Pelvic Pain Detail

Pelvic Pain (Symphysis Pubis Dysfunction) by KMom Copyright © 2001-2003 [email protected]. All rights reserved. Last updated: April 2003

DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider.

CONTENTS • Introduction • Anatomy and Structure • Symptoms • Cause • Implications for Malpositions and Cesareans • Tips for Coping with Pubic Symphysis Pain • Possible Treatments ○

Traditional Approach

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Chiropractic

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Osteopathic

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Other Alternatives

Planning For Birth • Other Common Questions •

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How often does a separated pubic symphysis occur

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Is this condition related to my build or size

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Should I have an elective cesarean

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Should I stop breastfeeding if I am still experiencing pubic pain postpartum

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Will this tenderness last after the birth

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Will I get this problem back with every pregnancy

Postpartum • Women's Stories • References • Resources •

Introduction

One problem that many pregnant women complain about is pubic pain. Yet doctors and midwives often dismiss this pain as either 'inconsequential', 'unfixable', or 'just one of those pregnancy discomforts that have to be endured'. Occasionally, some uninformed doctors have even erroneously told women that such pubic pain means that they would need an elective cesarean section in order not to permanently damage that area during birth, or as a result of prior damage to the area. Yet none of this is true. Pubic pain in pregnancy is certainly not 'inconsequential'; Kmom knows from experience that it can be very difficult to deal with. Although many doctors and midwives do not know what causes it or how to fix it, many women are able to get improvement or relief with chiropractic treatment or osteopathic manipulation. It is not something that you 'just have to live with'. And although extra care should be taken during labor and birth in order to prevent trauma, it absolutely does NOT mean that you 'have' to have a cesarean! This purpose of this FAQ is to discuss what causes pelvic/pubic pain, what some of the symptoms are, possible causes, hints for coping with pubic pain, how to prevent further trauma during birth, what kinds of treatments are available, and women's experiences with these treatments.

Anatomy and Structure Your pelvis is a kind of a circular bone that goes all around and almost meets in the middle in front. The two sides do not quite touch; there is a small gap between them connected by fibrocartilaginous tissue reinforced by several ligaments. This area is called the Pubic Symphysis. This is important for helping your pubic bone to move freely, stabilizing the pelvis while allowing a good range of motion. [An illustration of the pelvis can be found at http://omie.med.jhmi.edu/weblec/templatev1/lec11.html.] The Pubic Symphysis and the Sacro-Iliac joints (in the back of the pelvis) are especially important during pregnancy, as their flexibility allows the bones to move freely and to expand to help a baby fit through more easily during birth. In fact, the pregnancy hormones relaxin and progesterone help the ligaments of your body to loosen and be even MORE flexible than before, so that there is plenty of 'give' and lots of room for the baby to slip right through. Because of these hormones, it is normal for there to be some extra looseness and pelvic pressure in pregnancy. This is good---it means your body is getting ready for birth! It's loosening up to give you maximum space and flexibility, and to help make things easy for you and your baby. However, in some women, either because of excessive levels of hormones, extra sensitivity to hormones, or a pelvis that is out of alignment, this area is extra lax or there is extra pressure on the joint. In 1870, Snelling described this condition: "The affection appears to consist of a relaxation of the pelvic articulations, becoming apparent suddenly after parturition, or gradually during pregnancy; and permitting of a degree of mobility of the pelvic bones which effectually hinders locomotion, and gives rise to the most peculiar, distressing and alarming sensations."

Simply put, significant pubic pain is caused by the pelvic girdle area not working they way it should, probably because of hormones, misalignment of the pelvis, or an interaction of the two. Although not every provider has a name for this condition, it is most commonly called Symphysis Pubis Dysfunction (or SPD), especially in Britain. Other names for it include:

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pubic shear (osteopathic term)

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symphyseal separation

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pubic symphysis separation

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separated symphysis

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pelvic girdle relaxation of pregnancy

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pelvic joint syndrome.

Diastasis Symphysis Pubis (DSP) is the name for the problem in its most severe form (where the pubic symphysis actually separates severely or tears). For ease of use, in this FAQ the 'milder' form will be referred to as SPD.

Symptoms

The symptoms of SPD vary from person to person, but almost all women who have it experience substantial pubic pain. Tenderness and pain down low in the front is common, but often this pain feels as if it's inside. The pubic area is generally very tender to the touch; many moms find it painful when the doctor or midwife pushes down on the pubic bone while measuring the uterus (fundal height). Any activity that involves lifting one leg at a time or parting the legs tends to be particularly painful. Lifting the leg to put on clothes, getting out of a car, bending over, sitting down or getting up, walking up stairs, standing on one leg, lifting heavy objects, and walking in general tend to be difficult at times. Many women report that moving or turning over in bed is especially excruciating. One woman wrote, "There were days that I didn't think I was going to be able to get out of bed and actually had to roll out of bed and onto the floor to be able to do so!" [See her story below.] Many movements become difficult when the pubic symphysis area is affected. Although the greatest pain is associated with movements of lifting one leg or parting the legs, some women experience a 'freezing', where they get up out of bed and find it hard to get their bodies moving right away--the hip bone seems stuck in place and won't move at first. Or they describe having to wait for it to 'pop into place' before being able to walk. The range of hip movement is usually affected, and abduction of the hips especially painful. Many women also report sciatica (pain that shoots down the buttocks and leg) when pubic pain is present. SPD can also also be associated with bladder dysfunction, especially when going from lying down (or squatting) to a standing position. Some women also feel a 'clicking' when they walk or shift just 'so', or lots of pressure down low near the pubic area. Many women with SPD also report very strong round ligament pain (pulling or tearing feelings in the abdomen when rolling over, moving suddenly, sneezing, coughing, getting up, etc.). Some chiropractors feel that round ligament pain can be an early symptom of SPD problems, and indicate the need for adjustments. Other providers consider round ligament pain normal, part of the body adjusting to the growing uterus. If experienced with pubic and/or low back pain, it probably is associated with the SPD. Onset of Pain and Duration Pubic pain often comes on early in pregnancy, even as early as 12 weeks. One mother reports that she had it at 17 weeks. She says: When I woke up [from my nap] I could hardly move. It took me forever to walk into the next room. Felt like my hips/pelvis were glued together or something. Already this baby feels sooo heavy inside me, like lots of pressure. I've gained 4 lbs. so far, what's the deal? At night when I wake up to go to the bathroom, sometimes I can't move my legs/hips at all, and sometimes things have to 'pop' back into place. I think, what if there is a fire and I died 'cuz I'm too slow!...I thought this problem in my 1st pregnancy was from gaining so much/swelling and it got worse and worse and stayed till over 3 months postpartum." Indeed, although pubic pain often does go away after pregnancy, many women find that it sticks around afterward, usually diminished but still present. If treatment to resolve any underlying causes is not done, long-term pain usually sticks around. Anecdotally, this often seems to be associated with long-term low back pain or reduced flexibility in the hips. Even worse, if the mother is mishandled during the birth, the pubic symphysis can separate even more or be permanently damaged. This is called Diastasis Symphysis Pubis (diastasis means gap or separation). Summary To summarize, SPD is the mild form of this problem. Its symptoms often include one or more of the following: •

pubic pain

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pubic tenderness to the touch; having the fundal height measured may be uncomfortable

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lower back pain, especially in the sacro-iliac area

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difficulty/pain rolling over in bed

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difficulty/pain with stairs, getting in and out of cars, sitting down or getting up, putting on clothes, bending, lifting, standing on one foot, lifting heavy objects, etc.

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sciatica (pain in buttocks and down the leg)

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"clicking" in the pelvis when walking

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waddling gait

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difficulty getting started walking, especially after sleep

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feeling like hip is out of place or has to pop into place before walking

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bladder dysfunction (temporary incontinence at change in position)

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knee pain or pain in other areas can sometimes also be a side-effect of pelvis problems

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some chiropractors feel that round ligament pain (sharp tearing or pulling sensations in the abdomen) can be related to SPD

Cause No one knows why SPD occurs for sure, or why it happens in some women and not in others. Some ethnic groups report a high incidence, especially Scandinavian women and perhaps Black women. Other risk factors may include having lots of kids, having had large babies, pre-existing problems with this joint, past pelvic or back pain, or past trauma (car accident, obstetric trauma, etc.) that may have damaged the pelvic girdle area. It also seems logical that women who have broken or injured their pelvis in the past would probably be prone to this problem. Some sources view SPD simply as a result of pregnancy hormones. As noted, the pregnancy hormones relaxin and progesterone tend to loosen the ligaments of the body in preparation for birth. One theory is that some women have high levels of hormones before pregnancy, and then additional pregnancy hormones cause excessive relaxation of ligaments, especially in the pelvis. Another theory is that some women manufacture excessive levels of relaxin during pregnancy, causing pelvic laxity. However, although still popular, this theory seems to have been disproven by recent research. Another theory is that women whose joints are especially flexible before pregnancy may be more susceptible to the effect of hormones, or that some women's bodies are just more affected by hormones than others. Traditional medical sources tend to view the problem of pelvic/pubic pain (when they acknowledge it at all) as simply a hormone problem. A different theory holds that the problem is structural instead, and usually results from a misalignment of the pelvis. In this view, if the pelvis gets out of alignment, the bones don't line up correctly in front, and this puts a lot of extra pressure on that pubic symphysis cartilage. If the two sides are not aligned, it restricts full range of motion, pulling on the connecting pubic symphysis, and making it quite painful. The more out of alignment it is, the more painful this area becomes. It also tends to affect the back, especially in the sacroiliac area, since the pelvis and back are interconnected and work as a unit. And since many areas are affected by back problems, pain can also extend to other areas too. Kmom's personal opinion is that this condition is probably primarily a problem of misalignment, although hormone levels and sensitivity to hormones may also play a role. In her opinion, the first line of SPD treatment should probably address the possibility of misalignment. Others may not agree. But whatever the cause, SPD is certainly annoying and painful to deal with, and Kmom knows this from personal experience!

Implications for Malpositions and Cesareans One of the most interesting side-effects of a misalignment of the pelvic bones is that anecdotally, it often seems associated with malpositions of the baby, including: •

breech (feet or butt-first)

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occiput posterior (head-down but facing the mother's stomach instead of her back)

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asynclitic (head tilted to one side so that the parietal bones presents first instead of the crown)

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compound (hand or arm by face)

All of these malpositions tend to cause more difficult labors, with greater pain and often great difficulty in dilation or descent of the baby. There is a high rate of operative intervention when malpositions are present, including lots of forceps in vaginal births, and many cesareans as well. In fact, research shows that only a small percentage of babies with persistent malpositions actually are born spontaneously and without interventions. (See the FAQ on Malpositions on this website for further information and references.)

As noted on the website of the Australian Osteopathic Association: The descent of the baby through the pelvis is determined by factors such as ligament laxity, hormonal control, uterine contraction, gravity and position of the baby. If the mother's pelvis is mechanically unstable or is lacking mobility, it may interfere with the baby's passage through the birth canal. Unfortunately, very few doctors in recent years have paid much attention to malpositions (except to do cesareans for breech). Only in the midwifery, osteopathic, and chiropractic communities have these positions received much attention, and then only recently. Interest is now just beginning to re-surface in the obstetric community, but is very limited in mainstream obstetric journals as of now. There is little scientific data to show that pelvic misalignment is associated with malpositions because traditional medicine does not recognize misalignment as a problem or research it, nor do they take the idea of "pelvic misalignment" seriously. Really, they barely take the idea of non-breech malpositions seriously! Therefore, it cannot be stated from an evidence-based point of view that pelvic alignment is associated with fetal malpositions or difficult labors, or that re-aligning the pelvis would prevent malpositions, prevent cesareans, or lessen the incidence of difficult labors. Obviously, research into this issue is very important, but quite unlikely to occur anytime soon. The funding and interest is simply not there in the traditional medical community. This lack of data does not prove or disprove the misalignment theory; it simply has not been researched in the traditional scientific manner. Chiropractors, on the other hand, have seen in their own practices for years that women with misaligned backs and pelvises tended to have more malpositioned babies. There are some limited case series studies on this available in chiropractic research journals, but even this is not very well-documented. The first really significant work was done by Dr. Larry Webster, founder of the International Chiropractic Pediatric Association. He found that simply by realigning the pelvis and releasing the soft tissues, most breech babies turned head-down within a few treatments. It is important to emphasize that he did NOT manually turn the baby in any way, but simply realigned the mother's pelvis and 'released' the ligaments supporting the uterus. The baby then was not "constrained" anymore from assuming the best possible position, and so usually quickly turned vertex. Dr. Webster taught this "Webster In-Utero Constraint Technique" to many other chiropractors. Success rates depend on the skill of the practitioner, but usually are documented at about 80% or more in turning the breech baby. This is much higher than the success rates for manually turning the baby with the often-rough procedure known as a "External Cephalic Version". ECV success rates generally run anywhere from 40-65% or so, whereas the Webster Technique successfully turns 80% or so, at least in the data available so far. Thus, it seems likely that many cases of breech babies are quite probably associated with pelvic misalignment, and that treatment to re-align the pelvis may help many breech babies turn head-down. However, proof of this is limited to anecdotal evidence, lectures and articles from Dr. Webster, a few small case series, and surveys about chiropractors' experience with the Webster Technique. Not overwhelming evidence by any means, but all we have at this point. Yet it may be women's best bet in preventing malpositions and relieving pelvic pain. The Webster Technique also has a variant that can be used with babies that are head-down but facing the wrong way (posterior). Although little formal data exists on this, anecdotally many women and midwives have reported this to be helpful for non-breech malpositions as well. Thus, it is quite likely that in many cases, pelvic misalignment is often accompanied by baby malposition of varying types, not just breech presentations, and treatment may help resolve such malpositions. Anecdotal evidence also suggests that many women who have had past cesareans for non-progressive labor or "Cephalo-Pelvic Disproportion" (supposedly, baby too big or pelvis too small) actually may have had malpositioned babies. It's not that the baby was too big or the mom's pelvis too small, it's that the baby's position did not permit it to go through easily, causing it to get "stuck." These women (one of whom is Kmom!) often report that if they get regular chiropractic care in subsequent pregnancies, they frequently go on to have a Vaginal Birth After Cesarean because the baby malposition is prevented or is more easily resolved. They also regularly report that their pubic symphysis pain decreases significantly with treatment. So although little concrete scientific data exists from mainstream studies (largely because it has not been studied), and although anecdotal evidence has to be treated with caution, women with misaligned pelvises often seem to experience pelvic pain/SPD, and possibly a higher rate of malpositioned babies. It seems logical (though unproven) that treatment to help re-align the pelvis may help lessen pelvic pain, and may also prevent or correct a fetal malposition.

Although not every women with SPD experiences a malpositioned baby, it does seem to be very common in this group. Since baby malpositions commonly lead to lots of interventions like epidurals and forceps that tend to worsen pubic pain and may even damage the pubic symphysis permanently, checking for misalignments and working carefully to avoid/treat baby malpositions may be important to avoiding long-term pain or permanent pubic symphysis damage. This is a fascinating area that is just beginning to be researched but has potentially far-reaching implications.

Tips for Coping with Pubic Symphysis Pain Although the best idea may be to resolve chronic SPD pain through realigning the pelvis girdle and soft tissues, most women have at least some residual pubic and low back pain stick around for pregnancy and the early postpartum weeks because of hormones. Therefore, tips for coping with pubic pain tend to be a focus of many SPD websites. Many of the suggestions include: •

Use a pillow between your legs when sleeping; body pillows are a great investment!

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Use a pillow under your 'bump' (pregnancy tummy) when sleeping

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Keep your legs and hips as parallel/symmetrical as possible when moving or turning in bed

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Some women also find it helpful to have their partners stabilize their hips and hold them 'together' when rolling over in bed or otherwise adjusting position

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Some women report a waterbed mattress to be helpful

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Silk/satin sheets and nighties may make it easier to turn over in bed

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Swimming may help relieve pressure on the joint (many sites recommend avoiding breaststroke but Kmom did not find it to be a problem at all for her; see what works for you)

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Deep water aerobics or deep water running may be helpful as well (there are flotation devices to help you stay afloat easily during this; you do not need to know how to swim in order to do this)

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Keep your legs close together and move symmetrically (other sources recommend a very small gap between the legs with symmetrical movement)

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When standing, stand symmetrically, with your weight evenly distributed through both legs

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Sit down to get dressed, especially when putting on underwear or pants

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Avoid 'straddle' movements

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Swing your legs together as a unit when getting in and out of cars; use plastics or something smooth and slippery (like a garbage bag) on the car seat to help you enter car backwards and then turn your legs as a unit

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An ice pack may feel soothing and help reduce inflammation in the pubic area; painkillers may also help

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Move slowly and without sudden movements

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If sex is uncomfortable for you, use lots of pillows under your knees, or try other positions

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If bending over to pick up objects is difficult, there are devices available that can help with this

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Really severe cases may need crutches, although these should probably only be used as a last resort

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Sciatica may be helped by stretching the hamstring muscles with a stirrup around your foot (long piece of rope, two neck ties tied together, etc.) See the Elizabeth Noble book for directions (resources)

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Back pain can often be helped by resting backwards over a large gymnastic or 'birth' ball (see resources)

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Some women report that pelvic binders/maternity support belts are helpful for pelvic pain; brands in the U.S. include Prenatal Cradle or BabyHugger or the Reenie Belt. However, if the pelvic bones are really misaligned, some women report more pain with these. Listen to your body on whether to use these

Many sites also recommend a lot of bed rest, but Kmom has to disagree with this for most women. In Kmom's experience, her pain levels were much worse when she was inactive. Inactivity may lead to atrophy, and regular exercise is helpful in the prevention of many common pregnancy problems. Although the first 5-10 minutes of

activity were uncomfortable for Kmom, she always felt much better after that, and usually returned from her walks feeling much less fatigued and in less pain overall than if she had not walked at all or had stopped partway through. It's possible that in very severe cases, bedrest may be the best option, but Kmom would encourage most women to stay reasonably active as long as they use caution and listen to their bodies. Other tips that don't usually appear on SPD websites but which have helped Kmom cope include pelvic rocks, a lumbar pillow against the back when sitting, and very strong massage/counterpressure against the lower back. Pelvic rocks (getting on all fours and then slowly tilting the angle of the pelvis back and forth) are general recommended exercises for all pregnant women, plus they help promote good birth positions for baby. They can also help ease tight low back muscles. It is usually recommended to do 2-3 sets of 40 of these throughout the day. You can also do them sitting or standing against a wall, but on all fours is often most comfortable and has the added effect of helping the baby's position, which may be important with SPD. Lumbar pillows are very helpful to many pregnant women. They are available at many car stores, but if you cannot find one, try a small neck pillow (elongated like a tube), rolled up towel, or tube sock filled with rice or flax seeds. Put it behind your back when sitting, wherever it feels best; for some women this is down low in the small of the back, for some it is even lower against the sacrum, and for others it feels best up high in the middle of the back. Socks or pillows filled with rice or flax have the advantage of being able to be warmed in the microwave before using, which can feel really nice! Massage of the lower back or strong counterpressure in that area feels really great to some women. Some women like it just to the sides of their spine (helps loosen the muscles there), and some like it really low and farther out (there are trigger points there). Others like it all up and down on either side of the spine. See what feels best to you and go from there. If your partner's hands get tired (this is a tough place to massage!), try a rolling pin, tennis ball, or other hard object there. For women who like extra hard pressure on this spot, try getting on your hands and knees and arch your back a bit, then have your partner put his elbow against the area that feels best, lean his weight on it, and rub around in small circles. For others who like more gentle pressure, hand or finger pressure may be more than enough. Although it's possible to 'deal with the pain' or use these tips to help you cope with pelvic pain, these ideas only address the SYMPTOMS of the problem, not the root cause of it. If the source of your pain is purely hormonal, then addressing the symptoms is about all you can do until the baby is born and your hormones start to change. However, if the problem is in the misalignment of the bones creating stress on the joints, only fixing this misalignment can really help resolve the problem, and simply having the baby won't change much. It may make sense to at least get an evaluation of your pelvic area and back to see if there's a problem. Then you can choose whether to try any treatment or not.

Possible Treatments There are many treatment approaches available for SPD, although most websites have information primarily on traditional medical approaches. However, there are a number of other alternatives. Unfortunately, randomized trials examining the efficacy of different modes of treatment for SPD do not seem to exist. Obviously, Kmom's opinion is that chiropractic care is the best approach, since that was her experience and she knows a number of other women who have benefited from it as well. However, she makes no absolute recommendations to others as to what their best course of treatment would be, merely passes on her experience of what worked best for her. Each person must decide what treatment would be best for their situation. Don't give up easily in your search for effective treatment, however. Because the problem of pubic pain is so underacknowledged even in 'alternative' health care fields, women often have to search long and hard to find real help. Expect it to take a while to find effective help, and keep looking for a new provider if the one you're seeing does not take this problem seriously or cannot help. Be willing to try different treatment modalities, and be persistent---it took Kmom five years before she found help!

Traditional Approach It is often extremely difficult to get the traditional medical community (especially the obstetric community!) to take pubic pain/SPD seriously. They often simply ascribe pubic pain to the 'normal aches and pains of pregnancy' and brush it off as no big deal. They often believe that no real physical therapy or treatment is possible while pregnant and that it is just a matter of waiting it out.

Even when traditional practitioners take your pain seriously, the treatment recommended by most traditional providers is very conservative. Bedrest, painkillers, and anti-inflammatories are the typical recommendations. Some may also recommend wearing a maternity support garment or belt, such as the Prenatal Cradle, Reenie Belt, or Baby Hugger. For severe pain, some may recommend using crutches or a wheelchair as well. Again, this tends to treat only the symptoms, since they believe the cause to be hormonal, ending only with birth. In Britain, they have made some strides in recognizing SPD as a legitimate problem, but they often refer women to an 'obstetric physiotherapist'. Some women report being told that the physiotherapy needed should not be done on a pregnant woman and the physiotherapist would not treat them. Other physiotherapists would treat pregnant women; sometimes it was helpful, but many women report that it was not. Many of the treatments recommended tend to be very traditional (bedrest, crutches, painkillers) and not very effective. Postpartum, if the pain does not disappear or if the pubic symphysis is damaged due to obstetric mishandling, traditional medical treatment in Britain sometimes includes surgery to put a plate over the affected joint or to induce scarring over it in order to 'stabilize' it, or injecting a steroid directly into the pubic symphysis. Very invasive treatments indeed, and ones that involve a great deal of recovery time.

Chiropractic Chiropractic care aims to realign the pelvis, the back, and all affected areas through the use of manual adjustments. Many women with pelvic pain anecdotally report the greatest improvement from chiropractic or osteopathic treatment. Yet the majority of women on SPD websites apparently have not tried chiropractic care, and SPD organizations seem to be reluctant to promote chiropractic care as a possible treatment. Many people still see it as "too alternative" to actively promote. If the cause of SPD lies in pelvic misalignment, then only chiropractic or osteopathic manipulation will really address the root cause of the problem instead of addressing only the symptoms. There is no solid proof of this, but anecdotally, it does seem to be the most promising approach. The following information is designed to help women be more comfortable considering the possibility of chiropractic care, and to answer some of their concerns about chiropractic care. Be aware that like doctors, chiropractors vary in quality, and sometimes you have to see more than one to find the right one for your needs, and of course, it's also possible that chiropractic care may not be the right mode of care for you. Different Types of Chiropractic Care There are different schools of chiropractic technique. Some adjust with quick sudden movements, while others adjust only with gentle, almost imperceptible movement. Kmom has experienced both styles, and while she would have thought she would have preferred the gentler style, she didn't really find much relief from it. When she finally found the chiropractor who helped turn her baby, that chiropractor's style was the more sudden and forceful kind. It wasn't painful, but it was definitely startling! However, within an hour amazing changes began to happen, and Kmom's pain level was definitely MUCH improved. So while you think you might favor one style over the other, try to keep an open mind. It may be that one style helps you more than the other style, or that if you go for treatment only late in pregnancy, the 'gentler' style of treatment won't have enough time to work. If you find the idea of the stronger style of adjusting scary, be sure to tell the chiropractor ahead of time so they will know to take extra time to help you understand what will happen and help you relax into the adjustment instead of resisting it. That helps things considerably. Finding a Chiropractor Familiar with Webster's In-Utero Constraint Technique It is important to find a chiropractor that is well-trained in the treatment of pregnant women. Although most chiropractors receive some training in this while in school, some receive advanced post-grad training and are true specialists for pregnant women, babies, and children. In addition, many specially trained chiropractors will know the Webster Technique (which can turn malpositioned babies), something many other chiropractors are not familiar with. However, it is not always easy to find people with this training. If you can, it's best to find someone who specializes in "pediatric chiropractics." One possible way to find one is to check the website at www.icpa4kids.com and see if there is a specialist listed in your area. If there is not, you can email [email protected] or call 1-800-670-5437 and ask if there's one in your area. They have an extensive file of many chiropractors who are not listed on the site itself. Another excellent resource is the International Chiropractic Association (ICA). Call and ask for the Council on Chiropractic Pediatrics (1-800-423-4690). They also have an extensive list of people trained in this technique and

many others. It is not always easy to get through to this group, but their training is extensive and extremely detailed, so this is an excellent place to start. If there's no one listed in your area through either of these groups, start cold calling all the chiropractors in your area to find one who knows the Webster Technique. If there is no one in your immediate area that knows the Webster Technique, see if there is one within a few hours. In Kmom's opinion, it is definitely worth driving some distance in order to find someone specially qualified. It's better to drive a little than to endure the continuing pain of SPD, risk a long and difficult labor with a malpositioned baby, or possibly a cesarean because of a breech baby! So don't be afraid to go outside your usual range of driving. If there is truly no chiropractor in your area trained in Webster's Technique, try to find someone who has extensive experience and/or extra training with pregnant women. Some women have found that even though they didn't have the specific "Webster's Technique" done, they were able to get some pain relief from SPD, and sometimes their babies even turned. Webster's is the most effective treatment, so you should search long and hard for that before choosing someone else. BUT if you cannot find one trained in Webster's, a chiropractor with experience in treating pregnant women may be better than no treatment at all. Whatever chiropractor you see, it seems to be very important to have them not only evaluate the back and the sacroiliac joints, but also to evaluate and adjust the pubic symphysis directly, something many chiropractors omit, even those trained in Webster's Technique. Be sure they check and treat the pubic symphysis too! And if possible, they might want to try a "diaphragmatic release," a "Xiphoid Process Release," and Cranial Sacral Therapy as well (see below). What Is An Adjustment Like for Pregnant Women? Many women who have never seen a chiropractor before are understandably anxious about what an adjustment is like, and especially how it is done during pregnancy. A chiropractic adjustment during pregnancy usually involves the mom lying on her stomach on a pregnancy cushion that has an indentation designed to protect and cradle the baby. Baby is perfectly fine as long as mom is on this cushion. Some chiropractors have a table that is specially designed for pregnant women. The adjustment usually takes place on a special chiropractor's table called a 'drop table' (with the pregnancy cushion on top). Alternatively, the woman may also lie on her back for some adjustments as well. Parts of the drop table are able to be tilted up slightly, at an angle to the rest of the table. When the chiropractor does an adjustment, the tilted part of the table drops a bit. The adjustment plus that small drop (usually not very jarring) is often enough to realign the part of the body being worked on. Not all chiropractors use a drop table, but it's often a good tool with pregnant women because of limited ability to do other maneuvers. Other techniques that may or may not be used involve wrapping your arms around yourself like a pretzel while they adjust your back, leaning your hips/feet to one side, as well as other techniques that depend on the chiropractor's training and background. Some (but not all) chiropractors also believe in working with the soft tissues (i.e. ligaments, etc.) that surround the joints. They feel that if these soft tissues are not also 'released', then their tension may slowly pull the bones out of place again. This is probably an important part of treatment, one that should not be neglected if at all possible. Don't just get a spine or pelvic adjustment; also ask for soft tissue work. A 'diaphragmatic release' or a "xiphoid process release" has also been noted to help turn some babies even when the chiropractor did not know Webster's Technique. [Kmom is not familiar with what either of these processes involve, but they are not reported to be traumatic at all.] Another excellent treatment is called "Cranial Sacral Therapy" (CST). (It may have other names outside the US.) Kmom found CST highly effective too. If your chiropractor does not do soft tissue work or CST, you may want to supplement your treatment with someone else who can do these things (see www.upledger.com for CST practitioners in your area). Is Chiropractic Care Really Necessary? Is chiropractic treatment absolutely necessary to give birth? Of course not; women were having babies long before chiropractic treatment was invented. Your body knows what to do, and although misalignments might make labor harder or more inclined to malposition, it certainly is not an automatic sentence to a cesarean. Some women with SPD do have vaginal births (see below). There are too many variables in birth to say with certainty that SPD will cause problems. But because such a high percentage of women with SPD anecdotally seem to have malpositions and/or difficult births, it seems sensible to err on the side of treatment if you are experiencing significant discomfort.

What if you are experiencing some pain and discomfort, but not crippling amounts? Must any degree of SPD automatically be treated? Most chiropractors believe that any level of pain and discomfort indicate a need for treatment, and that this is your body's "early warning system" to tell you that something is wrong and needs fixing. Some degree of pelvic laxity is probably normal in pregnancy, but most chiropractors do not believe that pain, even minimal pain, is normal. From their point of view, it is better for women with mild SPD to get treatment in order to prevent the problem from becoming more severe later on and impacting birth. However, it is not absolutely required. Some women are understandably reluctant to try chiropractic care, something that is still on the fringes of mainstream medicine, and which, frankly, needs more scientifically rigorous study. Other women do not have the money or insurance to pay for chiropractic care, or cannot find a suitable provider near their home. As a result, some women elect to just live with mild to moderate SPD and only get treatment if things become severe. Kmom's personal opinion is that it's better to be treated, even with only mild discomfort, just in case. But if you really feel that treatment is something you cannot or prefer not to do, this is of course your choice. Some women with SPD do manage to get through pregnancy reasonably well and still have a normal birth. Chiropractic care is not a strict necessity for every woman, though probably a reasonable precaution. If you do not get treatment, keep in mind that you are probably at increased risk for pubic symphysis damage from birth so your providers should be aware of potential SPD problems ahead of time. They should watch for malpositions, stalled labor, and should be especially careful about maternal positioning during labor and birth (see below). These moms should also plan to avoid labor interventions in order to save strain on the area, and to preferably labor unmedicated so they can be more aware of any possible strain on the area. Hopefully, with care, you will be able to prevent or minimize any problems. Postpartum, women with mild untreated SPD may find that their pain seems to go away within a few weeks. Sometimes it is slightly worse right after birth but given time, resolves on its own. Here again, chiropractic care can be helpful but is not absolutely required. However, these women should be aware that the misalignment is probably still there at least minimally even once the pain ceases, and they should be conscious of the continuing potential for further damage from accidents or falls. If they show symptoms of problems in the future, they might want to again consider treatment. What Is a Typical Appointment Like? A chiropractor will feel down your back to see if there are any subluxations (misaligned parts). They may also test range of motion on you in certain joints. In addition, chiropractors trained in Webster's Technique will test you for pelvic alignment. The results are sometimes referred to as someone being "Webster Positive" or "Webster Negative." To find out if you are Webster positive or negative, you lie down on your stomach while your chiropractor gently pushes your feet towards your bottom. If one leg reaches further than the other, this means you are "positive" and could use the Webster. If your feet are even, then your legs are equal in length, and you are "Webster negative" and don't need Webster's Technique. Note that they are not talking about really big leg-length differences (which are unlikely) but rather about small and subtle differences between leg lengths. These indicate a pelvis that is out of alignment. Chiropractors will not do automatically do Webster's Technique on anyone; they test first to be sure it is needed. The Webster Technique is difficult for a non-chiropractor to explain adequately. (An technical description of it can be found in Anne Freye's book, Holistic Midwifery.) The following description relates Kmom's experience receiving Webster's Technique and then Cranial Sacral Therapy (at 36-38 weeks), but please note that since Kmom is not a chiropractor, these are only her impressions, which may not be completely accurate technically. Also note that the full version of Kmom's story is in the section on Women's Stories. First, the chiropractor watched me walk; she remarked on how 'off' my gait was. Then she took a history and we discussed my concerns extensively. Afterwards, she put me on my stomach on the pregnancy cushions on a drop table. She felt along my back to see how the joints were moving and to identify problem areas. Then she took my legs and bent them upwards at the knees towards my hips to see if they were the same length. (She was looking for subtle differences.) She found that one leg was indeed longer than the other, indicating that the pelvic area was out of synch. After checking several different things, she raised one small section of the drop table, the area under my hips. She identified the area that needed adjusting, asked me to take a deep breath in, then exhale deeply. During that exhale, she pushed sharply and strongly on that part of my low back/pelvis, and the table section under my hips dropped a bit at the same time. I wasn't quite sure what to expect and was really nervous about seeing this type of

chiropractor, so I was pretty startled by that drop to say the least. But it didn't hurt; it was definitely jarring but mostly it just startled me. She apologized and said that I was so far out of synch that she needed to use more of a drop than she usually used. Afterwards, she also put her hands on my abdomen at various points to help "release" the uterine ligaments and other supporting tissues. It's hard to remember if she adjusted anything else that day. Some sources say that you should not have any other adjustments done after Webster's Technique is initially done. I can't recall exactly everything that we did. I do remember clearly that she did finish up with soft tissue work (very gentle and non-invasive) and Cranial Sacral Therapy (which puts the weight of about a nickel on your head and sacral areas). At other visits, I know for sure she worked extensively on my Sacro-Iliac joints, my middle back, and to a lesser extent, my neck. As is common with chiropractors, she never checked the pubic symphysis joint, however. When I walked to the check-out desk after the first visit, I have to say I felt very foolish for being willing to try such a weird maneuver. As I wrote out the check, I felt like I had probably wasted my money. I was pretty emotional. My husband took me out to lunch afterwards to comfort me, and suddenly about an hour after the appointment, I noticed that my pain was gone and I was feeling terrific! It was weird how it took about an hour to "register" on me. All of a sudden I felt so good I felt like getting up and dancing around the room! I don't know if it was because the baby had suddenly turned or what. Whatever it was, it was just an awesome feeling, and I slept better that night than I had in a long time. My first visit to that chiropractor was about 45 minutes or so, while subsequent visits were about 15 minutes or so, give or take. After the first visit, the baby turned to the best birth position for the first time in pregnancy. The progress was really quite remarkable. I should note that I wasn't entirely pain-free afterwards, and since tissues tend to revert back to previous patterns, I eventually started to feel things go back again. But I felt so much better than I had before, it was like night and day! I had visits once or twice a week for 2+ weeks before the baby was born. Each time I would feel so much better! I just wished I had found her earlier in the pregnancy so I could have gotten some relief then and more fully resolved everything before the birth! I don't think we were able to fully resolve every alignment issue I had in that amount of time, but it sure helped! For the birth itself, I did have another malposition, though one more easily resolved than previously. However, I fell twice the day I went into labor, which could explain the malposition. It was a very rainy day, and I slipped and started falling. I saved myself from falling badly, but I could feel a big constriction in the PS area all of a sudden. Then later on, I was sitting on a stool and unexpectedly tipped backwards, landing on my tailbone and sacrum. I certainly felt that! The labor stalled about 5 cm, and became very painful for a while, probably indicating a malposition. I definitely had some pubic pain and major back pain during labor. However, the malposition resolved when I shifted my hips 'just so', and the baby was born shortly afterwards. I noticed that I made no progress when pushing in the "usual" position (hunched forward in a "C" with legs drawn back), but when I was able to arch my back REALLY strongly, the baby slipped right under the pubic bone and was born shortly thereafter. Instead of 5 hours of pushing (as with my previous child), this one was born in 12 minutes of pushing. It was short, intense, and wonderful. I had a normal vaginal birth after two previous cesareans for malpositions (believe me, the recovery was MUCH easier), and I give my chiropractic treatment a lot of credit for helping me with that. And I did NOT sustain any permanent damage to the pubic symphysis area from giving birth vaginally! It was a great experience overall. Postpartum, my chiropractor only treats the babies and not the postpartum mommies, so I did not get any follow-up care after the birth. The baby did have some significant colic (not unusual in malpositioned babies) so we took him in for Cranial Sacral Therapy. I was very dubious about taking a baby to a chiropractor (and my husband was even more doubtful!), but after having experienced for myself how very gentle it was, we decided to try it. It had remarkable results, and REALLY helped the colic. Postpartum, eventually my pain came back, especially the back pain. I saw an associate of my chiropractor, and we worked on improving my back. While the treatments did help, sometimes they had the side effect of causing hip pain and restriction. What we didn't realize was that the pubic bone was out of alignment and that was affecting everything else. It took us some time to figure out the problem, but eventually we tried doing a pubic bone adjustment. This had not been done for me in pregnancy; it's often not part of a routine check. But it seemed to be one of the main sources of problems for me.

In a PS adjustment, they use a drop table raised under the pelvis. The client puts her own hand over the pubic bone (so the chiropractor is not directly touching you 'there'), and they do a quick adjustment, just like on the back. The raised area of the drop table drops down, giving extra 'oomph' to the adjustment. I won't lie to you. A pubic symphysis adjustment definitely stings. The back adjustments never hurt me at all, but this joint does sometimes 'sting' when adjusted. It's not bad and goes away quickly (or I'd never do it!), but women should know that this adjustment is a little harder than the others, especially if the pubic bone is way out of alignment. To me, it was better to have a little sting now then months of discomfort, but it was definitely not as easy as the back adjustments. Harder, but worth it. Of all the adjustments we've done, I'd say this pubic bone adjustment is the one that's given me the most help. It also eliminated the hip discomfort and restriction I'd previously experienced from treatment. We are still working on the soft tissue angle; my recent adjustments have not included the ligaments and such, and probably should. But it is AMAZING how much the chiropractic care has helped! I'm not 100% pain-free at all times, but I am MUCH better. The difficulty we still have is in maintaining the adjustment long-term. We are still working on this. One of the important points of my story, though, is the importance of keeping up the search for the right treatment modality and the right provider; see below for the story of how long I actually had to search to find these treatments that helped! Caveats: It's important to know that just as with any health field, there are good and not-so-good chiropractors. Some are extremely well-trained and know exactly what they are doing; some do not. Most are ethical health providers, but just as with doctors, there are some quacks out there who are just looking to make a quick buck. Be cautious when selecting a chiropractor, and don't be afraid to switch if needed. The Importance of Perseverance Not every style or treatment plan works for every patient; some women have to see multiple chiropractors before they find one that really finds the key that resolves the problem. If the first chiropractor you see doesn't seem to change your pain levels, consider trying another. Kmom briefly saw 2 different chiropractors and 1 osteopath before she finally found the best approach for her (see her story below), and even now still is experimenting with treatment to find out what works best and what doesn't. Remember that there are different "schools" of chiropractic training and tradition too. If you go to one chiropractor, you may get one form of treatment, and if you go to another, you may get a totally different approach. That's why sometimes you have to search to find the approach that's right for you, and if you are not getting optimal results with one, why trying another approach may help. Of course, if you are unhappy with your course of treatment, it can be discontinued at any time. Don't feel tied to any one provider. In fact, if you feel you are no longer making progress with one provider, it may be that trying a new chiropractor will bring fresh new perspective on your situation. Just as with doctors, YOU are the employer, and you can "let go" your employee at any time. Have Realistic Expectations It's important to have realistic expectations going in to a chiropractor. Some people expect to have one adjustment and be forever free from pain or a recurrence of the problem. In reality, it usually takes multiple treatments (one criticism of chiropractic care), and sometimes it is a challenge to find all the sources of problems. Chiropractors are not miracle workers. Making a significant change can take time. While many women find total relief of pubic pain with treatment, others find it greatly diminished but not gone entirely. A really significant case of misalignment which has been around for years often takes quite a while to resolve, and some women struggle with chronic alignment problems all their lives. Many need periodic treatment to keep things working well, and if you later experience any falls, car accidents, or other trauma to the area, you may need intensive treatment again. A short-term course of treatment may not always completely fulfill your needs. On the other hand, sometimes a short-term course of treatment is all that is needed. The key is not to expect a miracle cure or a permanent total 'fix,' but to look for significant improvement in range of motion, pain levels, activity levels, and comfort. Although it is only human to look for a cure, any improvement is helpful, and hopefully long-term treatment can significantly reduce your discomfort. Don't be afraid to continue to look for additional help if needed, but keep your expectations realistic.

Osteopathic

Osteopaths also work with realigning the bones, ligaments, and soft tissues of the body but the philosophy and methods are slightly different. Osteopaths are trained in traditional medicine as well as the musculoskeletal system, but they tend to place more emphasis on preventive medicine, in looking at the body as an interconnected system, and often use osteopathic manipulation and other 'non-traditional' therapies. They use the initials "D.O." after their names instead of "M.D.", but because their training does include traditional medicine, many go on to become pediatricians, OBs, etc. as well. Although trained in osteopathic manipulations, many D.O.'s have gone very mainstream and no longer do manipulations, may do some only on a limited basis, or may not have much training in manipulation at all. Simply going to any D.O. will not guarantee that they can help you resolve this problem; you may need to search to find one that truly knows about manipulation and resolving pelvic issues. You may need what is sometimes called a "classical osteopath." At the International Cesarean Awareness Network Conference in April 2001, Kmom saw a presentation by Dr. Anita Showalter, a D.O. who is also an OB/GYN. Among other things, she mentioned the problem of 'pubic shear', where a misalignment of the pelvis causes one side to be higher than the other, resulting in tension and discomfort in the pubic symphysis joint area. A search for 'pubic shear' online brings up this technical definition from an osteopathy website:

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Inferior pubic shear (inferior pubis): a somatic dysfunction in which one side of the pubic symphysis is inferior to the contralateral side as the result of a shearing in the saggital plane.

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Superior pubic shear (superior pubis) reciprocal of inferior pubis.

At a follow-up after the conference, Dr. Showalter elaborated a bit more, explaining how pubic shear happens and what can be done to help. The following is a summary (from memory!) of her information; please be aware that because it is done from memory, it's possible there are errors. It's also possible that Kmom may have misinterpreted or misunderstood parts of the information, so insert caveats. Be sure to consult an osteopath familiar with this problem for further information or any treatment advice! As Kmom understood it, pubic shear is where the two pubic bones are not exactly parallel (in the same plane) in front; one is higher than the other. This creates lots of extra pressure on the cartilage and ligaments in the area, because they are being stretched and pulled on in a way they were not designed for. Pregnancy hormones exacerbate this problem. Hip movement can be restricted, movements that involve lifting one leg higher than the other are particularly painful, and problems in this area can affect other areas, such as the sacro-iliac area, etc. Dr. Showalter also showed Kmom and others a manipulation that she says helps many women with this problem (and it was nothing like the Webster's Technique Kmom had gotten previously!). Because it's hard to describe accurately, because people might hurt themselves doing it wrong, and because it is important to consult an expert before trying treatments like this, Kmom will not recount here exactly what this manipulation entailed. However, she will give a basic description so women understand that it really was not very interventive at al, but please don't try this based on this summary! It involved the woman lying on her back, having one knee drawn up (which knee depends on which side is out of alignment), and a D.O. or partner using gentle pressure on the opposite side of the pubic bone (towards the hip) while simultaneously pushing down the knee towards the foot until the heel slides down and the leg is stretched out on the ground like the other leg (it's trickier than that, but that's the basic idea). Doing follow-up with the soft tissues may also be helpful. Several women tried this with Dr. Showalter, and reported that it felt good. Kmom tried it but did not feel much difference, although since she was not pregnant at the time and had already had chiropractic adjustments, there may not have been much to affect! So finding an osteopath that knows how to help 'pubic shear' may be another option for treatment. When told that some doctors have told pregnant women that an elective c/s would be necessary to prevent permanent pubic symphysis damage, Dr. Showalter expressed great dismay. She was also upset at how many women are told that this pain is normal to pregnancy, and that the only fix is to take some Tylenol and wait for birth. She felt that treatment was very important, and reinforced that back or pelvic misalignment can increase the chances for malposition of the baby. When asked about permanent pelvic damage from this condition, she felt that in rare and extreme cases, the pubic symphysis can be torn or separate, but usually only by foolish actions on the part of doctors, nurses, or labor helpers. She said that virtually every case she's ever heard of has occurred when the woman had an epidural, was on her back, and had her legs flexed back too strongly by well-meaning but over-enthusiastic personnel. The epidural

prevented the woman from feeling the pain at the time, so nobody knew to stop. Thus the woman was injured during birth and no one realized it until later. One intriguing note written online by British osteopath Steve Pike observes that not enough attention is paid to the soft tissues when treating this problem. He feels that the 'clicking' problem many SPD women note may be related to a tendon problem instead of a bone problem. He writes at www.kamish.com/dsp/_disc2/0000008b.htm: I have successfully treated several patients with symphysis pubis dysfunction. It always amazes me that the muscles, ligaments, and connective tissues are virtually ignored in the discussion and treatment of this condition, all attention being focussed on the symphysis pubis joint and the sacroiliac joints. Yet the soft tissues are what binds the whole pelvis together and provide support and locomotion. Treatment of the soft tissues using osteopathic massage techniques almost always improves the condition--sometimes dramatically. I would add that the "clicking" often noticed by sufferers during walking, often does not come from the pubic symphysis at all but from the tendon of the psoas muscle---an indication that this muscle is tight and needs treatment. One British woman, Lia Hattersley, wrote about her experience with SPD and osteopathy at www.guardian.co.uk/health/story/0,3605,724347,00.html. The pain was so bad prenatally that she ended up in a wheelchair at times. Postpartum, she found Quentin Shaw, a "classical osteopath" who is a senior lecturer at Surrey Institute of Osteopathic Medicine. She says, "After one treatment I was able to walk and my crutches became obsolete." Her article recounts her whole experience, the lack of help she experienced from traditional treatments, the reluctance of medical authorities to consider alternative care such as chiropractic or osteopathic treatment, and the stories of a few other women also helped by alternative treatments. She ends her article with a call for more access and openness to these choices within the British medical system. In summary, osteopathic treatment may be another option for women suffering pubic symphysis pain. Osteopaths may be a little easier to find than chiropractors who know the Webster Technique, but not all osteopaths still practice 'osteopathic manipulation' techniques. Many no longer use manipulations, and of those who still do, not all are equally trained. It may be necessary to find a "classical" osteopath, especially one who specializes in pelvic problems. Treatment may also take longer. Again, be open to the fact that you may need to try several different practitioners or treatment modalities before finding what works best for YOU. If one osteopath does not seem to help you, don't assume that none can. Be willing to try several different ones. The quality of osteopaths, like chiropractors, seems to vary widely. You want one that regularly uses manipulations in their practice, and if possible, one that specializes in pelvic treatment.

Other Alternatives A. Polarity Therapy - Elizabeth Noble, a physical therapist and birth activist, wrote about pubic pain a bit in her book, Essential Exercises for the Childbearing Year. She describes polarity therapy for pubic symphysis pain this way on page 219: Lying on your side, a partner places all five finger tips firmly at the union of your pubic bones, and the other hand rests flat on your sacrum. The hands should remain still on these two points until warmth, tingling, vibration, pulsing or other evidence of your body's electric field can be felt equally in your partner's both hands. Usually only one to two treatments is necessary. I have successfully used polarity balancing to treat painful PS laxity for fifteen years. Kmom tried this with her husband and had no success with it; perhaps it was not done correctly. Kmom knows little about 'polarity therapy' but tends to be dubious so far. However, it's certainly unlikely to do harm to try it. Noble has many excellent ideas and exercises in her book, and does have some ideas for sacro-iliac pain as well, so this book probably is worth looking into for other issues. B. TENS - Some women report that TENS (Transcutaneous Electronic Nerve Stimulation) has helped improve their pain. C. Pressure Points - One mother with SPD reported that using pressure points seemed to improve her pain levels. Here is what she wrote about it: "If you can't [see a chiropractor], I will tell you of an exercise you can do at home to help relieve some of the pain yourself! First, I know you are going to say, 'Yeah, right, you've got to be kidding' but you have pressure points right on the top, corners and sides of your pubic symphysis bone [the pelvis]. Basically, lie down flat on your back (or as close to it as you can get!) and wherever you are feeling pain, take your fingers or thumbs and press on those point for about 10-20 second at each point and do this once or twice a day. It will hurt like hell at first but it will

actually feel a lot better once you do it. It's even better if you can get someone else like your husband to do it because they will exert a little more pressure than you will let yourself do! Just grin and bear the pain and I promise you that the pain will subside somewhat---maybe not all the way, but it worked wonders for me! "You can also have microcurrent therapy done on these spots (has to be done in the chiro's office) but it also works! It is amazing that my pain is almost gone, especially considering the amount of pain I was in...although I do still have some bad days where overuse and lots of activity give me pain....all I have to do now is do the pressure points and the pain is relieved....LIKE MAGIC!!" D. Movement/Strengthening Therapies - Several women have reported on other websites that movement and strengthening therapies like the Alexander Technique and Pilates have helped them postpartum. The Alexander Technique is supposed to help retrain you into more efficient and better muscle usage. Pilates is supposed to work on strengthening the core muscle areas (abs, back, etc.). However, some women report that Pilates actually worsened their back pain in the long run. E. Acupuncture - Acupuncture has also been reported to help pain levels. It does not resolve pelvic misalignment, but it has been used successfully to treat many different types of pain. Some acupuncturists are reluctant to work with pregnant women; seek someone who is very well-trained and experienced in working with pregnant women, even if you are postpartum. F. Homeopathy - Some women report improvement in pain with the use of the homeopathic remedy, Kali Carb, 30c. However, homeopathy is very much based on an individual's personal circumstances, personality, and needs, and you would need an individual consultation to know what remedy would work best for you. Many scientists are highly dubious of the value and efficacy of homeopathy; but there are also many devotees worldwide who swear it has been helpful. G. Herbs - In Cora's story, below, she recounts the use of herbs to help reduce her levels of pain, reputedly by helping to repair internal tears. Again, herbal treatment should be done only by a specialist in herbs, since over the counter herbs tend to vary widely in quality and strength, and because so many considerations must be balanced in treatment. The great herbalist Susan Weed recommended (about 3 weeks ago) Teasel tincture, which is for "internal tears that are hard to get at," and comfrey infusion (the other name for Comfrey is Knit Bone). Within 3 days of taking the Teasel (15 drops 3x a day) I started seeing improvement. Now I am 31 weeks and feeling almost no pain at all and can move more quickly and efficiently than I could at 18 weeks when the baby was so much smaller. I am amazed and thrilled that these remedies are working so incredibly well and thought that other women should know about them. H. Pelvic Support - A maternity support belt can offer extra support and firm pressure, which many women seem to find helpful. However, please note that if the pelvic bones are not in the 'right place', some women find that a maternity support belt can make the pain worse. One physical therapist at http://pregnancytoday.com wrote: If the pelvic ring, which includes your pubic bones and sacroiliac joints, is not lined up symmetrically, using the reenie belt will just increase the pain. This is because it serves to compress the front and back joints of the pelvis which are out of position...I recommend...a physical therapist in your area that specializes in treating pregnant women. The therapist can evaluate your problem carefully, and, if need be, provide hands-on treatment to restore normal joint alignment. Once you achieve that, the reenie belt can do its job of keeping the pelvis in alignment and will not be painful.

Planning for Birth Certain common obstetric interventions tend to make Symphysis Pubic Dysfunction pain worse, and may even lead to ligament damage or severe separation of the joint, causing true Diastasis Symphysis Pubis. Therefore, it is vitally important that your doctor or midwife understand and believe in the existence of SPD and realize its implications for birth. The following ideas (taken from a number of sources) are supposed to help maximize your comfort and help the normal birth process, while also minimizing the risk for pubic symphysis-related trauma.

1. Be extremely careful of birth positioning. Certain positions are better than others. Avoid stirrups! 2.

Be sure your labor assistants and providers know all about SPD, what movements can hurt or damage you, and what your comfortable range of motion is

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Avoid most common labor interventions, as these often cause pubic symphysis strain/damage

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Avoid an epidural if at all possible, as this often is associated with more severe damage

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Use a 'narrow gap' between the legs for any routine procedures that can't be avoided

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Hire a birth attendant that is familiar with and can help resolve baby malpositions

Specifically, you might want to consider the following: 1. Be extremely careful of birth positioning. Certain positions are better than others. Avoid stirrups!

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Don't give birth on your back - Many cases of pubic symphysis injury occur in this position

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Don't use stirrups - This widens the gap between the legs and strains the pubic symphysis

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Listen to your body - Your body usually will tell you what position you need to take in order to help baby out while avoiding damage to your joint. This may be contrary to what your nurses or provider are telling you, but give preference to the positions that feel best to you. For example, sitting forward in a "C" is the position promoted in most hospitals, but Kmom found arching the back to be most helpful. This helped her baby move under the pubic arch and be born rapidly, while in the traditional "C" semi-sitting position, there was no descent of the baby and great pain instead. Other women with pubic pain have reported that arching the back during pushing was helpful too. Use the position your body tells you to!

Don't give birth semi-sitting - This tends to force the baby's head against the pubic symphysis, putting pressure on it to 'give' more. It also prevents the coccyx/tailbone and sacrum from moving out of the way during birth, and thus the only joint available with any 'give' to it would be the pubic symphysis, which puts it at greater risk for damage Use 'alternative' birth positions - These include standing, kneeling, and all fours in particular. You may have to search for a provider that is comfortable using these positions throughout labor. Some doctors will 'permit' women to use alternative positions until just before baby's head crowns, but often want the woman back in the traditional stirrups or semi-sitting position for crowning of the head and delivery of the shoulders. However, crowning and birth of the shoulders is the most critical time for prevent pubic symphysis damage, so really look for a doctor or midwife that is willing to 'let' a woman be in whatever position feels best to her for birth. If you must be in a more 'traditional' position because of other concerns, try side-lying as this takes the pressure off of the pubic symphysis and allows the coccyx and sacrum to move somewhat. Otherwise, all-fours or leaning back over a birth ball may be best

2. Be sure your labor assistants and providers know all about SPD, what movements can hurt or damage you, and what your comfortable range of motion is

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Hire a birth attendant that takes SPD seriously - Many providers do not really believe that SPD really exists or that it is a serious concern for birth. Little mainstream literature exists on it, so you may have trouble convincing some providers that it is anything more than the normal aches and pains of pregnancy. If they do not really understand the concerns of SPD, they will not be as careful at the birth

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Hire a birth attendant that rarely uses interventions like stirrups, forceps, etc. - If these interventions are not part of your caregiver's normal procedures, chances are good that you'll avoid them. If your provider often uses these procedures, chances are they will have a hard time avoiding them, even when they know that they need to be avoided

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Consider giving birth in a non-hospital facility or at home - This might help lessen chances of damaging interventions, since stirrups, forceps, and other routine interventions are done less in these settings

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Educate your birth attendant, coaches, and other helpers about SPD - Raise the awareness of SPD problems with your attendants and helpers so they can help you avoid problems during the birth. Be sure to especially discuss with them the importance of a 'narrow gap', avoiding interventions whenever possible, and how to avoid placing extra strain on the pubic symphysis area

3. Avoid most common labor interventions, as these often cause pubic symphysis strain/damage

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Avoid the use of forceps or vacuum extractor - These may necessitate opening the legs wider than the pubic symphysis can safely tolerate

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Don't pull your knees back too far - This puts a great deal of strain on the pubic symphysis joint. Be sure to let your nurses, doula, or labor coach know not to do this!

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Don't put your legs on your attendant's hips - Again, this strains the pubic symphysis joint

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Avoid an induction if possible - Induction contractions are often abnormally strong and difficult to handle without an epidural to help, and this increases your chances of other harmful interventions

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Avoid breaking the waters early - Since malpositions may be more common with SPD, it is probably sensible to avoid breaking the waters artificially during labor. If baby is malpositioned and the waters are broken, then baby often moves down in that malposition, cannot turn, and gets 'stuck', necessitating a csection. If labor stalls around 4-7 cm or so in a woman with SPD, then baby malposition should be suspected, breaking the waters avoided, and changing maternal posture utilized to help baby turn

Minimize or avoid vaginal exams - Positions for vaginal exams tends to strain the pubic symphysis joint. Do as few vaginal exams as possible (most are not necessary anyhow) so there is less frequent strain, and use as small a leg gap as possible if a vaginal exam must be done

4. Avoid an epidural if at all possible, as this often is associated with more severe damage

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Avoid an epidural so you can tell if damage is imminent - Once your feelings are deadened, you may not be able to tell if they force your legs too strongly, and this is when many tears or severe separations occur

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Avoid an epidural to lower the chances for forceps, vacuum extractor, and stirrups - Stirrups are standard procedure in many hospitals with epidurals, and stirrups increase the chances of damage. In addition, one side-effect of epidurals is to strongly increase your chances of needing forceps or vacuum extractor during pushing, which also necessitate a wider leg position and increase the chance for pubic symphysis damage

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Consider hiring a doula (professional labor support) - A doula can often help you cope with labor without having to have an epidural; she can also help you remember to remind caregivers to avoid a wide gap. Research shows that need for epidurals and other pain relief methods is much lower with a doula present

5. Use a 'narrow gap' position between the legs for any routine procedures that can't be avoided

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Use a string to measure ahead of time the widest comfortable position for your legs - Have your coaches use that in labor to remind nurses and other attendants of the widest position that is wise

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Use a 'narrow gap' only - If vaginal exams is truly necessary or if any stitching is needed afterwards, be sure to remind the providers to use a 'narrow gap' only

6. Hire a birth attendant that is familiar with and can help resolve baby malpositions

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Research and understand the signs of a baby malposition - Baby malpositions may be more common in women with misaligned pelvises and pubic pain, and this can cause a more painful, difficult labor. Understanding the issues and knowing the symptoms may be very important in avoiding such a labor

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Understand how to prevent malposition or turn a malposition during labor - There are things that can be done to help avoid a malpositioned baby or even to help turn one during labor. Educate yourself more about this so that you can be proactive about prevention at home and pass on the info to your provider

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Hire a birth attendant that takes malpositions seriously and knows how to help them - Most doctors and many midwives do not really understand baby malpositions and how they can affect labor and birth. It would probably be very helpful to hire a birth attendant that pays careful attention to baby's position before and during birth, and knows how to use maternal positioning and other techniques to get a baby to turn. [For more information on this subject, read the FAQ on Malpositions on this website.]

Please note that when the pelvis is well-aligned and labor precautions are taken, most women are able to give birth vaginally without any problems or damage. An elective cesarean is NOT necessary for women with SPD; if precautions are carefully observed, the chances of pubic symphysis damage are greatly lowered and the significant risks associated with cesareans are avoided as well. However, because the pressure on the pelvic joints to expand is greatest as baby emerges, women with SPD may find that pushing is uncomfortable at times. If they are allowed to use the position that feels best to them and if birth

attendant pays attention to the baby's position, baby is usually born without difficulty and this discomfort is minimized and transient, unlike the post-surgical pain that would be associated with a cesarean. Being aware that pushing may be uncomfortable and knowing the importance of using alternative birthing positions (try arching your back!) may go a long way towards helping a woman be prepared for and deal with this. In Kmom's opinion, the most sensible approach to SPD is probably to carefully correct any pelvic or spinal misalignment during pregnancy and well before labor. However, because of the hormonal influences on the pubic symphysis area, it is probably also extremely important to utilize these labor precautions as well. Women with SPD can give birth safely vaginally, and this is usually best for both mother and baby. However, being proactive about positioning and avoiding interventions during labor is only sensible as well.

Other Common Questions How often does a separated pubic symphysis occur? No one knows for sure. Estimates range from 1 in 300 to 1 in 30,000. The difference probably has to do with the definition of 'separation' (how severe does it have to be before it is counted?) and differences in birth practices (it's probably more common where stirrups and epidurals, etc. are used aggressively). Is this condition related to my build or size? Many people have wondered whether their particular size or build contributed towards their SPD. The answer is probably not. In various resources on SPD, both a very large build and a very petite build have been blamed for causing SPD problems. If size/build really caused this problem, all fat women or all petite women would get it, and we know that this does not happen. Most likely it has more to do with hormone sensitivity or pelvic misalignment than build. A past history of pelvic trauma (car accidents, sports injuries, falls, etc.) seems to be common among many SPD sufferers, so this is more likely to be the source of the problem. Should I have an elective cesarean? No. This is a very common question; it seems logical that an elective c/s might prevent further damage to the pubic symphysis, but in reality the problem is caused during the pregnancy and an elective c/s won't fix that. The best option is to get the pelvic misalignment treated so that there is little danger of damage from SPD, and also to avoid the typical obstetric interventions (like stirrups) that tend to cause the severe problems that some women experience. Only rarely do most women fully appreciate the substantial risks associated with a cesarean, both to themselves, to the present baby, and to any future babies. A cesarean is MAJOR abdominal surgery. It doubles the risk of maternal death, and blood loss also tends to be doubled because of the surgery. This can cause anemia afterwards (a significant health problem), which can lower breastmilk supply or cause breastfeeding to fail. 1-2% of women who have cesareans have to be rehospitalized within a couple of months for complications; there is a 30x greater risk of being rehospitalized because of serious wound infections after a cesarean compared with normal vaginal birth. Women who have had cesareans have higher rates of gallbladder disease, appendicitis, chronic pain, internal adhesions, and bowel problems. They also have slightly higher rates of infertility, miscarriage, and ectopic pregnancy. Elective cesareans are also a risk to the baby, as significant breathing problems often occur without the benefit of labor. These can be temporary, or may end up long-lasting and debilitating. The risk for fetal breathing problems is particularly strong in elective cesareans before 39 weeks. Most alarmingly, a cesarean scar brings significant increased risk for future pregnancies. Uterine rupture can and does occur without labor. Placental abnormalities increase after a cesarean, and increase very strongly with multiple repeat cesareans. Placenta Previa (low-lying placenta which covers the cervix) is MUCH more common, and this presents a risk for severe hemorrhaging. Placenta Accreta (where the placenta grows into or through the uterine wall) is a very severe complication associated with Placenta Previa, and often leads to hysterectomy and occasionally to maternal death. Placental Abruption (premature detachment of the placenta) also is much more common after cesareans, leading to risk of severe hemorrhaging and fetal death. All of these are more common after a prior cesarean, and especially so after multiple repeat cesareans. These risks should not be taken lightly. Some women are tempted to have an elective cesarean because of past mismanaged births. Quite understandably, they fear a recurrence, and see elective cesarean as a way to eliminate the risk of mishandling completely. However, this simply trades old risk for newer and greatly underestimated risks. For women who have had very severe and long-lasting damage from the mishandling of SPD, or for women who cannot or will not find a provider that will

avoid the interventions associated with SPD, an elective cesarean may be worth the trade-offs. For most women with SPD, however, the tradeoffs of risk (particularly if they eventually want more children) are not worthwhile. An elective cesarean does not prevent symphyseal separation or strain, as this usually happens earlier during pregnancy. What it might prevent is making things worse through poor obstetric management. But the choice does NOT have to be between elective cesarean and vaginal birth with so much intervention that it causes damage. Finding a birth attendant that works outside the typical medical mindset and does not employ the damaging interventions IS a real and viable choice, and lowers the risk of problems during birth. But equally as important is checking for and fixing any pelvic misalignment well before labor. Should I stop breastfeeding if I am still experiencing pubic pain postpartum? No. For years many women were told that the hormones of breastfeeding were causing postpartum pubic pain, and that weaning would probably improve their condition. However, most women have not found that weaning improved their pain, and a substantial number found that it actually increased their pain levels. Relaxin and progesterone are the hormones that are most responsible for pubic symphysis laxity, yet these are reduced during the breastfeeding period. Instead, estrogen tends to be high during breastfeeding, and this has little bearing on pubic pain. In addition, breastfeeding provides so much immunological protection for the baby that early weaning is not advisable. It probably also helps decrease the risk for reproductive cancers in the mother, especially if it continues long-term. So weaning early would probably not provide any pain benefits and would almost certainly lose the protective effects breastfeeding has for both mother and baby. Don't wean early. Will this tenderness last after the birth? It depends. Some people have long-lasting pain and some don't. If it is really related to an underlying misalignment of the pelvis and back, then it is likely to stick around if that misalignment is not resolved, although it may lessen significantly once the pregnancy hormones are gone. If the condition was made worse during the birth because the attendants mishandled the situation, then it may even be worse postpartum. On the other hand, sometimes it goes away completely afterwards. [See the section on "Postpartum" for more details.] Will I get this problem back with every pregnancy? Most women have it recur every pregnancy, but this is not always true. Some get it worse with each successive pregnancy, while others never re-experience the problem at all. Again, if there is a misalignment of the pelvis or back and this is not resolved, chances are it will recur with each pregnancy. Or perhaps some women are just more sensitive to pregnancy hormone levels than others. Some women wonder whether to limit the size of their family because they find SPD so difficult to deal with. Before giving up on having more children, remember that many women DO find partial or full relief from various treatments, and that foregoing more children is truly not necessary. However, you may need to be very aggressive about finding a new doctor or midwife that will help you avoid iatrogenic (i.e., doctor-caused) problems with birth, and you may need to try a number of different treatment modalities or practitioners to find the ones that can most help in your situation.

Postpartum Some women may continue to have pubic and/or back pain postpartum, while others report that it gradually goes away. If the underlying cause is a misaligned pelvis and not just simply sensitivity to hormones, then the pain will probably continue in some degree unless it gets treatment. However, sometimes the body does seem to heal itself just fine on its own, or gets better enough that the pain is not so noticeable until another injury, pregnancy, etc. causes a recurrence. As noted, some women are told that breastfeeding hormones make pubic pain continue until weaning, but most women do not report that weaning lessens the pain. Therefore, SPD should have no bearing on the length of breastfeeding, and women should not wean their children in hopes that this will improve SPD pain. After menstrual cycles return, some report increased pubic pain premenstrually--usually during ovulation--while others do not see a cyclical recurrence. A few women also report the pain to be worse while on the Pill, though this does not seem to be universal.

It should be noted that if at any time you need to have a hysterectomy, you should carefully discuss your SPD history with your GYN and be sure that they understand the condition fully. Woman who have had vaginal hysterectomies (that is, a hysterectomy where the uterus is taken out via the vagina rather than through the abdomen) report that this has at times re-aggravated their SPD problems. Because this type of surgery is performed with women in stirrups, it certainly has the potential to create pubic symphysis problems again. Because vaginal hysterectomies present many advantages in other ways, women who truly need a hysterectomy should carefully discuss the pros and cons of all of their various options with a doctor who is very knowledgeable about SPD. The worst-case scenario for birth and post-partum is when a woman with SPD is mishandled, and use of stirrups, interventions, or 'wide gap' positioning damages or severely separates the pubic symphysis. At this point, SPD become Diastasis Symphysis Pubis (DSP), which can be very painful and difficult postpartum. DSP can only be officiallydiagnosed after pregnancy with an X-ray, ultrasound, or MRI scan that will measure the distance between bones. According to the British SPD Support Group website, when a woman is not pregnant the normal distance between the two pubic bones is 4-5mm. In every pregnancy, there is an increase in the gap of at least 2-3mm due to hormones. So a total width of up to 9 mm is considered normal for a pregnant woman. Within a few months after birth, this gap decreases and the supporting ligaments strengthen again. An abnormal postpartum gap is defined as 1 cm or more after the time when the joint should be back to normal. If the pain continues severely postpartum, traditional medical treatment involves several options. Injecting a steroid directly into the joint is one option sometimes recommended. Another option is surgery. Surgeons will sometimes take some bone from the hip area and make a plate to be screwed in over the pubic symphysis to try and stabilize the pelvis more. This is a very big surgery, it reportedly can take several months to recover from, and the success rate is apparently not very good (see Lia's story, below). Or they can try to create scar tissue over the area in hopes that it will tighten up the gap or act as a kind of 'plate' over the area too. For more information on these options, contact the British SPD support group, www.spd.-uk.org. Because many problems can be helped at least somewhat through chiropractic or osteopathic care, even those with more severe cases of pubic symphysis problems might want to consider these options before resorting to something as traumatic and irreversible as surgery. However, each person must do what seems best to them in their particular circumstances. Although it is very difficult to get health providers to understand and take long-lasting pubic pain seriously, it has the potential to affect a woman's whole body, and as a side effect, her emotions, her children, and her family life. Don't give up easily; many women have had to persist for many years before finding what works best for them in their situation.

Women's Stories Paula's Story I was one of the "fortunate" ones to be experiencing pubic symphysis pain, but I started going to my chiropractor again and VOILA! I am a new woman!! I will tell you that my pain was so bad there were days that I didn't think I was going to be able to get out of bed and actually had to roll out of bed and onto the floor to be able to do so! I went to a different chiropractor just to "see what he offered" and my appointments consisted of maybe 2 adjustments and that was it---less than 5 minutes in his office---and it took me 20 to drive there! He wasn't very open-minded about listening to my concerns or answering questions, so I chose to go back to the chiropractor I have been going to since I was 13. He knew exactly what was going on and I kid you not, within one adjustment, I could actually move my legs without feeling like I was going to die of excruciating pain. I have been seeing him for almost a month now, twice a week, and I am almost completely pain-free!!! For those of you who are experiencing pelvic pain, please go see a chiropractor!!

M's Story I had a cesarean with my first baby for breech. [With my second child,] I had severe pain in my pubic bone bad enough that I could barely walk...I felt TREMENDOUS pressure on my pubic bone while pushing with him, it was as significant as the ring of fire. Thank God I was in a squat so I could stop when it hurt too much!...[I also arched my back as I pushed.]

This time, when it started getting bad, I saw a chiropractor and it was gone the day he adjusted me...The spinal adjustments were normal for me, but the pressing on my abdomen was very painful. The Webster entails getting the back in alignment then releasing knots in the abdominal muscles. The muscle part hurt a lot. {Kmom note: Most women don't find it painful; this is an interesting difference} I think it was instrumental in [my third child] being vertex [head-down]. I'm pretty sure that she was breech the Thursday before I went into labor. I'd had the Webster done because I thought that it couldn't hurt her positioning. I felt BIG movement once I got to the receptionist's desk [after the Webster]. So who knows what was going on! [Follow-up Note: M had a cesarean with her first child for breech; her second child (10 lbs. plus!) was born by VBAC, despite significant pubic pain. Her third child (the one she saw a chiropractor for because of breech) was also born by VBAC. Her fourth child was recently born by VBAC at home.]

Jill's Story I had pubic symphysis dysfunction with both my pregnancies. Had chiropractic with my second PG---helped me to not have the sciatica I'd had the first time but I still had lots of pain when rolling over in bed, lifting one leg, lots of clicking and popping that was very unpleasant. (I've always had a misaligned pelvis...and my chiro worked on it constantly but within days of an adjustment it would slip back. I think if I'd been getting chiropractic care from birth, it's likely I wouldn't have such problems with my pelvis now.) I was at-risk for having [pubic symphysis damage]. Luckily I had a home birth and was not forced into lithotomy or stirrups, so it didn't happen. I think that what can happen to cause the ligaments to tear is that in lithotomy position, the sacrum and coccyx can't move as they normally would to allow the baby's head through, so the only other thing that can move is the pubic symphysis, and when it is forced to move too far, it tears the ligaments. Just my own little personal theory. This is probably 'too much information', but I pushed on hands and knees and my DH said he could *see* my sacrum and coccyx move back---said my butt got kind of square when she crowned. :-) [Jill had her first baby by c/s because of breech. Her second baby was born by VBAC at home.]

Veronica M's Story Kmom's Notes: (This is a drastically shortened version of Veronica's stories. The full version can be found under BBW Malposition Stories on this site.) Veronica experienced SPD symptoms in both of her pregnancies. Although it is not documented in her records, Veronica probably experienced a malpositioned baby with her first birth. It was able to resolve and the baby was born vaginally, but being placed in stirrups probably damaged her pubic symphysis, worsening her condition. The SPD pain was worse in the second pregnancy, but was brushed off by her provider. Again, she had a malposition, but this time the problem was documented as the nurses saw that the baby's hand was by its head as it was crowning. They put her on her back and pulled her legs back forcefully to her ears. This is called a McRobert's position. If the baby has trouble getting out this position can be useful, but in this case the baby's head was already crowning easily when the nurse did this so it was probably not necessary. Unfortunately, pulling the legs apart so strongly and back so far meant that the pubic symphysis joint got damaged long-term. Afterwards, her doctors dismissed or discounted the pubic pain, since few U.S. doctors know about DSP. Veronica's Story: During the third trimester of my first pregnancy, I started to have debilitating pain in my pubic region. I told my OB about my symptoms and she dismissed it as normal pregnancy aches and pains. Being my first pregnancy, I assumed she knew what she was talking about so I carried on best as I could. I couldn't roll over in bed or get out of the car or walk up the stairs without crying from the pain. My husband ended up pushing me around in a wheelchair the final weeks because he couldn't stand to see me suffer anymore. My water broke before labor started and I dutifully did I as I was told and went ahead to the hospital...Somehow I survived [an induced labor] and I got ready to push. I wanted to be on my side because of the pelvic pain I knew was still there somewhere...[but] they made me put my feet in the stirrups and told me to push with all my might. At this point my OB shows up and gives me an episiotomy which I had specifically requested not to have. It all turned out to be overkill as my 6 pound baby slipped easily out with 2 pushes. The pelvic pain subsided after that but returned during my next pregnancy. I was considering finding a different OB and hospital for my next birth, but for some reason I didn't...My second birth ended up exactly the same. The pelvic pain was terrible but still no one would listen. My water broke before labor again and again I dutifully went off to the hospital to be confined to the bed [and induced]...When I felt the urge to push, the nurse scoffed and told me I

was at -2 so there was no need to call my OB yet. I pushed anyway and the nurse screamed for a doctor (turned out to be a med student) because she crowned in one push. She had her arm up by her face so the nurse grabbed my legs and pushed them to my ears while at the same time pushing me flat on my back. I gave another push and she easily slipped out. I don't think it was necessary for them to panic like that and my pelvis has never been the same since then. After her delivery I was barely able to walk. The pubic pain had gotten worse and I had no idea what the problem might be. I talked to my OB about it and she did a quick exam, said she couldn't find anything wrong, and sent me home. My family doctor said I was just imagining it and to get some rest. My internist had an x-ray done of my tailbone and when it looked fine, he was very annoyed that I had wasted his time. Everyone told me that it was just normal post-delivery pains or that I just needed to lose weight. I was so upset and angry. I could barely get around but no one believed there was anything wrong. Aarghh!!!! Finally after 2 years it has resolved itself, but I still feel clicking and weird sensations when I lay on my side.

Kmom's Story I have had tremendous pubic symphysis pain since early in my first pregnancy, as well as lots of back pain too. After that pregnancy, my tailbone was also very painful and I had trouble sitting for a while. Starting in the second pregnancy, I had the pubic and back pain PLUS sciatica, and in the third pregnancy also added the hips 'freezing' into place as well as a 'clicking' in the pelvis at times when I would walk. Although the pain would diminish some between pregnancies, it never completely went away, and at times made it very hard to sleep through the night or roll over easily. I also 'coincidentally' had cesareans with my first two children after long hard labors with malpositioned babies. I first went with traditional medical routes to try and help this problem. I would mention the pubic pain to my OB or midwife, and they would smile and say ruefully, "Welcome to pregnancy!" Or I'd get the condensed version of the lecture on relaxin hormones and that this was normal. But if it was normal, how come not all pregnant women had these problems or felt this degree of pain? I *knew* there was something wrong, but each time they managed to convince me that there really wasn't a true problem, and all that could be done was pelvic tilts, Tylenol, and rest. After my first pregnancy, I thought maybe part of the problem was weak "core" muscles, so I went to a family doctor and asked to see a physical therapist to help build up my back and abdomen muscles. He didn't take it seriously, said there was nothing wrong, and would not make a referral for preventive measures. He said that if I still felt a lot of pain and discomfort in the next pregnancy, we could make a referral to a physical therapist then. I was disgusted---some preventative medicine!--but felt I had no other course of action open to me. Again, in the second pregnancy I complained to the midwives and OB about pubic pain. I was given sympathy but no hope for help. Despite doing everything I could think of, I still had another cesarean after 5 hours of pushing did not help baby descend. During the cesarean we found he was posterior, and those babies have a tendency to get 'stuck'. Apparently that's what happened. Great, yet another malpositioned baby. Once again, after pregnancy, the pain did not go away, and the low back pain seemed to almost get worse. I switched to a new family doctor who had a chiropractor on staff, and saw him that summer. I think I expected a miracle cure. Unfortunately, he dismissed the problem, did not even examine the alignment of my back, gave me exercises to do and glucosamine to strengthen the ligaments, and sent me home. Although these helped a little, they really didn't do that much. He was mostly a sports chiropractor, and seemed put off by my size. Although I exercised regularly, he badgered me to exercise even more and seemed to think that that would solve everything. After that, I basically gave up on chiropractic care. By the time I was pregnant with my third child, I had been suffering with this low back and pubic pain problem for five years. In the third pregnancy, the pubic pain, low back pain, and sciatica was almost unbearable some days. I was doing prenatal yoga and the teacher suggested that women with sacro-iliac pain might benefit from a chiropractor. I had seen information online about the Webster Technique, knew that I had a history of malpositions, and was convinced that my continuing back and pubic pain was not "normal." So I decided to give treatment another try in hopes of preventing a malposition and another cesarean. I chose to see an osteopath associated with my family doctor first, looking for a chiropractor who knew the "Webster Technique" for turning babies who was on my insurance. She examined me quickly, gave me lots of sympathy, but knew of no one who knew this technique, and she didn't want to work on me herself in pregnancy. So I bit the bullet and went to see the chiropractor recommended by my yoga instructor (paid out of pocket). He took my concerns very seriously, felt my sacral area was very 'locked up', but used a subtle technique of manipulation that didn't do much to help my pain. In the meantime, though, he found a chiropractor in the area

who knew the Webster Technique and sent me to her. I wasn't too sure about going, given all my prior disappointments and the fact that I had to pay out of pocket, and almost cancelled the appointment. Thank goodness I didn't! Because I was so determined to do everything possible to help ensure a fair chance at a VBAC and prevent another malpositioned baby, I did go to the appointment with the new chiropractor. She took one look at me walking down the hall and knew something was majorly out of whack. Guess I had that funny gait that SPD women get! She put me face-down on the chiropractor's table (with a special pregnancy cushion so that it was safe and comfortable) and checked things out. She found that one leg was shorter than the other, along with other problems. She used a drop table to help increase the effectiveness of the adjustment (the part of the table under the hips raises up a bit), and did a major adjustment. I was pretty tense and unsure whether I was nuts for trying this, and was very startled by the sudden nature of the adjustment. I felt very jolted. It was hard to relax into, and she worked to distract and relax me so that the next adjustment was easier, which helped. Then she followed up with soft tissues work and Cranial Sacral Therapy, which is extremely soft and light and very relaxing. I left not knowing quite what to make of it all, and not sure it was useful. I felt like I had probably just wasted my time and money. But within an hour, I started feeling like a new woman! I couldn't BELIEVE how much better I felt! It was amazing! I felt like dancing around, it was so much better. The pain was not completely gone, mind, but it was so much better it was remarkable. I slept better, and the next day my midwife found my baby optimally positioned for the FIRST time ever in the pregnancy. I saw the chiropractor again once or twice a week for the next 2-3 weeks, and then had the baby. I slipped and fell twice the day he was born, so I think I misaligned things a little bit, and he did have a minor malposition problem which eventually resolved. He was eventually born vaginally (VBAC) after 2 prior cesareans for "CPD"! Over time after the birth, I felt things beginning to slip back "out" again, so later that year I returned for more chiropractic care. Because I was no longer pregnant, I was seen by her associate and it took a while to establish a good treatment for my pain. But it really did help, and I was finally able to sleep a full night without back pain most days. However, at times the sacro-iliac adjustments seemed to make other problems; my hip movement and flexibility seemed more limited even though the back pain was helped. I just felt we were still missing something, despite all our progress. Eventually, after hearing Dr. Showalter's presentation at the ICAN conference, I brought the idea of 'pubic shear' up to the new chiropractor. He consulted another chiropractor, and together they did a pubic symphysis adjustment on me. This involved lying face-up on the drop table. They had me find the pubic symphysis bone and put my hand over it (so they are not touching the pubic area directly), and then the chiropractor put his hand over top mine and did the adjustment. It wasn't very comfortable emotionally or physically, and stung quite a bit at first! Ouch! But I was amazed at how much it helped, and seemed to REALLY help the hip flexibility problem I'd been having. It really has improved the lower back, pubic, and hip pain a LOT, and I hope it will help keep my baby optimally positioned in my next pregnancy. I am still not 100% pain-free; I think we are still searching for other possible things that have been affected, and probably we need to pay more attention to the soft tissues as well as the bones. But I can't begin to express HOW much better I feel compared to before! It really has been extremely helpful, and it demonstrates just how badly out of whack my pelvis has been. But it took 5 years before I finally got some help for this problem, and another year of fine-tuning to discover that we needed to add the pubic bone adjustment as well. So I think my story illustrates the importance of continuing the search for help if the first provider(s) you see don't resolve the problem, and being willing to consider nontraditional modalities of care. Many women seem to get a short "honeymoon" from pain like I did, but still have longer-term alignment issues that may take some time to address. Don't stop treatment too soon, and keep exploring different avenues of treatment. If you can FEEL that there is real pain, that indicates a problem that needs resolving. Keep looking till you find the person or technique that can help. DON'T GIVE UP. It can get discouraging, but in time, you CAN find help.

Nancy's Story ( www.kamish.com/dsp/_disc2/00000033.htm and also www.kamish.com/dsp/_disc2/0000002e.htm )

Summary: Symphyseal separation at birth, hip pain. Chiropractor gave great help; describes process a bit. Definitely a must-read story.

Hayrire's Story

( www.kamish.com/dsp/_disc2/00000086.htm )

Summary: Osteopathy to help pubic pain in pregnancy. Describes a couple of exercises she was also given to do, in addition to the osteopathic manipulation.

Katie's Story I got through 7 months of pregnancy with very little complications, [just morning sickness through the 8th month.] Towards the end of my 7th month...probably as a complication of her malpositioning, I started experiencing very severe hip pain. When I'd stand up, it felt like I had to wait for my hips to come together again before I could walk. When I sat, it felt like my hips would spread. Because this was also associated with pain turning over in bed and the inability to bend over and lift my legs to put pants on, I suspected I may have been afflicted with symphysis pubis dysfunction [SPD], but I was never diagnosed by a professional. I was aware of the SPD, and would have gotten chiropractic care had I been able to afford it.... Throughout my pregnancy, we consistently had trouble finding the heartbeat on doppler. However, my wonderful OB was persistent and always found it low on my right side. On the rare occasion we couldn't find it or couldn't hear it well enough, they got me on ultrasound to check. I think we all assumed the difficulty was due to my size, although nothing was ever stated outright. Come to find out, difficulty in hearing the heartbeat can be due to malposition, and this theory fits my situation. As it turns out, my baby was facing backwards---facing my front instead of my back. [Kmom note: Trouble finding the heartbeat is a classic sign of a posterior baby, esp. if they then find it low and on the right side. It can also be more difficult to find a heartbeat when the placenta is frontlying, as hers was.] I started doing exercises to try and turn the baby. For the last two weeks of pregnancy, I watched my position carefully. No more leaning back and putting my feet up as I had been (due to excessive swelling). I sat upright at all times, Twice a day, I relaxed in the knee-chest position for 10 minutes, followed by a few minutes of pelvic rocks (however long my knees could stand it). Something must have worked because the day before I gave birth, we found the heartbeat easily on the left side. She may not have been in the most optimal position (given my 25 hour labor) but it was better than what it had been. She was born facing my right leg, which I read is better than her facing my left leg (although facing down is optimal). Kmom note: From her description it sounds like the baby was occiput transverse (meaning that the baby was head down but her head was facing sideways), yet she had her baby vaginally despite its malposition. However, she ended up with an induction, a long slow labor, an epidural, 3 hours of pushing, a vacuum extractor, and a 3rd degree tear, probably because of the malposition. Still, it's an amazing testament to her pelvis that she had her 10 lb. baby girl vaginally in an apparent occiput transverse position!

Grainne's Story ( www.radmid.demon.co.uk/dsp1.htm ) Summary: Midwife who experienced SPD firsthand. Describes how she was afraid it might affect baby's positioning and how she worked hard to prevent that. Had an easy homebirth in the kneeling position, and describes how they avoided extra damage. However, does describe plenty of leftover postpartum pubic pain and how difficult it has been to deal with everything.

Melissa's Story This story can be found on this site under BBW Birth Stories: Vaginal Births. Kmom's Summary: This mom also had a lot of pubic symphysis pain during both pregnancies. Her first baby was probably malpositioned (Kmom's guess would be that the baby's head was tilted to the side). After stalling labor for some time, the position resolved quickly when she swung her hips strongly from side to side, a resolution typical of an asynclitic (tilted head) baby, or perhaps one with a hand or arm by her head. The mother's long labor (23 hours), stall at about 7 cm, quick resolution with a change of position (with the mother feeling the change when it happened), then the quick birth afterwards all point to a malposition. The mom's pubic pain resolved with the baby's birth and she did not experience any problems after the birth. In her second pregnancy, this mother also had some pubic pain, but not nearly as strongly as in the first pregnancy. Her second baby was born after a long prodromal labor and then a quick birth once her midwife broke her waters. However, this baby came down sideways (probably occiput transverse) and the mother was on her back with her legs really pulled up strongly, which probably caused a strain and temporary damage in her pubic symphysis area (DSP).

After he was born, she experienced a lot of pubic pain. She notes she could hardly walk for a couple of weeks, and she also had tailbone pain for several months. This is typical of women with DSP. Fortunately for her, it eventually resolved without treatment. Note that despite pubic pain/SPD in both pregnancies, this mom was able to birth vaginally. However, she did probably have a minor malposition of her baby in both births. In the second birth, the malposition plus the strain on her PS from her positioning probably caused some temporary damage to the PS area, but it did eventually resolve on its own.

A Veterinary Medicine Student's Story ( www.hillary.net/baby.html ) Summary: Story with classic symptoms of SPD that never really get recognized as such. Fortunately, all goes well.

Katherine's Story I just have to report that today I had my first chiropractic adjustments for the agonizing pelvic pain I've had during this pregnancy. Immediately upon getting up from the table I could feel an improvement. I felt so much better! I'll have two more adjustments this week, then we'll evaluate from there. I am just so grateful and happy. I didn't realize how bad the pain was until it got so much better.

Annette's Story When I was about 28 weeks pregnant with my 4th baby I started a childbirth preparation class. The teacher told us to do certain exercises daily, including lunges, side leg lifts while kneeling on all fours, and tailor sitting. I'd been tailor sitting a lot throughout that pregnancy after reading Husband-Coached Childbirth and had had no problem with it. The first couple of weeks I had no problem with the additional exercises either. Around 30 weeks pregnant I started having sharp pain in my right groin when I did the lunges and leg lifts. I discovered that if I tried to stand up right after that the pain would continue, but if I did at least one pelvic rock/tilt before attempting to stand, the pain went away. When I asked the teacher about the pain, she smiled and calmly said it was OK, it was normal, it was good because it meant I was getting really loose, and I should keep doing the lunges and leg lifts even more aggressively. She also encouraged me to have my husband press down on my knees while I was tailor sitting. So I continued to exercise to the point of pain, and even past the point of pain, and then do some pelvic rocks before standing up. By about 36 weeks pregnant, I was having pain when trying to roll over, get out of bed, walk, stand for any length of time, or sometimes for no particular reason at all. About that time some information on pubic symphysis caught my attention. I had never run across the term before. I started researching it and wondering if that might be my problem. I asked my OB about the pain and he too smiled, said it was normal, and told me to drop my knees as far out to the side as I could so he could do a vaginal exam. I felt intuitively that this pain was neither good nor normal, but I was having a hard time getting any support for dealing with it. During my VBAC I felt some pain during vaginal exams and while pushing, but I was able to continue labor with no particular problem. After my VBAC I still had the groin pain even though I was no longer doing any particular exercises. A friend suggested I always hold a pillow between my knees while getting out of bed, and that eliminated the pain during that maneuver. The OB said that if I could still drop my knees to the side while lying on my back then it was OK, no matter how much it hurt. He said pain was normal. About 6 months post-partum I asked a chiropractor about PS dysfunction and he examined me for it and said it had healed on its own by that time. (I had just recently stopped noticing the pain, within days or a few weeks before that.) He told me that contrary to what all my friends in high school had believed, being able to bend over without bending your knees and put your hands flat on the floor is not a sign of good flexibility, but rather of injured back tissues. A bell rang in my mind as I thought about my SPD. I concluded that over-exercising the PS area during pregnancy had injured the tissues.

Tracywag's Story Tracy's first baby was posterior but was able to be born vaginally. Her second baby was probably malpositioned, though it is difficult to know for sure. This baby was born by emergency cesarean after a cord prolapse during an induction. Tracy notes that she had a great deal of joint pain, sciatic pain, and round ligament pain, and that she had slipped and fallen prior to pregnancy. Tracy's full story can be found in the BBW Birth Stories: Malpositions section of this website.

Isadore E's Story Isadore experienced typical SPD symptoms in pregnancy. She states she had "severe pubic symphysis pain---rolling over in bed was excruciating (worse than labor!), lifting my legs hurt, etc...My pelvis was also misaligned (according to my doula who gave me a massage a couple days before I went into labor)....I will definitely get some chiropractic help next time." Kmom Note: Isadore did go on to have a vaginal birth. She went into labor on her own but got stuck at 7 cm for a long time, and the baby stayed stubbornly situated at a -1 position. This is typical of a malpositioned baby; however, she may also have experienced some emotional dystocia as well. She ended up getting an epidural and pitocin, and the baby was able to born vaginally without difficulty eventually. It's important to remember that while SPD can affect labor and impede it in some people, many babies are born vaginally despite the SPD.

Cora's Story I am pregnant with my first child. I originally injured my pubic symphysis with the birth of my first child. It felt like my bones were splitting apart and I was sore for about 6 months afterwards. With my second pregnancy 4 years later, I was running to catch a bus at 34 weeks and really tore the same spot. I could not move for two weeks at which time the pain was manageable. I was able to give birth vaginally at home in a birth pool. With this pregnancy I was afraid because of my previous experiences and was being extra careful in a precautionary sort of way. By 18 weeks I was in terrible pain, could not walk or stand for more than 20 minutes at a time, had awful pain turning in bed, could not stand on one leg, had difficulty lifting my leg to get in the shower, etc. The great herbalist Susan Weed recommended (about 3 weeks ago) Teasel tincture, which is for "internal tears that are hard to get at," and comfrey infusion (the other name for Comfrey is Knit Bone). Within 3 days of taking the Teasel (15 drops 3x a day) I started seeing improvement. Now I am 31 weeks and feeling almost no pain at all and can move more quickly and efficiently than I could at 18 weeks when the baby was so much smaller. I am amazed and thrilled that these remedies are working so incredibly well and thought that other women should know about them.

A Doula's Perspective Kmom note: This was originally a post written for a message board and then reposted to another mailing list. The author gave her permission for it to be reposted here. A "doula" is a professional labor support person, and this opinion is the result of this doula's experiences before and after her clients started getting regular chiropractic care in pregnancy. I started as a doula by attending my friend's birth almost 3 years ago. It ended in cesarean after DAYS of labour, contractions that never got closer together, but were coming every 2 minutes. The baby was in a posterior position---just like her first baby born by cesarean. Then I attended another birth. Cesarean. And another. Cesarean. I started to doubt myself and my ability to help women. I started joking that I was the "cesarean doula." All three of these births had something in common. The babies were all malpositioned. Posterior. I had heard bits and pieces about the Webster Technique, a chiropractic technique that was supposed to help babies get in the best position for labour. One day, I was staffing a booth at a baby show, when a young woman, a chiropractic student, stopped by. I asked her if she knew anything about it. She did indeed know it, and thought it could be quite useful. She even knew a chiropractor in my area who did this technique. So she "set us up." The day I met Dr. Karen Beal (not to put too fine a point on it), my life changed. I spent 2.5 hours speaking to her in her office on her day off. We had so much in common! Our belief systems meshed perfectly. Women's bodies were strong, filled with the innate wisdom to birth their babies. HOWEVER, we talked about the fact that many of us lead a sedentary life, have car accidents, fall down on our "tuchas," sit sideways at our computers, and recline in easy chairs all evening. All of these situations conspire to cause "constraint" (centered on the sacrum is the utero-sacral ligament). I'm not a chiropractor, so I can't do this justice, but suffice it to say that the Webster Technique reduces the constraint, allowing the woman's body and the baby to work together ('communicate') to get the baby in the optimal position for birth, most often Left Occiput Anterior. [Kmom note: baby facing towards mother's back, baby's back tending to lie along the left side of her tummy.] Okay, so what is [Webster's Technique]? I'm not going to explain this well, but it involves checking for resistance on each leg, gently pressing each leg towards your bum, then adjusting on the side that needs it. The adjustment is

merely pressing on the round ligament to cause the release. It is not an intrusive adjustment at all. [Kmom note: Actually, the adjustment does involve a bit more than this.] I probably just slaughtered that explanation, but you can find a chiropractor in your area who is certified in this technique by going to www.icpa4kids.com. At least you can call for a consult. You know, I don't keep stats, because each birth is individual, but I can say that I've attended fewer cesareans in the past 2.5 years than in my first 3 births. Coincidence? Maybe. But most of my clients go to see Karen [the chiropractor friend], and they tell me they feel better. So do their children---less colic, better breastfeeding, etc. This is all proved by research which you can find at the website. Do I sound like an evangelist? I could be. All I know is that I care about women, and I care that they have labours that they can look back on and remember their power as they pushed out their babies---not the incessant back pain, the failed epidural, the threat of cesarean for "failure to progress." My advice is to try [chiropractic care]. You've got nothing to lose.

Lia's Story (for the full story, see. www.guardian.co.uk/health/story/0,3605,724347,00.html ) Kmom's notes: Lia wrote up her story for The Guardian Unlimited. This is a brief summary of the article above, plus information from personal communications with the author. Kmom strongly recommends reading the full original article. At 22 weeks, Lia developed severe pains in the pelvis, especially around the pubic bone. She had trouble turning over in bed, walking, etc., and could hear her pelvic bones grinding. She said, "My body felt as if it were splitting in two." She was diagnosed with SPD in London, given painkillers, saw a physiotherapist who gave her crutches and a support belt. She was advised to keep her knees together when moving, and eventually she even needed a wheelchair. She did have a vaginal birth. She labored naturally (no pain meds) so that they could know exactly what was going on with her pelvis, and were very careful about positioning. The baby was born vaginally after a very short pushing stage (25 minutes). Despite all their care, she found that things got worse after the baby was born. She thinks it might have been because of the sudden absence of the baby's head, bracing things. She still had problems walking 5 months after the baby was born. Post-partum, as an outpatient, she tried physiotherapy exercises and Pilates without success. She was then referred to the orthopedics department to consider an operation that is supposed to stabilize the pelvis by stapling it, only to find out that this surgery is considered a last resort and doesn't have a very high success rate. She eventually found and joined a local SPD support club (there is more awareness of SPD in Britain so they have these resources), where she was shocked to learn that some women are left permanently disabled by SPD. Although the group was generally very reticent about recommending alternative medicine (chiropractic and osteopathic care), she did eventually hear about this as a possible treatment mode. Through the group she eventually she found people who had found help with SPD. One woman's OB had recommended she try some alternative therapies, so she started treatment with a classical osteopath named Quentin Shaw. He got her walking immediately. Another woman who had had postpartum SPD finally found "99%" relief through treatment with a chiropractor. In private communication, Lia expresses concern that women will visit any local chiropractor or osteopath, who either cannot help them or might even hurt them more, and then the women lose all trust in these treatment modalities and will not try again. She emphasizes finding providers who are truly knowledgeable about SPD. Quentin Shaw, the classical osteopath who treated the first woman above, states in the article, "SPD responds well to the correct treatment...Pregnant women suffer this when relaxin accentuates pre-existing pelvic and spinal misalignments, but these can be adjusted during or after pregnancy." He cites the example of a woman who had SPD for 23 years, visiting many osteopaths without any relief. Shaw was able to help her over a long-term course of treatment. Lia also booked an appointment with Shaw. After one treatment, she was able to walk, "and my crutches became obsolete." By the time she wrote the article she did not consider herself cured, but was "recovering fast." Shaw also told her that her pelvic misalignments could have been corrected during pregnancy, contradicting the common belief that nothing could be done during pregnancy itself. Lia says that she felt she was "spun a line" by conventional medicine when it told her that SPD was untreatable, and she was not warned that some women do not recover after the baby's birth. No one told her that chiropractors and

osteopaths can possibly treat SPD, either. In her article she advocates strongly for access to treatment such as this.

References Research Articles Snelling, FG. Relaxation of the Pelvic Symphyses during Pregnancy and Parturition. Am J Obs. 1870. 2(4):561596. [As quoted by www.kamish.com/dsp/physio2.htm] Heath T, Gherman RB. Symphyseal separation, sacroiliac joint dislocation and transient lateral femoral cutaneous neuropathy associated with McRoberts' maneuver. A case report. J Reprod Med 1999 Oct;44(10):902-4 "McRoberts' maneuver is often used prophylactically with the onset of active maternal expulsive efforts or immediately before delivery of the fetus. CASE: A 31-year-old woman, gravida 1, para 0, at 39 + 2 weeks' gestational age, was continuously maintained in an exaggerated lithotomy position while actively pushing during the second stage of labor. Immediately following spontaneous vaginal delivery of a 3,598-g infant, the patient noted left gluteal pain and left anterior thigh dysesthesia. Orthopedic evaluation revealed a 5-cm symphyseal separation, sacroiliac joint dislocation and transient lateral femoral cutaneous neuropathy. The patient underwent closed reduction of the left hemipelvis, followed by open reduction and internal fixation of the symphysis pubis two weeks later after failing conservative treatment. CONCLUSION: Although McRoberts' maneuver is generally safe, care should be exercised with use of excessive force or prolonged placement of the patient's legs in a hyperflexed position." Culligan P et al. Rupture of the symphysis pubis during vaginal delivery followed by two subsequent uneventful pregnancies. Obstet Gynecol 2002 Nov;100(5 Pt 2):1114-7. "BACKGROUND: Rupture of the symphysis pubis during vaginal delivery is a rare but debilitating complication. Factors contributing to rupture are poorly defined. CASE: A healthy primigravida suffered a rupture of her symphysis pubis during an otherwise uncomplicated vaginal delivery. She experienced significant pain and difficulty walking for 6 months after the injury. Her 5-cm symphyseal separation was managed successfully with physical therapy and activity restriction. The patient's two subsequent deliveries (one vaginal and one via cesarean delivery) were uneventful. CONCLUSION: Severe symphyseal rupture during vaginal delivery can be managed without surgery. Risk factors for rupture are not well defined. Based on a literature review, there is a significant risk of repeat symphyseal rupture with subsequent vaginal delivery." Musumeci R, Villa E. Symphysis pubis separation during vaginal delivery with epidural anesthesia. Case report. Reg Anesth 1994 Jul-Aug;19(4):289-91 "BACKGROUND AND OBJECTIVES. Peripartum pubic separation (diastasis pubis) is an uncommon event with a reported incidence varying between one in 521 to one in 30,000 deliveries. The injury is caused by the fetal head exerting pressure on pelvic ligaments that have been weakened or relaxed by the hormones progesterone and relaxin. Diastasis pubis has been previously reported in both obstetric and orthopedic literature. However, the authors have been unable to locate any discussion of this condition in the anesthetic literature. Historically, symphyseal separation has been frequently unrecognized. The authors present the case of a nulliparous woman who suffered a diastasis pubis during assisted vaginal delivery under epidural anesthesia. METHODS. Epidural catheter placement and administration of medications were performed using standard techniques described. RESULTS. The patient had an episode of breakthrough pain during labor despite adequate epidural analgesia and experienced postoperative pubic and thigh pain secondary to pubic separation. CONCLUSIONS. Diastasis pubis is an uncommon injury that should be considered when evaluating patients in the peripartum period who are experiencing suprapubic, sacroiliac, or thigh pain." Senechal PK. Symphysis pubis separation during childbirth. J Am Board Fam Pract 1994 Mar-Apr;7(2):141-4 "A severe case of separation of the symphysis pubis during labor and delivery is reported, which included severe pain and unusual complications of urinary outflow incontinence and fecal incontinence that gradually resolved with conservative treatment. The incidence of symphysis pubis separation is reported to be between 1:600 and 1:3400 obstetric patients. Treatment should generally be conservative and symptomatic. Prognosis for recovery is excellent. Recurrent separation of the symphysis pubis could occur during subsequent deliveries but generally is no worse than the first occurrence. This case report illustrates the unusual complications that can occur with severe diastasis of the symphysis pubis during pregnancy. Family physicians, obstetricians, and orthopedic surgeons could

encounter this complication of childbirth in their own practices. Although the symptoms are dramatically severe in presentation, a conservative management approach is effective." Luger EJ et al. Traumatic separation of the symphysis pubis during pregnancy: a case report. J Trauma 1995 Feb;38(2):255-6 "OBJECTIVE: To present an unusual case of traumatic extensive separation of the symphysis pubis during pregnancy and rationale for mode of treatment. DESIGN: Diagnosis for etiology of public and lower back pain following trauma in a 37-year-old woman in an advanced stage of pregnancy. METHODS: Physical examination and plain anterioposterior X-rays. CONCLUSION: Extensive traumatic separation of the symphysis pubis might result from a very forceful descent of the fetal head against the pelvic ring upon the mother's accidental falling. Propitious timing of a caesarian section permits the option of open reduction and internal fixation." Schoellner C et al. Pregnancy-associated symphysis damage from the orthopedic viewpoint--studies of changes of the pubic symphysis in pregnancy, labor and post partum. Z Orthop Ihre Grenzgeb 2001 Sep-Oct;139(5):458-62. "AIM: Is the sonographic measurement of the symphysis pubis enough to enable a prognosis of the occurrence of symphyseal pain during pregnancy and birth? METHOD: First of all, a simplified definition of symphyseal pain was categorized in order to make the classification more easy. The symphyseal widths of 171 pregnant women were measured during pregnancy and after birth. Our control group consisted of 25 non-pregnant women. 15 of the 171 patients suffered from symphyseal pain; however, 156 of the 171 did not. Additionally, we measured the intrapartal symphyseal width in 11 of the women. RESULTS: The average symphyseal width of non-pregnant women was 4.07 mm (s = 0.79; n = 25). Pre- and postpartally we measured 6.32 mm (s = 1.71; variation of 3 to 16 mm) in pregnant asymptomatic women. A significant increase in width was recorded in the 15 women with pain in the symphysis: the symphyseal width was 10.62 mm (s = 2.37; Variation from 6.7 to 15.25 mm). Intrapartally the symphyseal width varied between 5.8 and 1.2 mm. CONCLUSION: Ultrasound measurement of the symphyseal width shows around 4 mm in non-pregnant women. Asymptomatic pregnant women have an average width of 6.3 mm. The majority of pregnant women with 9.5 mm or more have symphyseal pain. If that is the case then conservative treatment is usually sufficient to cure this complaint." Snow RE, Neubert AG. Peripartum pubic symphysis separation: a case series and review of the literature. Obstet Gynecol Surv 1997 Jul;52(7):438-43 "Peripartum pubic symphysis separation is a recognized complication of pregnancy with incidence estimates ranging from 1:300 to 1:30,000. Characteristic symptoms of symphyseal separation include suprapubic pain and tenderness with radiation to the back of legs, difficulty ambulating, and occasionally, bladder dysfunction. Clinical history, presenting symptoms, and response to therapy are sufficient to make the diagnosis, although radiographic documentation of symphyseal separation by x-ray or ultrasound are frequently used to confirm the diagnosis. The underlying etiology of symptomatic symphyseal separation has not been fully elucidated. Associations with multiparity, macrosomia, pathological joint loosening, and increased force placed on the pelvic ring have been suggested as possible etiologies. Conservative therapy, including bedrest, pelvic binders, ambulation devices, and mild analgesics usually result in a complete recovery with 4 to 6 weeks. The occurrence of a symphyseal separation should not significantly alter the management of subsequent pregnancies, and conservative therapy is recommended for any recurrence of symptoms. A retrospective review of our experience with 5121 deliveries from 1994 to 1995 found 9 cases of peripartum symphyseal separation, resulting in an incidence of 1 of 569 deliveries. Details regarding this case series and a review of the literature are presented." Bjorklund, K et al. Sonographic Assessment of Symphyseal Joint Distention During Pregnancy and Post Partum with Special Reference to Pubic Pain. Acta Obstet Gynecol Scand. February 1999. 78(2):125-30. "OBJECTIVE: To elucidate whether there is a relationship between pregnancy-related pelvic pain and degree of symphyseal laxity. METHODS: Forty-nine women were interviewed and examined and ultrasonographic measurement of symphyseal width and vertical shift was conducted at 12 and 35 weeks of pregnancy and at 5 months post partum. The patients were retrospectively classified into four groups on the basis of presence and degree of pain in late pregnancy and presence or absence of pain at follow up. RESULTS: The prevalence of pelvic pain of any degree during pregnancy was 49%, of pronounced pain 16.3% and of severe pain 6.1%. Nineteen percent had any remaining pain at 5 months post partum. The median symphyseal width at 12 and 35 weeks of pregnancy and at 5 months post partum was 3.5 mm, 4.6 mm and 2.8 mm, the median vertical shift 0.0 mm, 0.8 and 0.9 mm respectively. Those with disabling pain during pregnancy and no pain at follow up had greater symphyseal width (6.3 mm) and vertical shift (1.8 mm) at 35 weeks of pregnancy than controls; 4.5 mm (p<0.01) and 0.5 mm (p<0.01) respectively. Those with disabling pain during pregnancy and persistent pain at follow up did not differ

significantly from controls in symphyseal width or shift. The most severe cases were in this group. CONCLUSION: There is a minor pregnancy-induced physiological increase in laxity of the symphyseal soft tissue. There is no evidence that the degree of symphyseal distention determines the severity of pelvic pain in pregnancy or after childbirth." Damen L et al. Does a pelvic belt influence sacroiliac joint laxity? Clin Biomech (Bristol, Avon) 2002 Aug;17(7):495-8 "OBJECTIVE: To evaluate the influence of different positions and tensions of a pelvic belt on sacroiliac joint laxity in healthy young women. BACKGROUND: Clinical experience has shown that positive effects can be obtained with different positions and tensions of a pelvic belt. A functional approach to the treatment of the unstable pelvic girdle requires an understanding of the effect of a pelvic belt on a normal pelvic girdle. METHODS: Sacroiliac joint laxity was assessed with Doppler imaging of vibrations. The influence of two different positions (low: at the level of the symphysis and high: just below the anterior superior iliac spines) and tensions (50 and 100 N) of a pelvic belt was measured in ten healthy subjects, in the prone position. Data were analysed using repeated measures analysis of variance. RESULTS: Tension does not have a significant influence on the amount by which sacroiliac joint laxity with belt differs from sacroiliac joint laxity without belt. A significant effect was found for the position of the pelvic belt. Mean sacroiliac joint laxity value was 2.2 (SD, 0.2) threshold units nearer to the without-belt values when the belt was applied in low position as compared to the case with the belt in high position. CONCLUSIONS: A pelvic belt is most effective in a high position, while a tension of 100 N does not reduce laxity more than 50 N. RELEVANCE: Information about the biomechanical effects of a pelvic belt provided by this study will contribute to a better understanding of the treatment of women with pregnancy-related pelvic pain." Davidson MR. Examining separated symphysis pubis. J Nurse Midwifery 1996 May-Jun;41(3):259-62 "Separated symphysis pubis (SSP) is a rare condition that results in a separation of the symphysis pubis bone in late pregnancy or during delivery and occurs in otherwise healthy pregnancies as a result of hormonal and/or biomechanical factors. Several researchers have examined the issue in the Scandinavian countries, where it appears to be more prevalent possibly due to a genetic link. Symptoms range from mild discomfort to total debilitation. Differential diagnosis includes exclusion of more serious medical conditions. The nurse midwife's role is prompt diagnosis, medical consultation, support, and education." Mau C et al. Rupture of the symphysis after spontaneous delivery. Surgical treatment of four cases. Ugeskr Laeger 2001 Mar 5;163(10):1442-3. Rupture of the symphysis pubis is a rare, but known, complication during labour. We describe four cases of rupture of the symphysis, for which surgical treatment was chosen shortly after labour (2-30 days). Internal fixation was done in two cases and external fixation in the other two. There were no postoperative complications. The patients were mobile soon after the operation, and had no pain and normal function at follow-up 6-12 months later. Damen L et al. Pelvic pain during pregnancy is associated with asymmetric laxity of the sacroiliac joints. Acta Obstet Gynecol Scand 2001 Nov;80(11):1019-24. "Increased [sacroiliac joint] laxity is not associated with [pregnancy-related pelvic pain]. In fact, pregnant women with moderate or severe pelvic pain have the same laxity in the [sacroiliac joints] as pregnant women with no or mild pain. However, a clear relation between asymmetric laxity of the [sacroiliac joints] and [pregnancy-related pelvic pain] is found. Bjorklund K et al. Symphyseal distention in relation to serum relaxin levels and pelvic pain in pregnancy. Acta Obstet Gynecol Scand 2000 Apr;79(4):269-75. "OBJECTIVE: To elucidate whether there is an association between symphyseal distention, circulating relaxin levels and pelvic pain in pregnancy. METHODS: Serum relaxin and symphyseal width were assessed in 19 consecutive referral cases with severe pelvic pain at 35 weeks of pregnancy and in a cohort of 49 women at 12 and 35 weeks of pregnancy. The referral cases were received over a period of two years and four months and the cohort was recruited over a period of two months. Relaxin was measured with an ELISA test and symphyseal width assessed using ultrasonography. All women with pelvic pain were clinically assessed. The women were divided into three groups; Group A (n= 38), cohort cases with no or mild pain; Group B (n= 11), cohort cases with disabling pain; and Group C (n= 19), referral cases. RESULTS: At 35 weeks of pregnancy, mean symphyseal width was 4.5 mm (s.d. 1.0 mm) in Group A, 5.7 mm (s.d. 2.6 mm) in Group B, and 7.4 mm (s.d. 3.5 mm) in Group C. The difference between Groups A and B is statistically significant (p=0.044) as is that between Groups A and C (p<0.0001). Serum relaxin levels were not associated with symphyseal distention or disabling pain. CONCLUSION: Severe pelvic pain during pregnancy was strongly associated with an increased symphyseal distention. However,

the severity of pain did not predict the degree of symphyseal distention in the individual case, indicating that other mechanisms are also involved. Serum relaxin levels were not associated with the degree of symphyseal distention or with pelvic pain in pregnancy." Heetveld MJ et al. Spontaneous expulsion of a screw during urination: an unusual complication 9 years after internal fixation of pubic symphysis diastasis. Urology 2003 Mar;61(3):645 "Nine years after treatment of symphysiolysis and dislocation of the left sacroiliac joint, a screw was spontaneously voided during urination. Unstable plate fixation of the symphysis pubis probably caused screw migration into the bladder, creating a fistula with abscess formation and septic complications."

Journal Articles About Alternative Medicine Treatments Pistolese RA. The Webster Technique: a chiropractic technique with obstetric implications. J Manipulative Physiol Ther 2002 Jul-Aug;25(6):E1-9 "OBJECTIVE: To survey members of the International Chiropractic Pediatric Association (ICPA); regarding the use of the Webster Technique for managing the musculoskeletal causes of intrauterine constraint, which may necessitate cesarean section. METHODS: Surveys were mailed to 1047 US and Canadian members of the ICPA. RESULTS: One hundred eighty-seven surveys were returned from 1047 ICPA members, constituting a return rate of 17.86%. Seventy-five responses did not meet the study inclusion criteria and were excluded; 112 surveys (11%) provided the data. Of these 112 surveys, 102 (92%) resulted in resolution of the breech presentation, while 10 (9%) remained unresolved. CONCLUSION: The surveyed doctors reported a high rate of success (82%) in relieving the musculoskeletal causes of intrauterine constraint using the Webster Technique. Although the sample size was small, the results suggest that it may be beneficial to perform the Webster Technique in month 8 of pregnancy, when breech presentation is unlikely to spontaneously convert to cephalic presentation and when external cephalic version is not an effective technique. When successful, the Webster Technique avoids the costs and/or risks of external cephalic version, cesarean section, or vaginal trial of breech.In view of these findings, the Webster Technique deserves serious consideration in the health care management of expectant mothers exhibiting adverse fetal presentation." Diakow PR et al. Back pain during pregnancy and labor. J Manipulative Physiol Ther 1991 Feb;14(2):116-8. "A retrospective study of 400 pregnancies and deliveries was undertaken by interview of 170 consecutive female patients presenting to five chiropractic offices in the Niagara Peninsula. Back pain was reported during 42.5% (170) of the pregnancies and 44.7% (179) of the deliveries. There was a statistically significant association between back pain during the two events (p less than .001). Of the 170 pregnancies with reported back pain, 72% (122) also reported back labor. A subsample of 170 painful pregnancies was divided into those that had received manual manipulation and those that had not. The treated group experienced less pain during labor (p less than .001)." Phillips CJ, Meyer JJ. Chiropractic care, including craniosacral therapy, during pregnancy: a static-group comparison of obstetric interventions during labor and delivery. J Manipulative Physiol Ther 1995 Oct;18(8):525-9 "OBJECTIVE: To determine whether the addition of chiropractic care including craniosacral therapy to a regimen of standard obstetric pregnancy results in fewer obstetric interventions during labor and delivery. DESIGN: Retrospective, case-matched, static-group comparison. SETTING: The study group was obtained from a college faculty-based clinic and received chiropractic care in addition to their routine obstetrical care. The setting for the comparison group was unkown, but the care rendered was presumed to be primary medical obstetric care only. PATIENTS: A consecutive sample of 63 pregnant women who sought chiropractic care within the period under study. The reason for seeking care was not necessarily related to the pregnancy. The sample was primarily between 18 and 35 yr, non-Hispanic caucasian and primiparous. After selection and matching criteria, 35 patients remained in the study group. INTERVENTION: Chiropractic care and craniosacral therapy delivered during pregnancy vs. unknown care within the same county. MAIN OUTCOME MEASURES: Obstetric interventions during labor and delivery as reported by the birth attendant on the certificate of live birth. RESULTS: No statistical differences were detected in the rates of obstetric interventions used during labor or delivery between the two samples. Approximate largesample 95% confidence intervals are provided. CONCLUSION: Because of the limitations in the design of the project, this study provides no evidence that the addition of chiropractic care and craniosacral therapy during pregnancy results in any observable benefit or detriment with regard to obstetric interventions used during labor and delivery and that chiropractic care for pregnancy-related neuromusculoskeletal disorders should not complicate labor or delivery."

Books

Noble, Elizabeth. Essential Exercises for the Childbearing Year. Harwich, Massachusetts: New Life Images. 1995. Discusses exercise before, during, and after pregnancy. Includes some alternative therapy discussions. Reports success with using "polarity therapy" for pubic pain. Phillips, Carol J. Hands Of Love: Seven Steps To the Miracle Of Birth. St. Paul, Minnesota: New Dawn Publishing. 2001. Available fromhttp://www.newdawnpublish.com/products.htm. Book by one of the premier chiropractors who specializes in pregnancy and chiropractic care. Contains an excellent explanation of the theory that pelvic misalignment/imbalance can influence the baby's position. A brief excerpt of this section is available online at http://www.newdawnpublish.com/Excerpts/98.htm. Also discusses the use of chiropractic care during pregnancy and labor, and has lots of information about Webster's In Utero Constraint Technique.

Media Articles About SPD •

www.guardian.co.uk/health/story/0,3605,724347,00.html - Newspaper article by Lia Hattersley of her struggle with SPD, and how treatment by classical osteopath Quentin Shaw enabled her to walk freely again. Brief summary of the article above, under women's stories, but Kmom HIGHLY recommends reading the whole article from the original source. A MUST-READ.

Websites with Information about Symphysis Pubis Dysfunction www.spd-uk.org/what_is.htm - British DSP support group website with lots of information www.pelvicpartnership.org.uk - Pelvic Partnership, British informational site about SPD, among other things http://pelvis.freeservers.com/welcome.htm - Kirstein Powell-Hutchison's site on DSP www.radmid.demon.co.uk/dsp.htm - Radical Midwives list archives with some info on this www.parentsplace.com/pregnancy/complications/qa/0,3105,821,00.html - Parent's Place question and answer about this problem www.kamish.com/dsp/ - written by a woman with SPD/DSP, contains a lot of info about it, plus message boards for women experiencing this problem www.pregnancytoday.com/experts/pt-pbseparate.htm - question and answer session with a physical therapist; notes that sometimes a pelvic support belt can make things worse www.osteopathic.com.au/about_pregnancy.htm - Australian Osteopathic Association's page about pregnancy and osteopathic treatment during pregnancy

Resources Finding A Chiropractor Trained in Webster's In Utero Constraint Technique www.icpa4kids.com - International Chiropractic Pediatric Association, or call 1-800-670-5437. These chiros are trained in pediatrics (adjusting kids), which includes kids in utero (pregnant women by extension!), newborns, babies, etc. as well as older kids. Many, though not all, are specifically trained in Webster's Technique. www.chiropractic.org - International Chiropractic Association, call 1-800-423-4690 and ask for the Council on Chiropractic Pediatrics to get a referral to a pediatric chiropractor (including pregnancy treatment) in your area. As with the ICPA, a pediatric chiropractor is trained in adjusting children of all ages (including newborns and babies), and many are trained in treating pregnant women as well. The Council on Chiropractic Pediatrics offers an extensive, long-term training program in chiropractic pediatrics. The difference between the ICPA and the ICA seems to be largely political, with some differences in the extensiveness of training. Either resource would probably work well for most women. Finding a Maternity Support Belt and/or Birth Ball www.prenatalcradle.com - maternity support belt that is a bit more comfortable than many are, and which comes in a wide variety of sizes (including supersizes) www.babyhugger.com - another maternity support belt that may help SPD pain

www.plusmaternity.com - Pickles and Ice Cream, online store with many pregnancy and nursing products in average sizes and plus sizes. Carries Mom-Eze and Reenie Belts, both maternity support belts. www.childbirth.org/CEP.html - Birth Balls area available from Cutting Edge Press owner Polly Perez, along with suggestions and advice for using them

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