  It would probably be very helpful to hire a birth attendant that pays careful attention to baby’s position before and during birth, and knows how to use maternal positioning and other techniques to get a baby to turn.  [For more information on this subject, read the FAQ on Malpositions on this website.]



Please note that when the pelvis is well-aligned and labor precautions are taken, most women are able to give birth vaginally without any problems or damage.  An elective cesarean is NOT necessary for women with SPD; if precautions are carefully observed, the chances of pubic symphysis damage are greatly lowered and the significant risks associated with cesareans are avoided as well.


However, because the pressure on the pelvic joints to expand is greatest as baby emerges, women with SPD may find that pushing is uncomfortable at times.  If they are allowed to use the position that feels best to them and if birth attendant pays attention to the baby’s position, baby is usually born without difficulty and this discomfort is minimized and transient, unlike the post-surgical pain that would be associated with a cesarean. Being aware that pushing may be uncomfortable and knowing the importance of using alternative birthing positions (try arching your back!) may go a long way towards helping a woman be prepared for and deal with this.


In Kmom’s opinion, the most sensible approach to SPD is probably to carefully correct any pelvic or spinal misalignment during pregnancy and well before labor.  However, because of the hormonal influences on the pubic symphysis area, it is probably also extremely important to utilize these labor precautions as well.  Women with SPD can give birth safely vaginally, and this is usually best for both mother and baby.  However, being proactive about positioning and avoiding interventions during labor is only sensible as well.

Other Common Questions
How often does a separated pubic symphysis occur?
No one knows for sure.  Estimates range from 1 in 300 to 1 in 30,000.  The difference probably has to do with the definition of ‘separation’ (how severe does it have to be before it is counted?) and differences in birth practices (it’s probably more common where stirrups and epidurals, etc. are used aggressively).


Is this condition related to my build or size?
Many people have wondered whether their particular size or build contributed towards their SPD.  The answer is probably not.  In various resources on SPD, both a very large build and a very petite build have been blamed for causing SPD problems.  If size/build really caused this problem, all fat women or all petite women would get it, and we know that this does not happen.  Most likely it has more to do with hormone sensitivity or pelvic misalignment than build.  A past history of pelvic trauma (car accidents, sports injuries, falls, etc.) seems to be common among many SPD sufferers, so this is more likely to be the source of the problem.


Should I have an elective cesarean?
No.  This is a very common question; it seems logical that an elective c/s might prevent further damage to the pubic symphysis, but in reality the problem is caused during the pregnancy and an elective c/s won’t fix that.  The best option is to get the pelvic misalignment treated so that there is little danger of damage from SPD, and also to avoid the typical obstetric interventions (like stirrups) that tend to cause the severe problems that some women experience.


Only rarely do most women fully appreciate the substantial risks associated with a cesarean, both to themselves, to the present baby, and to any future babies.  A cesarean is MAJOR abdominal surgery.  It doubles the risk of maternal death, and blood loss also tends to be doubled because of the surgery.  This can cause anemia afterwards (a significant health problem), which can lower breastmilk supply or cause breastfeeding to fail.  1-2% of women who have cesareans have to be rehospitalized within a couple of months for complications; there is a 30x greater risk of being rehospitalized because of serious wound infections after a cesarean compared with normal vaginal birth. Women who have had cesareans have higher rates of gallbladder disease, appendicitis, chronic pain, internal adhesions, and bowel problems.  They also have slightly higher rates of infertility, miscarriage, and ectopic pregnancy.   Elective cesareans are also a risk to the baby, as significant breathing problems often occur without the benefit of labor.  These can be temporary, or may end up long-lasting and debilitating.  The risk for fetal breathing problems is particularly strong in elective cesareans before 39 weeks.


Most alarmingly, a cesarean scar brings significant increased risk for future pregnancies.  Uterine rupture can and does occur without labor.  Placental abnormalities increase after a cesarean, and increase very strongly with multiple repeat cesareans.  Placenta Previa (low-lying placenta which covers the cervix) is MUCH more common, and this presents a risk for severe hemorrhaging.  Placenta Accreta (where the placenta grows into or through the uterine wall) is a very severe complication associated with Placenta Previa, and often leads to hysterectomy and occasionally to maternal death. Placental Abruption (premature detachment of the placenta) also is much more common after cesareans, leading to risk of severe hemorrhaging and fetal death.  All of these are more common after a prior cesarean, and especially so after multiple repeat cesareans.  These risks should not be taken lightly.


Some women are tempted to have an elective cesarean because of past mismanaged births.  Quite understandably, they fear a recurrence, and see elective cesarean as a way to eliminate the risk of mishandling completely.  However, this simply trades old risk for newer and greatly underestimated risks.  For women who have had very severe and long-lasting damage from the mishandling of SPD, or for women who cannot or will not find a provider that will avoid the interventions associated with SPD, an elective cesarean may be worth the trade-offs.  For most women with SPD, however, the tradeoffs of risk (particularly if they eventually want more children) are not worthwhile.


An elective cesarean does not prevent symphyseal separation or strain, as this usually happens earlier during pregnancy.  What it might prevent is making things worse through poor obstetric management.  But the choice does NOT have to be between elective cesarean and vaginal birth with so much intervention that it causes damage.  Finding a birth attendant that works outside the typical medical mindset and does not employ the damaging interventions IS a real and viable choice, and lowers the risk of problems during birth.  But equally as important is checking for and fixing any pelvic misalignment well before labor.


Should I stop breastfeeding if I am still experiencing pubic pain postpartum?
No.  For years many women were told that the hormones of breastfeeding were causing postpartum pubic pain, and that weaning would probably improve their condition.  However, most women have not found that weaning improved their pain, and a substantial number found that it actually increased their pain levels.  Relaxin and progesterone are the hormones that are most responsible for pubic symphysis laxity, yet these are reduced during the breastfeeding period.  Instead, estrogen tends to be high during breastfeeding, and this has little bearing on pubic pain.


In addition, breastfeeding provides so much immunological protection for the baby that early weaning is not advisable.  It probably also helps decrease the risk for reproductive cancers in the mother, especially if it continues long-term.  So weaning early would probably not provide any pain benefits and would almost certainly lose the protective effects breastfeeding has for both mother and baby.  Don’t wean early.


Will this tenderness last after the birth?
It depends.  Some people have long-lasting pain and some don’t.  If it is really related to an underlying misalignment of the pelvis and back, then it is likely to stick around if that misalignment is not resolved, although it may lessen significantly once the pregnancy hormones are gone.  If the condition was made worse during the birth because the attendants mishandled the situation, then it may even be worse postpartum.  On the other hand, sometimes it goes away completely afterwards.   [See the section on “Postpartum” for more details.]


Will I get this problem back with every pregnancy?
Most women have it recur every pregnancy, but this is not always true.  Some get it worse with each successive pregnancy, while others never re-experience the problem at all.  Again, if there is a misalignment of the pelvis or back and this is not resolved, chances are it will recur with each pregnancy.  Or perhaps some women are just more sensitive to pregnancy hormone levels than others.


Some women wonder whether to limit the size of their family because they find SPD so difficult to deal with.  Before giving up on having more children, remember that many women DO find partial or full relief from various treatments, and that foregoing more children is truly not necessary.  However, you may need to be very aggressive about finding a new doctor or midwife that will help you avoid iatrogenic (i.e., doctor-caused) problems with birth, and you may need to try a number of different treatment modalities or practitioners to find the ones that can most help in your situation.

Postpartum
Some women may continue to have pubic and/or back pain postpartum, while others report that it gradually goes away. If the underlying cause is a misaligned pelvis and not just simply sensitivity to hormones, then the pain will probably continue in some degree unless it gets treatment.  However, sometimes the body does seem to heal itself just fine on its own, or gets better enough that the pain is not so noticeable until another injury, pregnancy, etc. causes a recurrence.


As noted, some women are told that breastfeeding hormones make pubic pain continue until weaning, but most women do not report that weaning lessens the pain.  Therefore, SPD should have no bearing on the length of breastfeeding, and women should not wean their children in hopes that this will improve SPD pain.  After menstrual cycles return, some report increased pubic pain premenstrually–usually during ovulation–while others do not see a cyclical recurrence.  A few women also report the pain to be worse while on the Pill, though this does not seem to be universal.


It should be noted that if at any time you need to have a hysterectomy, you should carefully discuss your SPD history with your GYN and be sure that they understand the condition fully.  Woman who have had vaginal hysterectomies (that is, a hysterectomy where the uterus is taken out via the vagina rather than through the abdomen) report that this has at times re-aggravated their SPD problems.  Because this type of surgery is performed with women in stirrups, it certainly has the potential to create pubic symphysis problems again. Because vaginal hysterectomies present many advantages in other ways, women who truly need a hysterectomy should carefully discuss the pros and cons of all of their various options with a doctor who is very knowledgeable about SPD.


The worst-case scenario for birth and post-partum is when a woman with SPD is mishandled, and use of stirrups, interventions, or ‘wide gap’ positioning damages or severely separates the pubic symphysis.  At this point, SPD become Diastasis Symphysis Pubis (DSP), which can be very painful and difficult postpartum. DSP can only be officially diagnosed after pregnancy with an X-ray, ultrasound, or MRI scan that will measure the distance between bones.


According to the British SPD Support Group website, when a woman is not pregnant the normal distance between the two pubic bones is 4-5mm.  In every pregnancy, there is an increase in the gap of at least 2-3mm due to hormones.  So a total width of up to 9 mm is considered normal for a pregnant woman.  Within a few months after birth, this gap decreases and the supporting ligaments strengthen again.  An abnormal postpartum gap is defined as 1 cm or more after the time when the joint should be back to normal.


If the pain continues severely postpartum, traditional medical treatment involves several options.  Injecting a steroid directly into the joint is one option sometimes recommended.  Another option is surgery.  Surgeons will sometimes take some bone from the hip area and make a plate to be screwed in over the pubic symphysis to try and stabilize the pelvis more.  This is a very big surgery, it reportedly can take several months to recover from, and the success rate is apparently not very good (see Lia’s story, below).  Or they can try to create scar tissue over the area in hopes that it will tighten up the gap or act as a kind of ‘plate’ over the area too.  For more information on these options, contact the British SPD support group, www.spd.-uk.org.


Because many problems can be helped at least somewhat through chiropractic or osteopathic care, even those with more severe cases of pubic symphysis problems might want to consider these options before resorting to something as traumatic and irreversible as surgery.  However, each person must do what seems best to them in their particular circumstances.


Although it is very difficult to get health providers to understand and take long-lasting pubic pain seriously, it has the potential to affect a woman’s whole body, and as a side effect, her emotions, her children, and her family life.  Don’t give up easily; many women have had to persist for many years before finding what works best for them in their situation.

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Posted by on August 16, 2010 in All, Pelvic pain / SPD

 

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