Pregnancy and Pain

I’m a whole-body alignment lovah’ fo’ sho’, but for some reason, the pelvis and all that the pelvis does has always been a special interest of mine. And, even before I had a kid — like years and years before — I was always uber interested in the birthing pelvis.

I have also always been uber interested in those two little dots that go over the u in the word uber. How do I make those on my computer? I WANT THOSE DOTS!

Anyhow.

My fascination with pregnancy likely stems back to the fact that you, in utero, are at ground zero. The environment you are given at the time is a complex combination of what your mother is doing in terms of stressing, eating, her habitual body positions, and the amount of time she is moving. All of these things create an environment that you are responding to. You are responding in terms of your teeny-tiny baby alignment, your chemistry, etc.

There are a lot of other people way more qualified to talk about the chemical interactions of stress and poor nutrition, smoking and drugs, so I’ll leave that to them. What I will talk about is the alignment factor.

Is anyone surprised at that one? Anyone? Anyone?

Pelves** (the plural of pelvis) are my life. And, the more you learn about the pelvis, the more you realize you can’t have a “neutral pelvis” unless the rest of your body is neutral as well. But I’ll write more about whole-body neutral later, when we’re discussing solutions. Right now, it’s imperative that you understand the problem.

This is a two part post. The first part is a literature review and position paper from grad school and the second is an article I’m presenting at a midwifery conference in Nashville this April.

This is a small portion of my paper titled Postural Implications of Gestational and Postpartum Low Back and Pelvic Pain. Warning: You may find this a snoozefest unless you’re into pregnancy and stuff. Chances are, if you’ve read this far, you’re good to go. Second Warning: My copyeditor husband has suggested that I make an I was young and didn’t seem to know much grammar disclaimer. Whatever. Everyones a critik.

Drum roll please…

Although women have been giving birth since the beginning of time, researchers have just started looking at the physiological and biomechanical changes occurring with pregnancy. A major reason for this investigation is the large occurrence of lower back and pelvic pain during and after pregnancy. Many researchers have attempted to find the mechanisms that determine hip, pelvic, and sacral pain in general populations, but few have examined this situation as it pertains specifically to the maternal female.

The cultural perception of pregnancy-related pain and resulting issues is that these conditions are a normal part of the gestation process and perhaps not research-worthy. Data shows, however, that these ailments are not natural to the state of pregnancy, only normal. Studies suggest that 50% of all pregnancies will begin and end with debilitating back and pelvic pain, and even more alarming, that this pain continues postpartum. The role of exercise as both a treatment and preventive measure for these conditions is the newest addition current research.

Pre- and post-natal exercise has traditionally consisted of modified traditional aerobic and strength training exercise. This type of exercise can be beneficial to general fitness goals but lacks the specificity in design when it comes to other requirements of the maternal female, i.e. improving structural integrity, optimizing vaginal birthing mechanics, etc. The mechanical functions of the uterus are now understood to depend on pelvic loads and pressures, yet this content has not yet made it into academic curriculum of pertinent professional studies. Creating a movement program for this population that not only meets general health guidelines but facilitates and improves the state of pregnancy and delivery outcomes is a valid scientific endeavor.

What have studies shown to date?

Pain is difficult to quantify for research purposes and can reduce the validity and reproductability* of a study. The use of the questionnaire is common protocol for data collection. For new mothers, the format is more time effective than scheduled appointments, and data is easy to collect due to simple, multiple choice answers. Common pain assessment questionnaires are the visual analog scale (VAS), Zung, and Somatic Perception (Russell, Groves, Taub, O’Dowd, and Reynolds, 1993).  Pain drawings, on transparency, are also used to quantify location (Nilsson-Wikmar, Pilo, Pahlback, and Harms-Ringdahl, 2003). The transparencies are then stacked to analyze data (2003).  The most significant chronic pain patterns found in the pregnant or post-natal  were listed as the posterior pelvic-sacroilliac area (PPP), lumbar spine, or a combination of the two (2003).

Experience of pain itself is, of course, an issue of discomfort and not to be discounted. The much larger issue is, however, the daily limitation of everyday activity. Within the general population, adults experiencing low back pain find bending, twisting, and lifting difficult and painful (Youdas, Garrett, Egan, and Therneau, 2000).  For a new or impending mother the restriction of movement decrease the possibility of caring for and lifting a new baby, returning to movement for health purposes, or returning to work. This reality poses additional stress into an already psychologically demanding situation and could be a contributing factor to physical and psychological issues stemming from pregnancy.

{This is me, eight months prego, feigning back pain. Don’t you like the expression on my face?}

There are many circulating beliefs about where pregnancy-related pain comes from. Russell, Groves, Taun, O’Dows and Reynolds (1993) authored the first study to look at the effects of an epidural on lower back pain. Questionnaires were sent to 1615 women who delivered their first baby at St. Thomas’s Hospital in London. Following the questionnaire, the subjects with persisting pain were examined by a physiotherapist or orthopedic surgeon. It was established that LBP was equally evident in both epidural and non-epidural deliveries, and tended to be postural in nature (1993).

Pregnancy-induced posture and mechanical changes are common research topics when looking at possible causality of associated pain. What researchers have found is contrary to our beliefs about pregnancy related ailments. The adopted posture of pregnancy is individual in nature and not created by the state of pregnancy alone. While the increase of body mass and subtle forward displacement of a subject’s center of gravity is empirically valid for all pregnant women, there is no “pregnancy posture” that can be imposed on the state of pregnancy (Gilleard, Crosbie and Smith, 2002). It is generally believed that the pregnancy gait, or waddle, is a natural change due to the gestational condition. This is not the case. When healthy pregnant subjects were assessed against healthy nulligravidae, the kinematics were found to be very similar with only small changes in a maximum walking velocity (Wu et al., 2004). It is interesting to note that postpartum women with posterior pelvic pain showed large deviations in normal gait and large angular rotations of the hips and pelvis when compared to the healthy, pain-free pregnant population (2004). Wu et al. concluded that the pregnant female is intended to walk and move regularly, even with the extra mass of an impending baby.

These findings are very important contributions to solving pregnancy-related ailments. This data implies that it is not the physiological state of pregnancy that is responsible for pain, but the alignment and gait habits that a woman brings to her pregnancy that is the underlying cause.

Although conducting research on pregnant subjects will always be a difficult situation due to potential risk and liability, more studies are desperately needed. Studies on PPP could begin in the safer, postpartum realm. More recent studies have began to look at the benefits of strengthening exercise, specifically deep abdominal, pelvic floor, and gluteal musculature, as a possible, non-surgical method of dealing with varying pregnancy related ailments.

More studies are needed to quantify, define, and produce postural interventions to mitigate pregnancy related issues. Treating pregnancy-related conditions with medication and surgery is not only expensive, but also ineffective in the long-term. It is obvious that studies need to be developed observing less invasive, less costly repair. One glaring hole in pregnancy research and correlating back pain are studies that deal with the postural and muscle stability loss following cesarean section. Cesareans are major abdominal surgery and are bound to result in systematic, measurable changes that in strength and subsequent injuries to the lumbar spine, hips, and pelvis. With a developing trend of elective cesarean, it is imperative that as much information on recovery and long term effects be researched.

Due to the traditional lack of women in research, medicine, and science in general, it follows that the amount of studies pertaining to women’s issues be few in comparison.  As this slowly changes, studies examining traditional view points on the natural birthing process, especially the maternal mechanics of vaginal expulsion, be better understood by birthing professionals as well as those prescribing exercise.

Pre and post-natal exercise is not new to kinesiology communities, yet it has always been presented as a modified aerobic and strength training workout, allowing a participant to continue with a fitness-type exercise program during the gestational period. The numbers of those suffering through pregnancy should be taken as a signal to improve the education of birthing and kinesiology professionals. Exercise that is designed to facilitate an easy gestation period, delivery, and recovery must be studied and dispensed through the correct channels.

Due to the lack of clinical and scientific training for most kinesiologists, exercise is over-simplified when presented to the pregnant population. Physical and physiotherapists typically do not see the general population until a problem has manifested and even then, are often prevented by professional guidelines to address mal-alignments elsewhere in the body, even if they are related to the presenting injury. Where are women to find this information before they realize they need it?

Most reviewed articles called for a movement in pre-natal physical education. Because poor postural habits lead to low back pain in the general population (Youdas et al, 2000), it is only to be expected that participants with prior posture and lumbo-pelvic problems find that pregnancy exacerbates their problem. Deviations in alignment are indications of a failing muscular support system. This system can be improved through a restoration of muscle and joint positioning. Intervention in alignment could potentially eliminate pregnancy-related pain if good instruction and intervention is early. Potential candidates, those with LBP before pregnancy, should be given postural exercises or guidelines to offset gestational pain.

After reviewing the literature on pregnancy and related low back and pelvic pain, a common thread becomes apparent. While the physiological changes are fairly similar for various women during pregnancy, biomechanical changes seem to be of a personal nature. Of these mechanical changes, one’s postural habits seem to have the greatest effect on pain. It would seem from an evolutionary standpoint, that debilitating low back, hip and pelvic pain would not be conducive to the natural birthing process.

Wow. Better stand up and touch your toes. Maybe take a quick walk around the block and have a glass of water. And a nap. So now you have a bigger picture of the problem. I’ll write more later. I need to stretch after reading, writing, and editing this!

Reproductability*: Even in grad school, I was busy making up words.

**Pelves is pronounced pel-veees. It does not rhyme with elves, as in a group of elfs. Or elves, I guess. Although the idea of a fairy tale about a pelvic elf has just started to form up in my mind. Great. That’s not going to cause me any nightmares.

Chiarelli, P. & Cockburn, J. (2002)  Promoting urinary continence in women after delivery: randomised controlled trial.  BMJ, 324, 1241.

Elden, H., Ladfors, L., Olsen, M., Ostgaard, H.,& Hagberg, H. (2005).  Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial. BMJ, 330: 761.

Gilleard W., Crosbie, J., & Smith, R. (2002)  Static Trunk Posture in Sitting and Standing During Pregnancy and Early Postpartum.  Archives of Physical Medical Rehabilitation, 83, 1739-44.

Leivseth, G. & Drenup, B. (1997).  Spinal shrinkage during work in a sitting posture compared to work in a standing posture.  Clinical Biomechanics, 12, 409-418.

Nilsson-Wikmar, L., Pilo, C., Pahlback, M, & Harms-Ringdahl, K. (2003).  Perceived pain and self-estimated activity limitations in women with back pain post-partum.  Physiotherapy Research International, 8, 23-35.

MacEvilly, M., & Buggy, D. (1996).  Back pain and pregnancy:  a review.  Pain, 64, 405-414.

Rodacki, C., Fowler, N., Rodacki, A, & Birch, K. (2003). Stature Loss and Recovery in Pregnany Women With and Without Low Back Pain. Archives of Physical Medical Rehabilitation, 84, 507-12.

Russell, R., Groves, P., Taub, N., O’Dowd, J., Reynolds, F. (1993). Assessing long term back ache after childbirth.  British Medical Journal, 306, 1299-1304.

Sihvonen, T., Huttunen, M., Makkonen, M., Airaksinen, O. (1998). Functional Changes in Back Muscle Activity Correlate With Pain Intensity and Prediction of Low Back Pain During Pregnancy.  Archives of Physical Medical Rehabilitation, 79, 1210-12.

Van Dongen, P., deBoer, M., Lemmend, W., & Theron, G. (1999)  Hypermobility and peripartum pelvic pain syndrome in pregnant South African women.  European Journal of Obstetrics and Gynocology and Reproductive Biology, 84, 77-82.

Wu, W., Meijer, O., Lamoth, C., Uegake, K., vanDieen, J., Wuisman, P., deVries, J., & Beek, J. (2004).  Gait coordination in pregnancy: transverse pelvic and thoracic rotations and their relative phase.  Clinical Biomechanics, 19, 480-488.

Youndas, J., Garrett, T., Egan, K., & Therneau, T.  (2000)  Lumbar Lordosis and Pelvic Inclination in Adults with Chronic Low Back Pain.  Physical Therapy, 80, 3, March.

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44 thoughts on “Pregnancy and Pain

  1. Hah @ “Wow. Better stand up and touch your toes.” …I had already stood up by this point, and started stretching to ease the discomfort that was being exacerbated by the knowledge your literature review was providing for me. Not to mention the knowledge that it had been too long since I last stretched…!!! (I had been sitting for hours, working on my own grad school research… but that’s no excuse!)

    I too am looking forward to part 2 of this. Thirsty for more of the nitty gritty knowledge!

    And I have to say: thanks for the reminder to do stretching. More and more squats for me! I’m happy to say that I’m finding it easier and easier to go lower and lower for longer and longer. Oh, and I recently realized that my current squat ability has me able to get my knees to much less than 90 degrees, which was most certainly not true when I first found this site! And remembering to stick my butt out has definitely been helping my back feel much more awesome than I remember it ever being. Kudos to you! 🙂

  2. Yay! Can you talk about Pubic Symphysis Dysfunction? SO painful and unfixable by the Chiro and I’m thinking may be caused by laying on a slanted couch or with pillows behind my back. Completely debilitating I can’t even put on my own panties while pregs because of the screeching pain to lift one leg higher than the other. I did find relief by laying on my side, curling my knees up putting a fist between my knees and squeezing with all my might on that fist until I feel a pop in my pelvis. In Both pregnancies I had this pain and would love to prevent it completely with future happy pregnancies. 🙂

  3. FINALLY….Yes pregnant woman need to move!!! Throughout my two pregnancies (22 and 19 years ago) I never skipped a beat. I continued walking the ranch checking the irrigation, tending to my horses, taking my hikes…while everyone was telling me to stop those things. BUT, both my pregnancies were troublefree. No back pain at all. Second delivery was only three hours, no pain meds…and that was a VBAC. I attribute it all to just continuing moving like I did before pregnancy. Gotta move! You tell ’em Katy!

  4. The really frustrating part for me in a lot of your posts, is seeing that what I used to do instinctively as a kid (squat to play, run on my toes, spend large amounts of time hanging from trees) were the right things to do with my body. And knowing that well-meaning adults TRAINED me not to do most of those things. ok, all of them.

    I actually remember conversations with different “grownups” at different times, them telling me why it was important to change how I ran, sat, etc. So frustrating!!

    And back pain in pregnancy? Had that, too. But won’t again. 4 is enough kids!! 🙂

  5. You’re going to be in Nashville?!?!?! I live very near there. Maybe you will meet my midwife (Mary Anne Richardson). And hopefully I will have a huge pregnant belly by then–need any “before” examples for your talk? Ha ha! Would it be too weird if I tried to get you to take my phone number?

  6. Well said! More updated research is desperately needed. I see this everyday with the clients I recondition after childbirth. I wish more out there saw the benefits of preventative exercise instead of trying to be a gym rat during pregnancy.

  7. So glad to read this right now at 35 weeks pregnant and looking forward to part 2! I have pubic symphysis pain and various pains in my sacrum which I am sure come from misalignments that started way before pregnancy. I have a fusion at L5-S1 just on the left side that I was born with (as far as I know) and have built up a ton of muscular imbalances as a dancer. I’m eager to read your solutions and curious if you have thoughts about what can be done with a spine like mine that is asymmetrical. Might I have an uneven pull happening on my pubic symphysis because of the restriction of my L5-S1?

  8. Since you really want those dots, Katy, here’s the way…it’s simple. Look on your computer for “insert”, then “symbol”, then scroll through the letters and you’ll find the letter with the dots on top. Select it, hit “insert”, then “close”, and you should see the letter with the dots. This is for Word 2007 and maybe 2010…not sure what to do for Mac systems, but it’s probably similar.

  9. ü can be found in your “character map” if you have a PC. You can find hearts and all kinds of symbols there! I don’t know what you do if you have a Mac ♥ ♥ ♥

  10. Fascinating stuff! Thank you so much for posting this information. I am generally physically fit, but had a pretty dramatic reaction after my son’s birth. I kept thinking I’d overstretched my pelvic floor and was kegaling like mad, only to eventually make it to a trained physical therapist who pointed out that I was *overtight* and that was what was causing all of my problems. Ever since, I’ve been extremely interested in this subject.

    Oh, and to make umlauts, you need only (in Microsoft Word) hit ctrl + shift + : then release all of that and hit your U. Giving you ü. For the internet, I can’t figure out how to do it, so I write my word in Microsoft Word, then copy and paste and it keeps it for me. 🙂

  11. Sing it to me!

    I am so looking forward to reading Part Two.

    My first pregnancy was a total breeze – lots and lots and lots of walking. But…I never got back to being very active after my non-sleeping baby was born. My second pregnancy was opposite the first – at one point I was unable to walk due to back/leg pain. Kept getting different advice “don’t do ANY walking” and “yes! you should walk!” In the end a physio gave me some exercises on a ball, which helped quite a bit. Now I’m on a quest to achieve alignment!

      1. Songs about pregnancy should be set tot he tunes of lullabies.

        Hush little mommy, don’t you complain,

        pregnancy’s are meant to be filled with pain.

        If that pain’s no fun for you,

        try a minimalist kind of shoe.

        If that shoe gets chewed by the dog,

        try squatting daily like a frog.

        If the older kids laugh when you do,

        tell them they should do it too…..

  12. Part 2 Part 2 part 2!!!!!!!!!!!!!!!!!!!!! I did a number on my already SPD inflicted pelvis last night, and need more help!!!!!

    p.s. I LOVE how you write! We could totally be friends.

  13. Here’s the character code for a u with an umlaut (that’s what those little dots are called!): & # 2 5 2 but leave out the spaces.

    Er… anyway.

    I’m looking forward to the next installment! I’ve had debilitating pain during my last two pregnancies. I had a tremendous amount of relief this last time (my baby is 2 months old) with acupuncture and I was wishing I had done it months before as the pain seems to start around 15 weeks. Also, my toddler was born posterior AND face-first (as in, yes, the first part to come out was his lips). In the research I’ve done, I’ve come to the conclusion that he didn’t choose that, my body did. I did a ton of work in this last pregnancy to prevent that happening again and it did go much better, but I still have work to do, I know.

  14. Move in pregnancy, move in labor! I swam a mile the day before I went into labor and at least 3 times a week during pregnancy. Swimming relieved SI pain and pubic symphysis pain better than anything. Great post!

  15. I don’t know which was more delicious: the home made cornbread, chili and quinoa or the words I was reading while chowing down. So dang sensible. And obvious, once I read it. I get your point about the lack of studies. If men weren’t so darn nulligravidae/nulliparae I’ll wager there would be tomes written on the importance of gestational bio-mechanics. I look forward to that changing.

    I want to thank, as well, those who wrote in with the solution to one of modern life’s questions; I can’t wait to try an umlaut or tilde or circonflex!!

  16. Thanks Katy, very interesting. I’ve had SPD in both pregnancies and the advice is always to do LESS, don’t walk, don’t do anything with legs unequally loaded or apart, don’t stretch, and wear a support belt. If I had any strength in my postural muscles it’s certainly much diminished after a month of that frustrating regime! Looking forward to reading part two, as pelvic pain really concerns me for a possible future pregnancy.

    1. I know — it’s logical advice, but it’s kind of a little too late kind of thing. If your body is breaking under the weight, it’s difficult to start at that point. You can do it though, with gentle, corrective exercise following the guidelines to a “T”… Start NOW, not later.

  17. this is great info. i ran 3 miles on my due date w/ my first baby, had a fast 3h labor, bladder prolapse, and never got back to exercise at all… during my second pregnancy i had such horrible pain in the end, which i called “crotch pain” that i had to sleep with a heating pad between my legs. my boss sat me in an exam room and brought my patients to me bc i couldnt walk. the second labor was 30min. worst 30min of my life. the up side is i felt so amazing when that baby came out, like my pelvis and body was new…a second chance. thats when i found katy’s blog. no more babies, please! but i am getting down with the alignment thing.

  18. I can testify to this. My first pregnancy I was walking all over the place and had almost no pelvic pain at all (although I did start waddling when the baby dropped…how are you supposed to walk normally with a tiny head wedged in your pelvis???). It was a lot harder to get out with a toddler, so I had some pain my second pregnancy, and it was inversely proportionate to how much walking I did. If I was consistently getting four miles or so of walking in a day, I had almost no pain; stop for a few days and it came back.

    Would love to learn more about the mechanics of pushing a baby out. My second came out in one grand push.

  19. Just out of curiosity, any idea whether a breech baby could be caused by mom’s posture/movements? My 3rd baby was breech. I’ve had low back issues for a very long time.

  20. The thing is, with severe symphysis you CAN’T move. Believe me, I wanted to, but I was in constant pain. My symphysis kicked in after only 12-13 weeks of pregnancy, and when I was due I could only walk really short distances.

    However, this was expected. I had a tilted sacrum for years, which noone knew about until I met some physical therapists that had special education in this area. They helped me to get it straight again, but said that my pregnancies would be really troublesome. (One said I shouldn’t have children at all!) Now my child is one year old, but I’m still in a lot of pain.

    What would you advise someone like me?

    (Muscles constantly get too tight on one side and pull on my sacrum. That is part of the problem. But one of my physical therapists also said that the bones could have been affected as well…)

    1. Well, I think the issue is, when you hear “exercise” or “move” you’re thinking large, whole body motions, instead of small, tiny corrective stretches you need to do to get out of the pain. There is a solution, I promise!

      1. I did water exercises during pregnancy. That was all I could do.

        After delivery I got mostly core exercises. (No crunches, of course) And piriformis stretches I have been doing for years. (Although I have to be a bit careful)

        The thing is, I happened across this site when I was searching for exercises for DR (I have a mild one). And when I read “What a waist”, I realised that I have been living with a tucked pelvis. When I tried to “untuck” it, I found that tucking it really tightens a lot of muscles in the butt/pelvis area that someone like me don’t want tightened. So, now I’m really interested in everything you have to say! 🙂

  21. Where can I find the exercise info. I have been sleeping in a recliner for the past month and a half due to severe pelvic pain. I cannot lay on my side at all. Then tonight I read about recliners and baby in a posterior position. I am 30 wks and need relief, especially for breastfeeding since I co sleep and nurse while lying on my side. If you could send me in the right direction of a book or DVD that would show me what I need to do. Thank you!

    1. Sorry Shannon! Just saw this. Check out the Pain Free Pregnancy Kit on this site! That’s where the solution is…FEEL BETTER and congratulations!

  22. For my first pregnancy I used the Webster Technique, due to over-tight hip flexors and to try to turn my breached baby. It did not “turn” her but made me feel a lot better. For the second kiddo something happened towards the end that meant I was in intense (hip and lower back) pain and needed a walker to walk. What happened?? No one could tell me, except maybe she was pressing on a nerve. I still have constant pain 5 years later in my left hip and all down my left leg. I have tried a chiropractor (who recommended massage therapy because he said my hip flexors were so tight they feel like concrete!). I have tried yoga (for the past 4 years) – it helps it now and then. But I feel like there is something else I could do. I stretch almost everyday – calves, hips, hamstrings, feet, but nothing seems to loosen the hip muscles! There are nerve points that are so sensitive to touch – one in the middle of the buttock, one on the side of the hip, one on the inside of the thigh, one mid-way down the outer thigh, one half-way down the outer hamstring, and underside of the foot is sensitive (all only on the left side). Any advice? Anything if very much appreciated.

  23. If you have a Mac, Option + u will put the two dots over whatever letter you type next. So Opt-u + u = ü. (There’s a lot of other cool ones too, Opt-` + e = è , etc …)

    If you don’t have a Mac, and you’re doing these blogs on a PC, well then I just feel sorry for you. 🙁

  24. Yay! So happy to read that back pain is not a normal side effect of being pregnant. Loved reading all of this. I’m experiencing insane lower back pain this pregnancy (my 5th). Never had any pregnancy pain before. Now I can barely walk. I will blame the frequent shoveling of snow I’ve been doing lately. (I’m 20wks). Anyways, I’m reading your blog archives and book and seriously thanking God for this crazy pain because I’m learning so much because of it. Thank you! Off to read part 2.

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