Pelvic pain during pregnancy

Your pelvis goes through incredible changes during pregnancy. It can be movable and flexible to make it easier for the baby to come into the world and into your warm arms. Sometimes, however, these dramatic physical changes can also cause problems. This is generally referred to as pelvic pain. Pelvic pain can appear in any trimester, but it is most common that it first appears in the 16th-24th week of pregnancy. Severe pelvic pain can have a negative impact on pregnant women and can reduce their quality of life; however, it is often an underdiagnosed problem, and even misdiagnosed as lower back pain. Lower back pain is an very common problem due to the changes that occur in a woman's body during pregnancy, but pelvic pain has a different pathology and is generally considered a more serious condition. Therefore, it is often accompanied by worse pain.

Causes of pelvic pain

The pelvis has only three joints: two sacroiliac joints on each side of the sacrum and one symphysis pubis joint in the pelvis. Pelvic pain can originate in one, two or all three of these joints. Pelvic pain is actually a normal complication of pregnancy, but they vary in severity among pregnant women and can cause varying degrees of pain and impairment of quality of life. It is, therefore, necessary to intervene with appropriate treatment if pelvic pain starts to affect the woman's daily life.

It is not known what exactly causes pelvic pain, but it is believed that it is possibly caused by  an increase in the hormone relaxin along with biomechanical factors due to changes in the center of gravity during pregnancy. During a healthy pregnancy, there is an increase in the hormone relaxin which affects the body's soft tissues. Joints and ligaments stretch and soften causing increased movement in the hips as the dimensions of the hips expand. All of this makes it possible for the baby to move down the birth canal and into your arms.

When the center of gravity in the woman's body changes during pregnancy and moves forward due to the growing uterus and baby, there is increased and asymmetric pressure on the connective tissue and ligaments in the joints of the pelvis. This can lead to an imbalance and tension in the muscles in the pelvis, causing excruciating pain and even sprains.

Pelvic pain symptoms

Pelvic pain is different and varies from woman to woman depending on the nature of the cause and severity. They can occur due to imbalance in the hips, straining of ligaments or muscles in the hips, misalignment of the pelvic bones, muscle tension and inflammation. The pain can appear on either side or on both sides of the sacrum and/or over the pelvis. They can lead up to the lower back, out into the hips, down into the groin and thighs. The pain increases with asymmetric movements, comes in spasms and can vary between days and even over the course of the day. These pains can have a negative effect on the mental and physical health of pregnant women and can lead to varying degrees of mobility impairment. Certain movements and postures that place asymmetric stress on the pelvis, such as walking up and down stairs or turning the body when getting in and out of a car, cause increased pain. Staying in the same position for a long time, whether lying down, standing or sitting, can also cause increased pain. It also has an effect on sleep during the night when the woman has to constantly wake up to turn in bed. It is common for pregnant women to find it difficult to walk, while some even waddle. Up to 15% of women need to use crutches, and in the most severe cases, they require a wheelchair. Pelvic pain is the main reason that pregnant women stop working earlier during pregnancy. Also, women with pelvic pain are more likely to need more sick days than women with low back pain.

Major risk factors for pelvic pain

Women with a history of lower back pain before pregnancy and/or injury or misalignment of the pelvis are particularly at increased risk for pelvic pain during pregnancy. Other factors can also increase the chances of pelvic pain during pregnancy such as: a high body mass index, older age, number of pregnancies, physically demanding work, limb length discrepancy and unhealthy lifestyle behaviors such as smoking.

Diagnosis

No single diagnostic method is recognized as the most reliable for diagnosing pelvic pain. When diagnosing pelvic pain, it is therefore desirable to take the woman's past history into account, but keep in mind that the cause of pelvic pain is due to a variety of factors and risk factors that play a role. The diagnosis process can therefore often be extremely complicated, also because of how different symptoms can be between women. In addition, the pregnancy itself can make the diagnosis difficult due to the many body changes in the woman during pregnancy

It is important to rule out other complications first, such as urinary tract infections or other infections that can present with similar symptoms. In order to diagnose pelvic pain, a referral to a doctor and/or physiotherapist is required. A comprehensive pain history must be taken from the woman and a detailed physical assessment must be carried out along with the use of diagnostic tests that assess mobility, pain and stability of the pelvis. When the pain is assessed, it is necessary to identify its nature, whether it increases during movement, during which movement, whether it increases at rest, is constant or comes in bursts.

Treatment

There are many ways, apart from drug treatments, to reduce pain in the pelvis, such as heat and cold therapy, acupuncture, correcting the body position, proper exercise, training with specialized exercises, etc. Recommendations based on evidence-based knowledge preferably emphasize referral to a physical therapist with expertise in pelvic pain during pregnancy along with pain medication. Although exercise is recommended during pregnancy, the World Health Organization has also reported the ineffectiveness of exercise for women with pelvic pain, as it can further aggravate the pain. However, the National Institute for Health and Care Excellence in the United Kingdom has advised pregnant women with pelvic pain to do light exercises in water. Studies have shown moderate utility of acupuncture and support belts as pain relief for women with pelvic pain. Support belts are used for short periods of time over the course of the day to support and relieve the weight on the pelvis as well as to improve posture, but the need for such support belts should be assessed by a doctor and the woman will be given a referral to purchase the assistive device. Both the World Health Organization and the National Institute for Health and Care Excellence suggest to the need for further research on pelvic pain during pregnancy.

The role of the midwife

It is important that health professionals take pregnant women seriously when they seek help for pelvic pain and that their experience is not underestimated. Women sometimes experience helplessness, anger and increased anxiety about the birth itself when they experience pelvic pain during pregnancy.

A midwife in antenatal care usually rules out other possible problems and reasons for pelvic pain, such as contractions, a fall or a urinary tract infection. After receiving confirmation from a doctor or physiotherapist that it is pelvic pain, the midwife in maternity care provides the woman with education, instructions and teaches her the desired physical exercises that reduce the strain on the pelvis. In case of severe pain, it may be desirable to provide appropriate pain medication in consultation with a physician and encourage the expectant mother to ask for and accept all available help.

Summary and useful advice

The exact cause of pelvic pain during pregnancy is not known, but it is believed to be a combination of hormonal and biomechanical factors. There are various risk factors for pelvic pain and can include age, number of pregnancies, poor posture, injury or misalignment of the body frame, high body mass index and history of lower back pain. Pain usually subsides completely soon after birth. It is important to correct the body position, use the correct work positions and body posture as well as train with specialized exercises.

Body position

·       Stand with equal weight on both feet

·       Pull your shoulders back

·       Keep your body in a straight and even position

·       Think about your pelvic tilt

·       Do not lock your knees

·       Sit with equal weight on sit bones/don't cross your legs

·       Lean forward when standing up and have one foot in front of the other

·       Sleep with a pillow between your feet and ankles

Movement

·       All exercise is good if it is within the pain limit, start slowly and increase the intensity according to your physical ability

·       Training in water can be beneficial (prenatal swimming/water exercises)

·       Pelvic floor exercises can be helpful

·       Pregnancy exercise classes with certified professionals

·       Walking is a very good exercise, but it is good to take small steps when walking and to walk briskly

·       Go for many short walks rather than one long one

·       Use shoe spikes in icy conditions

·       Wear comfortable shoes with good cushioning

·       Take one step at a time with the same foot in front of the stairs and use the elevator if possible

·       Use handrails for stairwell support

·       Get into the car by sitting first and then lift your legs together and place them parallel into the car

·       It is good to use a plastic bag or a slide sheet in the car and in bed

Positions during labor and birth

Try to prevent stress on the pelvic joint during childbirth and choose a position that increases the mobility of the sacrum. Recommended positions are:

·       All positions in the bath

·       Side-lying

·       Hands and knees

Prepared by Björk Jómundsdóttir, nurse and midwifery student at the University of Iceland, in collaboration with the midwives of the Reykjavík Birth Center