9.1 Back and Pelvic Pain
EXPLANATION OF CONDITION
Back pain is a common disorder, accounting for significant use of health service resources and sick leave2. A childbearing woman may either have a previous history of medical or ‘alternative’ treatments. Alternatively, they may present for the first time in pregnancy. ‘Backache’ is so common in pregnancy that it is described as one of the adaptations to pregnancy3 with symptoms usually presenting between 4 and 7 months of gestation4. A variety of classifications are in use and there is a lack of consensus about the manifestations and treatments5.
Common presentations comprise:
- Low back pain
- Pelvic girdle pain
- Sacroiliac dysfunction
- Sciatica
Diagnosis is complex. Backache is often referred pain, in particular from the pelvic organs. This needs consideration prior to assuming that the pain is orthopaedic in nature. There is a psychological impact, and this can influence the perception of pain and disability6.
COMPLICATIONS
- Worsening mobility
- Impaired driving ability
- Difficulty continuing with everyday tasks, work commitments, or caring for other children
- Insomnia leading to tiredness and irritability
- Fear avoidance behaviour2 leading to physical deconditioning, further pain and employment difficulties6
NON-PREGNANCY TREATMENT AND CARE
Careful assessment and treatment are required for any back or pelvic joint dysfunction, including orthopedic or physiotherapy referral.
Modern management encourages mobility and an early return to work6 with reasonable adjustment to prevent recurrence of the injury. Treatment is specific to the cause.
Low Back Pain
Pain is usually low in the back, sometimes radiating into the buttocks and thighs, and occasionally down the legs as sciatica. There is also a great variation in the severity of symptoms between individuals. Some women have transitory stiffness or discomfort, whilst others are severely affected4. Pain is exacerbated by prolonged standing or sitting, forward bending and lifting. Some women experience pain over the symphysis pubis or thoracic spine at the same time.
Associated factors include7:
- Increased parity
- Back pain in a previous pregnancy
- Increased weight and tiredness
- Postural changes and adaptations
- Joint and ligamentous laxity
Treatment includes:
- Individual education can reduce symptoms8 by empowering women to understand their condition9
- Back care and postural advice4
- Management of activities of daily living to keep pain level as low as possible4
- Maintain a comfortable level of activity and exercise10
- Analgesia may be prescribed on a gradient, or ‘pain ladder’ (see Appendix 9.1.1) and adjusted accordingly11
Sacroiliac Dysfunction
Pregnancy can affect the sacroiliac joints in several ways:
- Joint laxity may allow enough repetitive new movement at one or both joints to cause pain (a hypermobile joint)
- Alternatively, the newly permitted movement could result in the uneven joint surfaces moving on one another and then becoming ‘stuck’ (a hypomobile joint)12
Treatment includes:
- Appropriate exercise and advice
- It is sometimes appropriate for gentle manipulative or self-manipulative techniques to be tried by a physiotherapist4
Sciatica
Pain in the distribution of the sciatic nerve occurs, which may accompany backache and sacroiliac dysfunction and rarely occurs alone. The sciatic nerve runs immediately in front of the sacroiliac joint and could become involved in any dysfunction or inflammatory process that is occurring there. The most common cause is a prolapsed intervertebral disc. An exaggerated lumbar curve could also affect the nerve, especially in lying and standing.
Treatment includes:
- Assessment by a physiotherapist or doctor to exclude other back problems and assess the sacroiliac joints13
- Pelvic support might be fitted to assist with a co-existing problem such as pelvic instability10,13
- Advise sleeping on her side with a pillow between her knees13
- Advise the woman to roll over in bed keeping knees and shoulders in line to avoid twisting13
PRE-CONCEPTION ISSUES AND CARE
- Women who have had back problems in previous pregnancies are more susceptible in subsequent pregnancies, and may benefit from referral for stability exercises pre-conceptually
- Women with current back symptoms need a medical review of current drug treatments, especially for fetal risk, and substitutions made where indicated (see Appendices 9.1.1 and 11.1.1)
- Measures to reduce obesity
- Encourage physical activity to increase muscular strength
- Multiple pregnancy
- Fetal position, especially malposition
- Take a pain history with attention to pain on standing and sitting
- Physical examination. European guidelines recommend24:
- For pelvis function: active straight leg raising test
- For sacro-iliac (SIJ) pain: posterior pelvic pain provocation test; Patrick’s faber test; palpation of the long dorsal SIJ ligament
- For symphisis pain: palpation of symphysis pubis; Trendelenburg’s test of the pelvic girdle
- For pelvis function: active straight leg raising test
- Investigations of any neurological symptoms
- Be aware that backache can be musculoskeletal or can be associated with other pelvic conditions such as infection
- Analgesia with regular review; augment as per symptoms (see Appendix 9.1.1)
- Early maternity leave may be needed, and ‘sick note’ required
- Accurate booking history to identify previous ‘backache’ and treatment
- Be aware that increasing lower back pain in dark-skinned or veiled women may indicate vitamin D deficiency requiring medical referral
- The care and advice of non-pregnancy (previous page) should be reinforced
- Advise to wear low-heeled shoes and bend at the knees when lifting
- Monitor the progression of symptoms to determine if referral is necessary
- Specific exercise advice and encouragement for25:
- Strengthening exercises
- Pelvic floor exercises
- Sitting pelvic tilt exercises
- Aquarobics (water gymnastics)
- Strengthening exercises
- Encourage good posture and to avoid ‘slumping’ when sitting25
- Ascertain if a pelvic support belt would be suitable for the mother, and assist with fitting. A simple belt is most likely to increase compliance19
- Physiotherapist can advise the most suitable positions for labour and delivery
- Maternal concerns should be taken seriously
- Antenatal pilates and yoga exercises are beneficial; the mother should be advised to check that the instructor is qualified to teach ante/postnatal women25
- If a mother asks about acupuncture she must be advised to only consult a practitioner experienced and trained in using acupuncture in pregnancy25
- Some women are best remaining comfortably supported in labour rather than moving around, which could exacerbate symptoms20
- Epidurals are not harmful per se, but the relief they give allows positions to be adopted which may further exacerbate the pre-existing condition. There is no evidence to link use of epidurals with subsequent back pain21
- Mothers may request water immersion in the first stage; note there is a theoretical chance of difficulty in getting out of a bath/pool
- Review analgesia options
- Avoid, or take care with lithotomy position which may cause nerve root compression from disc protrusion
- Agree a birth plan which allows for flexibility with choice of mobility or rest during labour, and position for delivery
- For water immersion confer with obstetrician; ensure a hoist is available
- Suitable delivery positions may include side-lying, kneeling on all fours or semi-reclining with the legs well supported14
- If the woman requires assistance to move her legs, they must be moved together at the same time
- The ligamentous changes of pregnancy can take up to 6 months to reverse10
- Many women who have back pain during pregnancy find that it persists, or recurs, after the birth15,22
- Persistent postpartum backache requires accurate investigation and a diagnosis made before further pregnancies are planned, as the pain may result from an underlying condition such as osteoporosis, which could be exacerbated by subsequent childbearing23
- As for antenatal care
- Women who continue to have poor postpartum mobility may require venous thrombo-embolism prophylaxis
- Re-refer to a physiotherapist if pain persists
- Arrange any necessary outpatient appointments
- Midwife and physiotherapist to give consistent advice on:
- good posture when feeding, nappy changing, etc.
- wearing flat-heeled shoes
- appropriate postnatal exercises
- the best time to resume pre-pregnancy exercise regimes
- seeking medical advice if the back pain persists beyond the postnatal period
- good posture when feeding, nappy changing, etc.
9.2 Diastasis Recti Abdominis
EXPLANATION OF CONDITION
Diastasis of recti abdominis, aka divarication of recti abdominis is known colloquially as ‘abdominal separation’. It is a separation of the recti abdominis muscles, often appearing in the second or third trimester, or as a result of bearing down during delivery1.
The abdominal muscles are stretched and elongated during pregnancy, and can become separated along the linea alba, which has become softer and more elastic. The hormonal and mechanical stresses placed on the abdominal wall are believed to facilitate this separation2.
The diastasis can vary from a small vertical gap 2–3 cm wide and 12–15 cm long, above or below the umbilicus, to a gap measuring 12–20 cm wide and extending almost the whole length of the recti muscles3. This weakens the abdominal support, which potentially could increase the vulnerability of the back to injury.
Women Most at Risk
- Multiple pregnancy
- Polyhydramnios
- Multiparae
- Women with a narrow pelvis and large baby
- Women with weak abdominal muscles pre-pregnancy
COMPLICATIONS
If left untreated, diastasis recti abdominis can lead to long-term problems, in particular:
- Abnormal posture
- Back pain
- Pendulous abdomen (with sequelae of fetal malpresentation and malposition in subsequent pregnancies)
Rupture of the rectus abdominus muscles is very rare, mainly occurs in multigravid women, presenting in late pregnancy and is often precipitated by expulsive coughing4.
NON-PREGNANCY TREATMENT AND CARE
All newly-delivered women with the condition should ideally be referred to an obstetric physiotherapist, who is likely to first check the width of the gap.
With the woman in crook lying, supported on one pillow, she raises her head to reach with her hands towards her feet. With the fingertips of one hand placed widthways across the abdomen in the midline, just below the umbilicus, the medial edges of the two recti muscles can be palpated as the woman raises her head. The degree of separation is measurable in fingertip widths5.
The physiotherapist will then:
- Teach appropriate abdominal exercise6
- Advise regarding activities of daily living
- Encourage constant awareness of the abdomen, so that the woman retracts her abdominal muscles frequently7
- Encourage the woman to roll onto her side to get into and out of bed, reducing the amount of strain placed on the muscles and the back
- Determine if the woman would benefit from wearing an abdominal support such as Tubigrip, in the interim period, to provide some abdominal support
- Review the woman regularly until the diastasis has improved
In extreme cases, where the condition persists after physiotherapy and abdominal musculature is severely impaired, corrective surgery by abdominoplasty may be considered. This entails suturing the rectus bellies together and removing the distended pendulous fat and skin7.
PRE-CONCEPTION ISSUES AND CARE
It is thought that women who take regular exercise before pregnancy have a reduced risk of developing diastasis recti abdominis because their muscle tissue is healthier as a result8. Hence all women should be encouraged to exercise, and this especially applies to women with a past history of diastasis as well as women generally in the pre-conception period.
The woman with a past history of the condition should be encouraged to:
- Use effective contraception until the diastasis has improved, and effective muscle tone has been achieved
- Exercise regularly, especially swimming
- Have a well-balanced diet to reduce obesity
- Adopt a positive body image
- Avoid, or take care, with lifting – especially lifting her own children6
If a woman has had surgical treatment by abdominoplasty, further pregnancies are not usually recommended, as the repaired abdominal muscles may not stretch adequately in pregnancy. If a woman still wishes for a pregnancy she would benefit from advice and counselling, because she is likely to experience increasing discomfort as the pregnancy progresses.
- Healthy pregnant women should be encouraged to remain active. Mild to moderate exercise is beneficial, provided that overheating or exhaustion does not occur5
- Swimming provides a toning and strengthening activity which increases physical fitness as well as promoting a sense of wellbeing
- A mild diastasis, with inter-recti distance of two finger widths is considered normal, and should not prevent the mother from having low-risk midwifery care, unless further complications occur
- An inter-recti distance of four or more finger widths is considered abnormal
- Fetal parts are readily identifiable on abdominal palpation, and the fetus is theoretically more vulnerable to trauma under the diastasis gap. Skin over the gap may be inflamed or itchy
- There is a theoretical risk of pendulous abdomen developing in grand multiparae, which can pre-dispose to fetal malpresentation or malposition
- Women with previous abdominoplasty will experience significant pain and discomfort. It is difficult to palpate the abdomen, and it is misleading to measure fundal height against the umbilicus, necessitating ultrasonic scans
- Examine the mother and monitor the condition if referred
- No specific medical interventions are proven
- Skin treatment may have to be prescribed if moisturisers have failed
- Refer to the obstetric physiotherapist for treatment as below
- Be aware that a mother with a previous diastasis may have a recurrence in the current pregnancy, and that diastasis can also present for the first time in the second/third trimester1
- Take care when performing abdominal palpation, as a mother with diastasis may feel especially sensitive in the midline
- Advise the use of moisturiser cream for itchy/flaky abdominal skin
- If a pendulous abdomen develops refer to the obstetrician, and be alert for fetal malpresentation or malposition
- Ascertain if the mother has an occupational risk of contact pressure on her abdomen, which may necessitate adaptation of occupation
- Refer the mother to the obstetric physiotherapist if the diastasis presents (or re-occurs) with an inter-recti distance ≥4 finger widths
- The physiotherapist might fit a Tubigrip abdominal support in late pregnancy or in readiness for labour11
- To roll onto her side to get in and out of bed, to reduce excessive strain on the abdominal muscles
- To avoid strenuous abdominal exercises (sit-ups) and contact sports which might worsen the condition.
- To attend aquanatal classes, informing the instructor of her condition
- That labour is likely to be normal, unless other problems develop
- A woman with a significant diastasis may benefit from wearing a piece of size ‘L’ Tubigrip (xiphisternum to symphysis pubis) during labour to help to support the abdomen, if tolerated
- This is dictated by fetal malposition, otherwise labour can be managed normally by the midwife
- Gentle, but accurate, abdominal examination in labour as it is important to identify fetal malposition or malpresentation
- Assist the mother with significant diastasis to put on the Tubigrip belt, and be aware that the mother may feel ‘hot and sweaty’ under the belt and require assistance with washing
- Labour should otherwise be managed normally
- Whilst the inter-recti distance should reduce after delivery, some degree of diastasis may persist for 30–60% of postpartum women1 and non-resolution postpartum is associated with chronic lower back pain9
- Advice and treatment in the puerperium remains the same as for non-pregnancy
- The inter-recti distance should reduce naturally, but some degree of the gap is likely to persist for up to 12 weeks postpartum10. The gap is larger when measured in a resting posture postpartum10
- Be aware of the risk of bowel incarceration, which can result when muscle tone improves and the gap narrows
- Assess the inter-recti distance as part of the routine postnatal examination, measuring in both active and resting positions10
- Re-refer the mother to the obstetric physiotherapist, who is likely to assess the width of the diastasis gap, and advise on abdominal exercise (see previous page)
- Reinforce the advice of the obstetric physiotherapist
- Give practical advice to the mother on posture and picking up her baby, and returning to pre-pregnancy fitness; in particular, to ‘draw-in’ her abdomen when walking and prior to picking up the baby
- Advise the mother that this condition could recur with future pregnancies, and she should wear abdominal support promptly11
9.3 Pregnancy Related Pelvic Girdle Pain
EXPLANATION OF CONDITION
The symphysis pubis forms the strong midline union between the pubic bones of the pelvis. It is a unique joint comprising a fibrocartilaginous disc sandwiched between the articular surfaces of the pubic bones and is capable of a 2 mm amount of movement and 1° rotation3. The hormones of pregnancy, especially relaxin, induce resorption of the symphyseal margins and structural changes in the fibrocartilaginous disc thus increasing the symphyseal width and mobility during pregnancy3.
Pain and varying degrees of dysfunction of the symphysis pubis can present in some pregnant women and a plethora of classifications exist. European guidelines now advocate the use of the ‘umbrella’ term pregnancy related pelvis girdle pain (PRPGP)4 which encompasses more specific conditions as described below.
Symphysis Pubis Dysfunction (SPD)
Symphysis pubis malfunction results in varying immobility or disability. It is associated with obesity especially when the BMI >305, and is also more common in those with joint hypermobility problems and connective tissue diseases especially Marfan’s and Ehlers–Danlos syndromes6. There are no definitive tests that prove or disprove its presence, the diagnosis being made on the basis of symptoms alone.
Signs and symptoms of SPD include:
- Mild to severe pain in the symphysis pubis joint, hips, groin, lower abdomen, inner thighs and back
- Exacerbated by all weight-bearing activities, especially walking, stairs, sitting to standing, standing on one leg, abducting the legs (e.g. getting in and out of a car)
- Painful to roll over in bed
- Clicking or grinding noises from the symphysis pubis
- Women often walk in a ‘waddling’ fashion
NB, Palpation of the symphysis pubis should be performed cautiously as it can be extremely tender.
The pelvic girdle is responsible for the transference of large forces from the upper body onto the legs during walking. It is therefore essential that the three joints of the pelvis are strongly supported and stable. Stability of the pelvic ring is provided by close fitting joint surfaces, strong pelvic ligaments and support from pelvic and trunk muscles. This means that any dysfunction (stiffness or hypermobility) at one joint could have an effect on the others. Women presenting with SPD often complain of low back pain and vice versa.
During pregnancy, pelvic stability can be compromised by ligamentous laxity that occurs as a result of the hormonal changes. The normal gap between the pubic bones in pregnancy varies from 4.5 to 9 mm. However, separation can exceed 10 mm. In some cases, severe dysfunction and pain can occur as a result of these changes.
Symphysiolysis
Symphysiolysis is the name given to pain in the symphysis pubis only. This group of patients tend to hormonally-mediated changes alone7,8 (the other groups have additional biomechanical and articular changes) and the best outcome with full postpartum recovery7.
Diastasis of the Symphysis Pubis (DSP)
Diastasis (separation) of the symphysis pubis (DSP) may develop from chronic SPD, or present acutely with the same symptoms. Definitive diagnosis can, however, only be made radiologically. The definition is separation of the symphysis pubis of 10 mm or more, and a vertical shift of 5 mm or more9. There is often no association between the severity of symptoms and the degree of separation at the symphysis pubis10. Traumatic separation can occur as a result of:
- Precipitous delivery
- Cephalo-pelvic disproportion
- Excessive abduction of the thighs during delivery3
- Pelvic girdle pain in a previous pregnancy
- Previous pelvic damage
COMPLICATIONS
- Long-term morbidity can be experienced by some women, who may ultimately require internal fixation
- Adverse impact on daily life, parenting skills, housekeeping
- Mechanical difficulty with sexual relationship
- Feeling of frustration, helplessness and loss of control11
- Increased risk of recurrence in subsequent pregnancy
NON-PREGNANCY TREATMENT AND CARE
Symptoms may persist postpartum and women may require physiotherapy for several months with an emphasis on:
- Advice on adapting to daily living and employment
- Promoting good posture
- Teaching core stability exercises
- Hydrotherapy enhances movement whilst causing less joint pain
Most cases resolve by 6 months postpartum. In non-resolving cases orthopaedic referral may be necessary, and, on occasion, surgery for internal fixation of the symphysis pubis may be necessary.
PRE-CONCEPTION ISSUES AND CARE
- SPD often starts earlier in subsequent pregnancies, and symptoms can be more pronounced
- It is best to recover from previous pregnancy effects before embarking on another, hence effective contraception is required
- Calculate the BMI and consider weight reduction measures
- Identification of women with hypermobility or connective tissue disorders, especially Marfan’s syndrome, who may need referral for that condition and also exercise advice as below
- Pelvic stability exercises can assist future pregnancies
- Once pregnant early referral to a physiotherapist is advisable for assessment and prompt symptom control
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