Royal Society of Medicine Forum.Symphysis pubis dysfunction.

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Thursday 23rd September 2004.

The meeting was chaired by Avril Hillyard, Obstetric Physiotherapist, Queen Charlotte's Hospital, Hammersmith Hospital, London.

For reasons of copyright it has proved impossible to include a report of the presentation of Lucy Townsend, obstetric physiotherapist.

SPD: The clinical presentation, prevalence, aetiology, risk factors and morbidity.
Malcolm Griffiths (MG), Consultant Obstetrician and Gynaecologist, Luton and Dunstable Hospital

Little seemed to be known and understood of symphysis pubis dysfunction (SPD) by me and others when in 1992 I came across an article on the subject in the Journal of Chartered Physiotherapists in Obstetrics and Gynaecology (Deborah Fry). Shortly thereafter the profession published some empirical guidelines on the management of the condition.

In medical history the condition was noted by Hippocrates and later by others, until in 1926 it was demonstrated that relaxin caused separation of the symphysis in rodents.

The pubic symphysis has an imperfect joint cavity; it is supported by superior and arcuate ligaments, and it is these which are supposed to be softened by relaxin. The sacroiliac joints are synovial, but their movement is restricted throughout life and they are progressively obliterated by adhesions. The nature of the bony pelvic ring with its three joints determines that no one joint can move independently of the other two. For the same reason orthopaedic surgeons know that the pelvis rarely fractures in only one place.

Estimates of the incidence of SPD have ranged very widely; current realistic estimates vary between 0.1 and 14%, and the condition probably affects about 1% of pregnancies significantly. Symptoms are likely to be interpreted differently according to the stoicism of mothers and the sensitivity of their attendants.

More than half of SPD cases have an onset during pregnancy which may be sudden or gradual, often in the first trimester. Symptoms include pain in the lower abdomen or groin, and are accompanied by a characteristic waddling gait. Women may complain of pain when they rise from sitting, on climbing stairs, and when turning over in bed. Their pain may be confused with preterm labour, placental abruption, and urinary tract infections; its resolution may be rapid, following a birth within hours or days, or protracted, or may even fail to occur at all. It is impossible to predict the course that the symptoms may take, and it is important to maintain a dialogue with an affected mother and to arrange all possible support.

Experience of a group of only 19 women suggested a recurrence rate of about 50%. Subsequent pregnancy and vaginal birth may be followed by no symptoms whatsoever, but when it recurs it may do so with a different pattern of timing and severity than formerly. This implies that CS to avoid postnatal recurrence is rarely if ever indicated, but should be considered if a mother's symptoms makes it probable that she can expect a very painful labour.

Research has been unhelpful in defining the role of relaxin in human pregnancy. Risk factors for SPD include multiparity with or without a history of pelvic pain in previous pregnancies, the large baby, unsatisfactory work ergonomics, lack of exercise, conditions associated with general joint laxity, and previous back and low abdominal pain not associated with pregnancy. There may be a family history of SPD or of hip joint dysplasia.

Foremost in the obstetric management of SPD are diagnosis and explanation, but thereafter it is referral to experienced obstetric physiotherapy which is most likely to be helpful. Physical supports and medium strength analgesics can be useful, but bed rest may occasionally be necessary. Induction of labour and elective CS have a small place, and it is wise to consult a paediatrician where a premature birth is a possible outcome. TENS may help, but cases with severe pain may need the attention of an anaesthetist, who should be able to produce relief for a useful period with the epidural application of opiates.

Discussion.

MG in reply to Beverley Beech of AIMS: if a mother so chooses support when standing in water could provide worthwhile relief.

A prenatal teacher: Positions placing strain on the symphysis pubis should be avoided in labour, for example semirecumbent with the legs spread apart. Also harmful positions may be taken up under epidural analgesia and stress the symphysis without warning pain being felt. The all fours position is the one least likely to place strain on the symphysis. MG: It can be useful to tie the mother's knees loosely together as a reminder to avoid spreading them in labour; the supervision of a birth partner in this respect is also helpful.

Mother and SPD sufferer.
Sarah Fishburn. (SF)

I wish that I had known in my first pregnancy what I learned through my second and third pregnancies, and I hope that by passing on my experiences of what have been painful years I shall be able to help other women avoid such pain and disability. It has chiefly been manual physiotherapy which has enabled me to complete my family, despite pain and immobility, and to lead an independent life.

My symphysis pain started half way through the first pregnancy six years ago, and I accepted the reassurance of a physiotherapist that it it would remit after the birth; my baby was delivered by forceps in the 42nd week with my legs slung asymmetrically in the lithotomy position, and I now wish that I had protested about this at the time. I was told that the increase in pain which I experienced after the birth was to be expected for various reasons other than SPD, and I believe that had I received manual treatment by a physiotherapist at that time the subsequent course of my condition might have been very different.

Two months later pain was causing me significant handicap; I could not pick up my baby or push a pram, and taking stairs and driving were painful, if just bearable. As a first time mother I was unaware that this was particularly abnormal, and that other mothers were out and about, active and free from pain at that stage. Among other guesses it was suggested that the pain was mediated hormonally, and would improve when I stopped breastfeeding; there was little insight into the extent to which it was affecting my life. There were serial predictions of the duration of my pain, and after a year it was suggested that I might be one of the unlucky few whose pain would persist.

A succession of physiotherapists suggested various exercises, and advised loss of weight and getting fit; by now my GP presumed that my symptoms were psychosomatic, and there was an element of depression, reactive as I believe to my situation. More than a year had passed, and nobody had checked my pelvic alignment or tested for asymmetry. When my GP suggested that I could start another pregnancy, when the condition might not recur, I realised that she was unaware that it had never left me.

Many of the activities of normal life were now impossible for me. A talk by a colleague of physiotherapist Lucy Townsend convinced me of the reality of my problem, and I saw Malcolm Griffiths, who was the first doctor to take my condition seriously. We discussed the management of another pregnancy, and he referred me to Lucy; she made a full assessment of my pelvis and treated me manually with immediate benefit. The pain improved with further treatments, I used a gym ball at home, and did stability exercises. Later I started a second pregnancy, feeling that I could cope.

It was not long before the pain increased again, but Lucy kept it under control with further manual treatments. Wishing to avoid a repetition of my first delivery I asked for elective caesarian section, to which a sympathetic obstetrician agreed, but which was left as a back up when I decided to try for normal birth - feeling that the first birth had been something of a failure on my part. Now I needed some special equipment, but neither my GP nor the midwife knew where to refer me; I found an occupational therapist for myself, and got a monkey pole Monkey pole which allowed me to turn over in bed,a perching stool Perching stool for the kitchen, a shower seat and a bath board, and Helping Hand Helping Hands for upstairs and downstairs.

I started using crutches when I was six months pregnant, when my pelvis began to feel particularly unstable and painful; I would have become virtually housebound had I not been able to get a disabled parking permit (requested with some loss of self-respect), and eventually changed to a car with automatic transmission.

I found a more supportive GP, but met with some insensitivity in the antenatal clinic: "So apart from the SPD everything is fine?". But of course because of the SPD nothing was fine. Friends, some of whom had personal experience of SPD, were very supportive and practically helpful also. My husband and I were both very pleased to have an au pair as suggested by the health visitor; online shopping proved to be a great boon also.

Next time I had a three-and-a-half-hour labour and a water birth at 42 weeks. With my physiotherapist's help and advice my postnatal recovery was a huge improvement on the first time; I took analgesic and anti-inflammatory drugs, was driving the car after the six weeks and after six months I was getting only occasional pain. I could walk, climb stairs, sit on the floor to play with my children and take both of them to the toddler group on my own. In my third pregnancy I benefited from previous experience, and in addition took advantage of Shopmobility and a Red Cross wheelchair. I enjoyed the pregnancy, and I enjoy my children; I get great support from The Pelvic Partnership, in which I am active. (The Pelvic Partnership was created by people who have experienced SPD personally, and exists for the benefit of others who might be affected by the condition. Support is available through publications and email contact via the website).

More on Shopmobility

Discussion.

(MG) Relaxin is produced in the ovaries.

(MG in reply to Wendy Savage) I too have never seen an Asian woman with SPD.

(An obstetrician whose wife had SPD) I was able to help my wife turn over in bed without pain by pulling her; to get out of bed she learned to keep her knees together and move both legs as one. (SF) The following works in cases of moderate severity: getting on to all fours and turning under in bed. It takes pressure off the sacroiliac joints, and avoids abduction of the hips. But it is difficult in the late stages of pregnancy.

There may be a biomechanical knock on effect due to pronation of the feet if unsuitable footwear is worn (e.g. flip-flops). An appropriate change can be surprisingly effective.

(MG) If SPD is suspected, rather than palpating the symphysis immediately, which can be very painful, listen carefully to the pattern of the symptoms, and then carry out a full assessment.

(Wendy Savage to MG) Please write a RCOG Commentary on the subject, to inform the numerous ignorant among our colleagues. Too often patients with persistent symptoms which are difficult to diagnose are written off as psychological problems.

(The chair summarises) The message of meetings such as this evening's should be spread far and wide: avoid meaningless reassurance, take a full relevant history, and make a full biomechanical assessment. The crucial step is for midwives or obstetricians in the antenatal clinic to refer the mother in pain to physiotherapy, so that the she can be made aware of her condition and be guided throughout the remainder of her pregnancy. The rule in the delivery suite must be the avoidance of forcible abduction of the hips, for example by supporting the mother's lower limbs on the hips of her attendants. Birthing pools can provide excellent relief of pain.
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