Pelvic Girdle Pain – DSP or SPD

• Managing Symphysis Pubis Pain
• Elective Caesarean for SPD/DSP?
• Positions for Birth
• Birth Stories
• Links to other sources of information

Managing Symphysis Pubis Pain

I had some SPD after having my second baby in Dec 99. I had no problems at all the first time around [aside – do you think the baby’s position can affect it? My second was stubbonly posterior]. I only had a few twinges during the pregnancy, but really felt it for months after the birth.

My GP reckoned that anti-inflammatories could break the cycle of pain – inflammation – more pain – more inflammation, but they only provided very temporary relief for me.

The thing that helped most for me was keeping mobile. The pain was at its worst when I had been still a long time – getting moving to get out of bed in the mornings was horrible. Having someone there to lend a hand each morning and take some of the strain helped, as did moving very, very slowly!

Personally, I found cutting out any form of exercise other than walking was what made the really difference. I had been swimming regularly and doing a weekly aerobics class, but anything other than gentle daily movements seemed too much for my poor old pelvis.

Otherwise, hot water bottles and hot baths brought me the most relief.

Charlotte
Student midwife and mum of 2

My feeling is that if a woman is suffering to the degree where the pain is restricting her movements then it may be a good idea to seek referral to and help from an Obstetric Physiotherapist.

With SPD it is important to support the pelvic bones and move correctly, i.e. not to abduct the thighs to far.

An Obs Physio may suggest the following forms of support:- A trochanteric belt, a Tubigrip (size K) or a sacro-iliac support. In addition s/he can demonstrate ways of avoiding/managing straddling movements, e.g. getting in and out of the car/bed/bath.

Movements where one leg is raised higher than the other all increase pain. So it is important to reduce these activities, e.g. stairs.

If the degree of SPD is quite large, then during labour the choice of positions and pain relief must be considered carefully. For example, positions where the thighs are not abducted too far are important and if a women has an epidural, she can no longer feel her lower half, this has the potential to increase pubis dysfunction after the birth if her thighs/legs are moved beyond the comfort zone while she is unaware of pain. Therefore SPD should be highlighted in the antenatal notes so caregivers are aware of the problem during labour.

Sue

I too suffered with rather severe SPD during my last pregnancy. I was lucky enough to be cared for by a wonderful physio at my local hospital. I had to wear a Tubigrip for the last four months of my pregnancy and although I went on to have a home birth (despite all the scaremongering from some!) my son did have a very flat head at the back, wide at the front…He is almost two now and, although he is fit and health,y I would still say his head is a bit on the flat side. I have often wondered if this is a result of wearing the Tubigrip constantly? When I mentioned this to the Paediatrician who checked him over she said it might be!

I know it became really difficult to even stand up at the end of my pregnancy, unless I had my Tubigrip on. One bonus of having SPD I suppose, for me was I became so familiar with pain and discomfort when Labour actually started I found I could cope with the pain, SPD prepared me for my son’s birth in many way’s(11lb 4oz homebirth)!!!

dinny, student midwife

I’m working with a midwife who has a woman on her caseload – 35 weeks, para4. She has severe symphysis pubis pain, has been to the Physio, has analgesia from GP and support belt etc. She is still in a lot of pain, but does not want to go into hospital for bedrest as has other small children to look after. She is booked for a homebirth and is against any suggestion of early induction.

Does anyone have any suggestions for this sort of pain, or anything she can do to help herself through the last few weeks? She’s quite desperate.

Carol, student midwife

Don’t know whether there is any research on this one – but! What about hiring a birthing pool and using it to relax in every night – weightlessness does wonders for the pain. It is also useful to have water in labour as movement is sooo much easier, and the support is good. Expensive I know. One company does a pool that you fill once then filter the water constantly (www.birthworks.co.uk), other pools you need to refresh every 24 hrs.

Jane

I came across the same sort of thing at the end of last term, and the lady in question had acupuncture (although she was in hospital for bed rest at the time). She found it quite helpful, but I am not sure it would either appeal or even work for everyone.

Isabelle (2nd year student)

Chiropractic seems to work better than osteopathy, in my limited experience, but I’m not sure why. Certainly the stresses on the spine appear to be more carefully considered by chiro than osteo, and the stress isn’t always pelvic. Sometimes nothing works – that’s depressing for the woman, but as other posts have shown, the outcomes are not always depressing!

Lesley

Elective Caesarean for SPD/DSP?

I would like to know if anyone has come across women who have chosen caesarean sections as a means of minimizing further damage to the pelvis in labour, and if so, what was the outcome.

I am a mother of one (born at home with independent midwives) am now 34/40 into my second pregnancy aand suffering once again (actually, still, 4 years on) with symphysis pubis pain. I am very seriously considering a c-section as means of delivery as the post-natal pain was worse than the antenatal pain and nearly drove me to depression and caused serious problems in caring for my child, particularly in the first year, but also in general and certainly now with this next pregnancy.

The advice I have recieved has been mixed and, to some degree, unsuitable. Pilates exercise to strengthen the area left me unable to walk. Physiotherapy was suggested by many: homeopaths, midwives, obstetricians; but the physiotherapist basically sent me away after one session saying most treatments were contraindicated during pregnancy and ‘here’s a belt’ (uncomfortable and uselesss for me) . Her suggestions for birth positions (left lateral) were in opposition to others’ suggestions ( supported squat).

In the end, I felt that only I could decide what is right for me.. a decision I have taken on before, obviously, having had my first child at home. However, I don’t take the decision to have a c-section lightly, especially as I wanted a family-centered birth with my son there to witness the miracle of birth and life first-hand. But at the end of the day, I feel my ability to happily care for a four year old and a newborn is more important than any of my other wishes and if I can prevent further damage to my pelvis by missing out on pushing out a big baby through a small pelvis (my first son was 9lb 3oz and I had a 6 hr second stage) I wish to do so.

My pelvis suffered some damage from my first baby 1 year ago. He was 9lb 4 1/2 oz at birth and his head swelled whilst in my pelvis. After 5 hours of pushing the hospital delivered him by forceps. I fell pregnant in February, which was planned, and the pain has got worse each week that has passed.

I have now been given crutches to use when possible. I am now 27 weeks pregnant and have just found out that I have Diastasis Symphisis Pubis and this worries me.

Do you think that I should consider having this next baby by caesarian section? I don’t know if I have my baby naturally whether I will damage myself anymore than I am already.

Your request for advice about whether Caesarean Section is advisable with this condition is one that we looked into very seriously as a midwifery unit. We have a working party of Obstetricians, Midwives and Physiotherapists and had a very well-attended meeting to evaluate all the literature. The overwhelming conclusion was that it is not an indication for a caesarean.

The main problem is one of pain, as you have experienced this pregnancy. Some women have this condition in their first pregnancy – brought on simply by the ‘relaxing’ hormones that help prepare the pelvis for giving birth. The opinion of all those who read the literature was that any measures that help with the pain, such as crutches and pain relief, are a good idea.

For labour an early epidural was advised – being comfortable for internal examinations was a big concern. Some ladies have a piece of string with them to show how much they can comfortably open their legs for an examination. However this distance is not thought to be of importance once an epidural is in place as the condition is not one of ‘damage’, therefore damage cannot be done by giving birth vaginally or by opening legs wide for examination or delivery.

In discussions it was mentioned that a CS may make things even more problematic for women after giving birth as it takes a little time for the condition to resolve and an operation may make mobility problems even more difficult.

Another positive thing to come out of our discussions was that there really had been no good comparison of the different pain relieving treatments and this is something we now hope to look into.

Fran

Positions for Birth

If the degree of SPD is quite large, then during labour the choice of positions and pain relief must be considered carefully. For example, positions where the thighs are not abducted too far are important and if a women has an epidural, she can no longer feel her lower half, this has the potential to increase pubis dysfunction after the birth if her thighs/legs are moved beyond the comfort zone while she is unaware of pain. Therefore SPD should be highlighted in the antenatal notes so caregivers are aware of the problem during labour.

Sue

For labour an early epidural was advised (by our midwifery unit) – being comfortable for internal examinations was a big concern. Some ladies have a piece of string with them to show how much they can comfortably open their legs for an examination. However this distance is not thought to be of importance once an epidural is in place as the condition is not one of ‘damage’, therefore damage cannot be done by giving birth vaginally or by opening legs wide for examination or delivery.

Fran

“the condition is not one of ‘damage’, therefore damage cannot be done by giving birth vaginally or by opening legs wide for examination or delivery.”

I disagree. We know that DSP is basically a hormonal condition but many women report that it first started after a birth in which they were in lithotomy position or an instrumental delivery or had their feet up on the attendant’s hips. This surely aggravated it.

Mothers who develop DSP in their pregnancy have already had to cope with day-by-day pain. They know what they can and can’t do. This includes difficulty sitting down, bending, lifting, turning over in bed etc and each mum gets to know just how to move herself so that she doesn’t cause further pain. If she has an epidural in labour then obviously she won’t be feeling pain. She will be more likely to get into positions that otherwise she would not have done. She will suffer the next day instead!

What is important as well must surely be which position mum takes up for the birth. In a semi-prone, sitting back position, as the baby’s head comes through the pelvis, it is the symphysis pubis which moves. This thought is enough to give sufferers of DSP nightmares! By turning over onto all-fours, kneeling or standing, it is the sacrum instead which moves thus less ‘damage’ will be caused.

Some mums with DSP have a pelvis which is out of alignment. As a sufferer myself, I found cranial-sacral osteopathy the only method of re-aligning my pelvis.

As you can see it is as subject close to my heart. I am delighted that Fran’s unit is looking into pain relieving treatments – this will be really helpful for sufferers.

Elizabeth
Midwife, DSP Sufferer.

A friend has asked me if I know where she can buy/hire a birth chair. She is particularly interested in a chair since she has sympysis pubis dysfunction and birth chairs are recommended on the SPD website. She is having her baby at home.

Dot, midwife

In the UK, you can hire a birth stool, with its own tray which sits neatly underneath, from Birthwise (www.birthwise.co.uk) – £45 for 4 weeks, including delivery.

Alternatively if you would like to buy one, you can import a birth stool from the USA for little more than it costs to hire here. See Birth Supplies (www.birthsupplies.com) for a wooden birthing stool which you can buy for $65 excluding shipping.

I would also suggest that your friend consider giving birth in the Left Lateral (LL) position with her knees together and flexed almost under her chin. That is how I helped two recent women with SPD give birth and they coped beautifully….

We had a consultation with an obstetrician for one client, and I put it to him that in the event of an assisted birth being needed, were his Registrars skilled in doing forceps or Ventouse in the LL. He said he jolly well hoped they were. Woman immediately said “What do you mean ‘hope they are‘?” and he said that he was sure they were. If he is incorrect in his hopes, and we had needed assistance for the birth, I planned to contact him personally.

Mary Cronk
www.marycronkmidwiferyservices.co.uk

The first spd birth I attended was to a woman who, from kneeling knees together on a hospital bed, gleefully shouted her baby out in exultation. She just needed to part her knees about 9 inches to ease the shoulders out and my second midwife was amazed………so was I. I had rushed in from an antenatal class where we had all been practising squats to “help get the baby out”.

Chris

My girlfriend has recently been told that she ‘may’ have SPD (the symptoms certainly seem to suggest this) and has been referred to a physiotherapist.

We’ve both been reading up on this and the effects during and after pregnancy but what we seem a little short on information about is the actual birth and labour itself!

What can we expect during labour? are there positions that will help? (other than not lying back with feet on the midwife etc)

Does SPD mean a long and painful labour? Should having SPD even hinder the birth at all?

Steve

..I have just helped a woman with quite severe SPD have her first baby. She birthed at home and the baby was born with her lying on her left side and keeping her knees together but knees bent up as far as was comfortable for her.

Basically SPD is of itself not a reason to fear a longer or a more difficult labour in fact some midwives feel that the SPD indicates a flexible pelvis which assists the labour to be shorter and easier.

Mary Cronk
www.marycronkmidwiferyservices.co.uk

The main difficulty with SPD in labour is that it can be quite painful to open your legs wide. It can also cause damage to the symphysis pubis. One of the things that the physiotherapist will do is to find out how far apart it is safe for your partner to open her legs. This means that it will be difficult for her to give birth flat on her back, or in a semi sitting position. She should also avoid squatting. Alternative positions, such as on all fours, standing, or lying on her side (usually the left) are better for giving birth anyway, and especially suitable for people with SPD. The physio may give your girlfriend a loop to put around her knees to prevent her opening her legs beyond the safe point while giving birth, or you can make one yourselves.

Theoretically birth should be easier – after all the pelvis has got extra give in it!

Viv

Birth Stories

I have just helped a woman with fairly severe SPD have her baby at home.

She started labouring on Sunday afternoon following a ‘false’ labour the previous day. She spent much of her labour lying on her bed on one side or the other, or sitting bolt upright. Kneeling or standing was too painful though we tried both.

During the night about 2am I did a VE she had a posterior cervix, head midcavity, (I’m not clever enough to measure the Cms above or below the spines) cervix fairly well applied to bulging membranes 4cms dilated. She had a full rectum as well so she accepted my advice to have an enema and “Oh the relief” she said.

Contractions increased in strength frequency and length and by 3am she was finding them pretty painful, so after discussion she had 100 mgm Pethidine (aka Demerol) which enabled her to continue to cope with the contractions and to sleep between them with husband tucked up beside her. They were a lovely picture, like two spoons.

By 6.30am peth wearing off. She asked for more so I did another VE – cervix thin 8cms head well down, I advised against more pethidine so we used entonox until about 9.00 to 9.30ish when she started to have a few pushy feelings. I did not say anything, just observed as they got stronger and she stopped using the entonox and pushed just as and when her body wanted to.

She was initially on her r. side then turned to her l. She continued to keep her knees together with just a thin pillow stopping them rubbing together.

Andrya joined me and we watched with that feeling of awe that I still get after 30 odd years, as the perineum bulged, the labia parted, and the little head slowly emerged still in the membranes, at 11.30, Mum’s knees still together.

I have no real idea when the second stage started but I think it was about 2+ hours of gently increasing involuntary pushing. The membranes were visible at the vulva during contractions for over 3/4 hour.

The couple had wished to have cord blood saved for stem cell banking and this was a first for me and Andrya. We got the cord blood easily about 100 ml. I had to clamp and cut a cord for the first time for years. We took the clamp off the maternal side after we had collected and it seeped a little, then we just waited for a contraction and when I had signs of placental separation and descent, I did gentle Controlled Cord traction. Haven’t done that for years either! All in the L lateral.

The contraction that separated the placenta gave quite a large spurt of blood about 250 ml. I wonder if it was larger than usual because of the early cord clamping? We also gave 5 units syntocinon after the placenta was out because the uterus was not very well contracted and the loss was more than I felt happy about.

I wish we had had a picture of the head emerging in its membranes. It was lovely but the couple did not want photos, so the picture has joined other lovely ones in my memory bank.

Mary Cronk
www.marycronkmidwiferyservices.co.uk

Links to other sources of information:

British SPD Support Group (formerly British DSP Support Group, but still supports SPD and DSP. Tel 01843 587356
(www.spd-uk.org)

Exercise for SPD sufferers – article by a physiotherapist – basically about running in a swimming pool! (http://home.sol.no/~omlundby/om-engelsk.html)

Chartered Society of Physiotherapy
(www.csp.org.uk)

AH updated 11 April 2002