Pubic Symphysis Pain during Labor and Delivery

“Please tell me I'm not the only one who has had pain like this, and that you can have the birth of your dreams when you feel like you can't even walk sometimes.”

“I have horrible pubic symphysis pain and I’m scared about labor.”

“Will birth make my pubic pain last forever?”

***Not sure what pubic symphysis pain is? Head over here to see what exactly it is and why it happens. Trying to navigate lightning crotch in pregnancy? Find out different exercises you can consider to help you get on your way to feeling better.***

Can I give birth if I have pubic symphysis pain in pregnancy?

First things first, only YOU can decide if you feel comfortable giving birth with pubic symphysis pain. My goal isn’t to persuade you one way or the other but to give you facts and support rather than fear… which is probably all that you are hearing.

Pelvic pain generally doesn’t limit birth options. During labor, our pelvis is designed to open and expand. Some women notice that once they are in labor and these natural changes are occurring their pubic pain goes away because the ligaments have done exactly what they need to do- stretch and open. Having pubic pain during pregnancy does not guarantee having pubic pain during labor. 

Labor and Delivery Considerations with Pubic Symphysis Pain / Lightning Crotch

One way to help relieve pubic symphysis pain during labor is to move. Ideally, you can move in whatever position you feel comfortable. This is a great time to listen to your body and baby—if you feel like walking, walk. If you feel like lying on your side, do it. There isn’t one position that is best so find what works best for you at that moment. 

There are positions that research has shown you may not find comfortable if you have pubic pain. Those include:

• Squatting: especially with your knees wide. Some mamas are able to squat if their knees are closer together

• Side-lying or half laying back with hips spread wider than 45 degrees

• Lithotomy: this is when a mama is on her back with her feet in stirrups pushing

There are also positions you may find more comfortable in labor:

• Side lying with hips spread less than 45 degrees: you have two options for this one…you can place a pillow between your knees for support or you can prop your top foot up on an object while keeping your lower knee level

• Semi reclined with knees on pillows

• Quadruped (all-fours)

  • You can modify this position by having your knees closer together and your feet further apart

  • For added comfort, someone trained in Rebozo can also help sway the hips to relax the muscles around the pelvis

• Upright kneeling

Cliff notes: Find a position that works for you and try to keep your knees closer together than your feet.

Is there anything I can do to help pubic pain if I have an epidural or give birth on my back?

If you lie on your back without support, your sacrum (the large bone between your spine and tailbone) can’t move and open. Our bodies are amazing and will steal that movement that it needs from somewhere else, generally being the pubic symphysis which can create more pain. If you have chosen to use an epidural or give birth on your back, you still have options! One of the easiest things you can do is roll hand towels (or partly rolled towels) up and place them on either side of your sacrum.

You can also place a pillow under your low back (follow the natural curve of your spine) to help promote extension. This is helpful because it allows the low back and hips a little more space to move and open. 

One key part that we often forget during labor is what the foot is doing. It’s common for mamas to have their feet in stirrups or a person holding their leg up during labor. Fun fact: when you bring your toes towards your head, you actually activate the pelvic floor which is great for exercise but not so great during labor when we want the pelvic floor to relax and lengthen. To help relax the pelvic floor, try to keep your feet flat on the bed. 

Cliff notes: Place a rolled up hand towel on the sides of your sacrum, have a pillow under your low back and keep your feet flat on the table.

If I have pubic symphysis pain during pregnancy, will I have it forever?

The majority of mamas (62.5%) will have spontaneous recovery of pain within one month after delivery. At 4-6 months postpartum, that goes up to 75% of mamas not being in pain. At the end of 6 months 92% are fully recovered. If you are part of the 8% who still have pain at 6 months postpartum, you still have options. Heck, even if you have pain one month after delivery, you still have options! I’d highly recommend finding someone in your area trained in pelvic floor rehab. They can evaluate the muscles, bones, joints and how everything is working. From there they can give you specific exercises based on YOUR needs to help you recover faster. 

One thing I want you to understand is how your mind is related to pain. There was an interesting study that showed the greatest predictor of pregnancy-related pelvic pain post delivery is the belief that you will continue to have pain. Your pelvic isn’t unstable. You are not broken. Working on calming the nervous system and having a positive outlook can help relieve your pain.

If I had lightning crotch with one child, will I get it again with the next?

I wish I could give you a better answer, but it’s basically a flip of the coin. Research has shown that 41-77% of mamas will experience the pelvic pain again with another pregnancy. One of the best things you can do is find someone trained in pelvic floor rehab postpartum or during your next pregnancy so they can help you get the care you deserve. 

Resources:

1. Howell, E. 2012. Pregnancy-related symphysis pubis dysfunction management and postpartum rehabilitation: two case reports. J Can Chiropr Assoc. 56(2): 102-111.
2. Leadbetter R.E., Mawer D., Lindow S.W. 2006. The development of a scoring systems for symphysis pubis dysfunction. J of Obstet and Gynac. 26(1) 20-23.

3. Prather H., Spitznagle T., and Dugan S. 2007. Recognizing and treating pelvic pain and pelvic floor dysfunction. Phys Med Rehabil Clin N Am. 18: 477-496.

4. Hastings-Tolsma M, et al. 2007. Getting through birth in one piece: protecting the perineum. MCN Am J Maternal Child Nurs. 32(3):158-64

5. Boissonnault JS. 2002. Modifying labor and delivery positions for women with preexisting spine and pelvic ring dysfunction. J of Sec of Women’s Health. 26(2).

Squats and Pregnancy (Part 2): Squats to take you from "Pregnancy Butt" to Peaches

The Many Faces of Squats during Pregnancy and Postpartum

Did you know there’s a million and one different ways to squat? And guess what, there is not a “best” squat for everyone, find the best squat variation for YOU that works with your goals! Squats are one way to help turn "pregnancy butt" into peaches.

Body Weight Squats during Pregnancy

The first set of squats are great because as parents we frequently get up and down from the ground, chair or couch and it’s great to replicate these movements. Being able to do these squats can help so we don’t get stranded on the ground or trapped under a sleeping baby unable to move. 

1. Body weight transition from Bear to Squat and Tripod to Squat —> for when you sit on the ground and need to stand
2. Body Weight Air Squats—>squatting is one of the most basic functional movements we have and it is great to train for everything from sitting on a chair to picking things up off the ground
3. Box Squats, both Conventional Stance Box Squats and Sumo Stance Box Squats—> If you ever go from sitting in a chair to standing then you already do box squats, so let’s focus on doing them correctly and utilizing the glutes to our advantage.

Weighted Squats during Pregnancy

Weighted squats are a great addition to a workout routine. As parents, we must be able to move with weight for everyday function. This includes picking kids up, carrying carseats, putting kids into beds/cribs and even bending down to pick something up from the bottom shelf of the grocery store. It’s important to add weight as it is nearly impossible to go through life without it…as much as we train for birth it is equally important to train for life.

1. Goblet Squat—> If you are new to lifting weights or need a confidence boost, goblet squats are a great exercise as it moves the load closer to your center of gravity, helping you get into a better position. Better yet, if you can’t squat low, this is a great exercise because the weight helps act as a counterbalance making it a little bit easier so you can train for progress
2. Front Squat—> This is a great squat variation for those looking to improve flexibility while strengthening the upper back and quads
3. Back Squats—> A back squat can help improve overall glute, low back and hip strength
4. Bulgarian Split Squat—> This squat help you get both deep and low into your squat, allowing for the pelvic outlet to fully open. Added bonus in the fact it helps prevent muscle imbalances, challenges mobility, all while recruiting the glutes and improving core strength and stability

Improving Squat Mobility while Pregnant

Needing a little TLC to get into the squat position? Try some squat therapy to help mobilize the hips and upper back to get you to a better squat today! Also, did you know that not being able to do a squat could be caused by anything from foot mobility to a tight upper back? If you are looking to improve your squat, give us a call at (331) 307-7110 to schedule an appointment today and start building those peaches. 

Squats and Pregnancy (Part 1): Should they be avoided?

More and more I have been asked the same line of questions, “Can I squat during pregnancy? Is it safe to squat? Why should or shouldn’t I squat?” Here are a few considerations for squatting while pregnant. As always, it’s important to work with the body you have today and do what is best for you!

Considerations for Squatting while Pregnant

1. Squatting with abducted thighs expands the pelvic outlet, the area the baby must descend from in order to be birthed but closes the pelvic inlet (3)

   1. Squatting increases the pelvic outlet by one centimeter in the transverse diameter (side to side) and two centimeters in the antero-posterior diameter (front to back). The overall result is an increase of 28% in the pelvic outlet while squatting compared to lying on the back. (1)
   2. Due to the opening of the pelvic outlet and thus closing of the pelvic inlet, deep squatting may not be recommended for babies with a breech presentation. If the baby is in a less than ideal position, it may close off the top of the pelvis and give baby less room to move around and get into the ideal position. For this reason it is generally not recommended to perform deep squats after 32 weeks unless you know the baby is head down
2. Health Considerations
   1. Pelvic organ prolapse: If you have a diagnosis of a cystocele or rectocele, then a deep squat may not be ideal until the prolapse has been corrected
   2. Hemorrhoids: Deep squatting may increase the risk of hemorrhoids due to poorly managed intra-abdominal pressure 
   3. Other health concerns as discussed with your healthcare provider
3. If you have pain during squats, please reach out! Squats should never be painful and there may be changes we can help you with to make squats pain-free.

Training for Birth: Why Should I do Squats While Pregnant?

“Squat 300 times a day and you will give birth faster” - Ina May Gaskin

We love to train for birth - doing movements that are going to help prepare you for childbirth or help with the postpartum healing processes. Squatting is one of the movements we love! The thing about squatting is that in our Western culture, we have moved away from training our bodies to squat. This is highlighted by Alternative Birth Positions which stated, “Most North American women are not used to squatting, and cannot maintain the position for long.”(6)

While the squatting position can be a great asset during labor (see Part 3- Squatting During Labor: The Research), “squatting, even unsupported can be tiring and may need to be practiced during pregnancy.” (5) The book, Pregnancy Fitness, stated that “If you haven’t been accustomed to squatting and then try to do it in labor, you may not find the success you were hoping for.” The second stage of delivery, when your cervix is fully dilated and you are pushing, can last anywhere from 20 minutes to 2 hours. You wouldn't run a marathon without training, so why not train squats in preparation for birth? 

Squats help strengthen the pelvic floor muscles in a way that is functional and natural. The muscles utilized during a squat are the same muscles needed to stabilize the core, low back and pelvic floor. Squats are a great asset to any workout regime because they help strengthen and stabilize the body in a ways that we move everyday!

Added bonus? Just because you are pregnant does not mean you do not have to have pregnancy butt (aka mom butt, pancake butt, flat butt). We believe all butts can be peaches and squats may just help build those peaches. 

References:

1. Russell, J.G.B., “The rationale of primitive delivery positions”, British Journal of Obstetrics and Gynaecology, Sept. 1982, Vol. 89, pp. 712-715.
2. Di Paolo, Julia, Montpetit-Huynh, Samantha, Vopni, Kimberly, “Pregnancy Fitness”
3. Russell, J.G.B., “Moulding of the Pelvic Outlet”, J. Obstet. Gynaec. Brit. Cwlth, Sept. 1969, Vol. 76, pp. 817-820.
4. Penny Simkin, Janet Whalley, Ann Keppler, Janelle Durham, April Bolding, Preconception: Improve Your Health and Enhance Fertility
5. Vicky Chapman, Cathy Charles, The Midwife's Labour and Birth Handbook
6. Reid, Harris., Alternative Birth Positions. CAN. FAM. PHYSICIAN Vol. 34: SEPTEMBER 1988
7. Valiani M1, Rezaie M1, Shahshahan Z2. Comparative study on the influence of three delivery positions on pain intensity during the second stage of labor. Iran J Nurs Midwifery Res. 2016 Jul-Aug;21(4):372-8. doi: 10.4103/1735-9066.185578.
8. Gupta JK1, Sood A2, Hofmeyr GJ3, Vogel JP4., Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2017 May 25;5:CD002006. doi: 10.1002/14651858.CD002006.pub4.
9. Lawrence A1, Lewis L, Hofmeyr GJ, Styles C., Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev. 2013 Aug 20;(8):CD003934. doi: 10.1002/14651858.CD003934.pub3.
10. Nasir A1, Korejo R, Noorani KJ. Child birth in squatting position. J Pak Med Assoc. 2007 Jan;57(1):19-22.

Understanding Pelvic Floor Disorders

Pelvic Floor Disorders

Understanding the signs, symptoms & causes of pelvic floor disorders

What are pelvic floor disorders (PFDs)?

pelvic floor disorders, pelvic pain, DRA, diastasis, women's health

First off, the pelvic floor is made up of a network of muscles and connective tissue that provide both structure and support of the pelvis and connecting joints, assist in urination and defecation and aid in sexual performance. The pelvic floor consists of three layers of muscle — the superficial perineal layer, the deep urogenital diaphragm layer and the pelvic diaphragm, including the levator ani muscle.

Pelvic floor disorders are any disorder affecting the pelvic floor, including urinary incontinence (stress and urgency), overactive bladder, pelvic organ prolapse (POP), and fecal or anal incontinence.1 Urinary incontinece and fecal or anal inconincen are best described as a loss of the body’s ability to control urination, defecation or flatulence. Pelvic organ prolapse is when the bladder, uterus or rectum drops from its normal place in the lower abdomen down into the pelvis.

How common are PFDs?

Pelvic floor disorders are fairly common, with studies showing that 23.7-34% of women have at least one PFD.2,4 Additionally, while 46% of these women had one PFD, 16%-33% of symptomatic women had two or more disorders.3 A study showed that although PFDs are common, only 25% of symptomatic women seek care.4

What are the signs and symptoms of PFD?

• Incontinence

  • This includes any amount of leaking urine, feces or even gas at any time

  • Whether you are leaking when sneezing, laughing, coughing, doing box jumps or any jumping, lifting heavy, and doing double unders, this is a sign of PFD

  • Frequent urination (more than 8 times in 24 hours) or urgency are also a sign of PFD

  • Pain with sexual intercourse, bowel movements or urination

    • This also includes constipation or feeling like you are not able to complete a bowel movement

    • Hemorrhoids - internal and external

    • Constipation

    • Pressure or pain in the lower abdomen and pelvis

      • This can include feeling like you have numbness, heaviness, bearing down sensation or bulging near the vagina

      • Low back, pelvic, SI and hip pain

        • All of the muscles of the body are interconnected. If you are experiencing pain in any of these areas it may actually be referred from the pelvic floor or referring to the pelvic floor

What are the contributors of PFD?

*Note I did not say CAUSE of PFD. I know we all want one cause, and therefore one treatment to cure PFD. Unfortunately, it is not always that easy as it is typically multi-faceted and has more than one contributing factor.*

Vaginal Birth

• A study showed that vaginal delivery increased the odds of pelvic organ prolapse but additional vaginal deliveries did not increase the odds of developing PFD.5,6,7

• Additionally, urinary incontinence is also associated with vaginal childbirth.5,8,9

• The risk of PFD is does not appear to be correlated with caesarean delivery as PFD has not been found to increase with a history of active labor or complete cervical dilation prior to cesarean delivery.6

Assisted Vaginal Birth - Episiotomy, instrumented delivery, etc.

• The use of instruments in delivery is associated with an increased risk of PFD. This includes the use of forceps or vacuum which significantly increases the risk of PFD and specifically POP.

• “Magnetic resonance images provide evidence that show that the pelvic floor regions experiencing the most stretch are at the greatest risk for injury, especially in forceps deliveries.”15 and “risk factors for pelvic floor injury include forceps delivery, episiotomy, prolonged second-stage of labor, and increased fetal size.”16

Obesity

• Handa found that obesity is not only a risk factor for incontinence but may also accelerate the progression.8

• Another study showed that weight loss from either diet or exercise can experience a “70% reduction in the frequency of total and urge UI episodes” with a 5-10% loss of body weight.18

Birth Weight

• A large birth weight has been shown to increase risk of pelvic floor dysfunctions.16,17

Levator ani injury

• Levator ani muscles have been shown to increase with long second stage, anal sphincter tear, and older maternal age.

• A study by Miller showed that at “seven weeks after delivery, 91% of women showed some form of musculoskeletal injury that involved the pubic bone or levator ani muscle: 66% had pubic bone marrow edema; 29% had pubic subcortical fracture; 90% had levator muscle edema, and 41% had low-grade or greater levator ani muscle tear.”10

What about muscle stretching?

During normal pregnancy, the pelvic floor muscles can stretch over 3 times the usual length to allow for the descent of the baby’s head.11,12

A study performed on rats showed that the pelvic floor muscle fiber length increases between 21-37% and the quantity of extracellular collagen matrix increases by 140% in the pelvic floor muscles. The collagen matrix is a normal protein that “may shield the muscle fibers from excessive mechanical strain during delivery by providing a parallel elastic element that limits fiber strain.”14 This study showed that the extracellular matrix remained elevated at 12 weeks postpartum but the fiber length returned to normal.

It’s easy to look at these numbers and think, “holy cow, my pelvic floor just stretched three times the usual length, that can’t be good,” but the body actually does this to help prevent pelvic floor dysfunction by allowing the pelvic floor muscles to open and move in preparation for the baby’s arrival. This is one reason that one thing we regularly say at BIRTHFIT is “slow is fast” because it takes time for the body to naturally heal.

What can I do about it?

While pelvic floor disorders are common, they are not normal and should not be minimized or ignored. If you are experiencing any sign or symptom of pelvic floor dysfunction, please reach out to a women’s health physical therapist near you. Not sure where to start? Check out these resources to find a local women’s health physical therapist near you. If you’re local, I’d love to help you on this journey!

• United States: http://www.womenshealthapta.org/pt-locator/ 

• Canada: https://www.pelviennewellness.com/apps/find-physio

References:

1. Hallock JL, Handa VL. The epidemiology of pelvic floor disorders and childbirth: an update. Obstetrics and gynecology clinics of North America. 2016;43(1):1-13. doi:10.1016/j.ogc.2015.10.008.

2. Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, Spino C, Whitehead WE, Wu J, Brody DJ, Prevalence of symptomatic pelvic floor disorders in US women.Pelvic Floor Disorders Network. JAMA. 2008 Sep 17; 300(11):1311-6.

3. Gyhagen M, Åkervall S, Milsom. Clustering of pelvic floor disorders 20 years after one vaginal or one cesarean birth. Int Urogynecol J. 2015 Aug; 26(8):1115-21.

4. Rortveit G, Subak LL, Thom DH, et al. Urinary Incontinence, Fecal Incontinence and Pelvic Organ Prolapse in a Population-Based, Racially Diverse Cohort. Female Pelvic Medicine & Reconstructive Surgery. 2010;16(5):278–283.

5. Quiroz L, Muñoz A, Shippey SH, Gutman RE, Handa VL. Vaginal Parity and Pelvic Organ Prolapse. J Reprod Med. 2011;55(3–4):93–98.

6. Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Muñoz A. Pelvic Floor Disorders 5–10 Years After Vaginal or Cesarean Childbirth. Obstetrics & Gynecology. 2011 Sep;:1.

7. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG: Int J O&G. 2012;120(2):152–160.

8. Handa VL, Pierce CB, Muñoz A, Blomquist JL. Longitudinal changes in overactive bladder and stress incontinence among parous women. Neurourol Urodyn. 2014;34(4):356–361.

9. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. A comparison of the long-term consequences of vaginal delivery versus caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women. BJOG: Int J O&G. 2013;120:1548–1555.

10. Miller, J., Low, K.L., Zielinski, R., Smith, A., DeLancey, J., and Brandon, C. Evaluating maternal recovery from labor and delivery: bone and levator ani injuries. Am J Obstet Gynecol. 2015; 213: 188.e1–188.e11

11. Hoyte, L., Damaser, M.S., Warfield, S.K. et al. Quantity and distribution of levator ani stretch during simulated vaginal childbirth. Am J Obstet Gynecol. 2008; 199: 198.e1–198.e5

12. Lien, K.C., Mooney, B., DeLancey, J.O., and Ashton-Miller, J.A. Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol. 2004; 103: 31–40

13. Alperin, M., Lawley, D.M., Esparza, M.C., and Lieber, R.L. Pregnancy induced adaptations in the intrinsic structure of rat pelvic floor muscles. Am J Obstet Gynecol. 2015; 213: 191.e1–191.e7

14. New directions in understanding how the pelvic floor prepares for and recovers from vaginal delivery. Nygaard, Ingrid. American Journal of Obstetrics & Gynecology , Volume 213 , Issue 2 , 121 - 122

15. Ashton-Miller JA, Delancey JO. On the biomechanics of vaginal birth and common sequelae. Annu Rev Biomed Eng. 2009;11:163–176. PubMed PMID: 19591614. eng.

16. Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse. Obstet Gynecol. 1996;88(3):470–8. doi: 10.1016/0029-7844(96)00151-2.

17. Dietz HP, Wilson PD. Childbirth and pelvic floor trauma. Best Pract Res Clin Obstet Gynaecol. 2005;19:913–24.

18. Wing RR, Creasman JM, West DS, et al. Improving Urinary Incontinence in Overweight and Obese Women Through Modest Weight Loss. Obstetrics & Gynecology. 2010;116(2, Part 1):284–292.

19. Bump RC, Norton P. Epidemiology and Natural History of Pelvic Floor Dysfunction. Obstetrics and Gynecology Clinics of NA. 1998;25(4):723–746

*Disclaimer:

The information by Dr. Lauren Keller of Elemental Chiropractic, Inc. is provided for general information only and should in no way be considered as a substitute for medical advice or information about any particular condition. While every effort has been made to ensure that the information is accurate, Dr. Lauren Keller nor Elemental Chiropractic, Inc. make no warranties or representations as to its accuracy and accept no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. If you have any specific questions about any medical matter or think you may be suffering from any medical conditions, you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.