Symphysis Pubis Dysfunction

What is it?

In every pregnancy there is a natural increase in the width of the symphysis pubis - pubic bone joint - due to the softness of tissue under the influence of hormones. This can cause the joint to move excessively. It has also been noted that severe dysfunction and pain may occur irrespective of clinical evidence of joint disruption. The symptoms are a pain which can be insidious or sudden and felt in the pubis, groin and medial aspect of thighs, either unilaterally or bilaterally. It is frequently accompanied by low back, sacro iliac and pain just above the pubic bone. This pain can be mild to severe pain. Of course, reading this you are probably aware that there are many other things which can cause these symptoms e.g. repetitive kicking from your baby in the womb, stretching of the uterine ligaments. What often helps identify the symphysis pubis pain is that it can feel quite burning and usually there is some pain specifically in the pubic bone itself.

What can make it worse?

What makes it worse are any activities or movements which involve opening the hips i.e. turning from side to side in bed at night, breast stroke swimming (legs), squatting. The problem is that in its early stages the pain may not be felt while doing these activities, only several hours later so the connection is not always made. Walking and all weight bearing activities can aggravate it. Symphysial "clicking" or grinding may be audible and can be felt by the woman. There is a characteristic waddling gait. It is not to be confused with urinary tract infection.

It can come on gradually in pregnancy, usually in the last trimester with a first pregnancy. It can appear from 20 weeks and usually starts early in a second or subsequent pregnancy. It can be caused by labour usually by being in stirrups for extended periods.

What is it caused by?

The numbers of women experiencing this problem are growing. I think that it is caused by modern lifestyles which mean we are sat down at desks a lot more, driving around rather than walking. This means that our muscles are less toned/strong and therefore support the whole pelvic girdle less effectively during pregnancy. I also feel that there is a stress link. Women who are working outside the home during pregnancy are not always able to rest as much as they need to and the body copes less well with the physical demands of the pregnancy.

The other group of women who tend to suffer are those who did excessive amounts of hip opening exercises while young e.g. gymnasts or ballerinas. Women who have suffered from any kind of pelvic injury are also more likely to suffer as in these cases there is usually a slight displacement of the pelvis which means that the symphysis pubis is placed under an unequal stress on one side.

The amount of processed food we eat and pollution is probably also having an effect on our hormones, so that our body may over-produce relaxin, the hormone which softens the tissue.

What should I do?

If you suspect that you have any of the symptoms, then avoid, as much as possible, for one week any movements where you part your legs. If turning in bed at night try and keep your knees together as much as you can. It is best if you can to turn over by rolling into all fours and then lying on the other side. Try to minimise for this week the amount of walking and lifting that you do. If you notice a difference, then the chances are you have symphysis pubis diastasis and then continue in this way. If you notice no difference, then it is probably something else.

As it is caused either by lack of exercise or excessive exercise, then correct exercise is important. Do some back and abdominal strengthening exercises, to give support to the pelvis. You must make sure you are only doing movements which don't involve moving your hips apart and where your knees are close together. A good exercise is the yoga cat stretch.

As stress is also a factor, having some form of bodywork which can relax you, as well as addressing the physical problems is extremely helpful. Shiatsu is excellent. You may also like to try massage or acupuncture.

If you do need to walk distances or have a toddler you can't avoid picking up much, then you can ask your midwife to refer you to an obstetric physiotherapist who can prescribe a kind of tubigrip support belt which helps hold the pubic joint together. If you do get this, you must still follow all the above advice.

If you follow all this, the chances of having a relatively pain free pregnancy are high. You can not "cure" it, as the amount of relaxin increases until the end of pregnancy and your baby is getting heavier, but you can learn to be relatively pain free.

Labour

You can have a vaginal delivery but you must make sure that you labour and ideally deliver if possible in the all fours position, keeping your knees as close together as you can. Avoid stirrups if at all possible. Discuss it with your midwife. Otherwise you can aggravate the problem and so it remains a problem postnatally.

Postnataly

If you have followed all the above advice in pregnancy and labour, you may well find that as soon as you have delivered there is no pain. You still need to be careful to avoid leg abduction movements for 4-6 weeks postnatally and then resume them gradually. In the first 4-6 weeks follow a gentle back/abdominal/pelvic floor strengthening programme. If you can, continue to have some shiatsu or massage from a trained specialist in maternity skills.