SPD -- Symphysis Pubis Dysfunction

This is something important for all women to know about. It is a lot more common than you might think, despite the fact that most doctors in the US don't know about it, or don't believe it exists.. Don't ever let your doctor tell you that excruciating pain is "normal" or tell you to "just deal with it". If you are experiencing a large amount of pain, you have every right to adequate treatment of the cause, not just of the pain! If you suspect you may have SPD, and your doctor refuses to refer you to a specialist, find another doctor. SPD can cause permanent, sometimes debilitatingly severe damage if not handled properly. Please see the warning about labor and delivery near the end of this post for more information on this.

What is SPD?

SPD stands for Symphysis Pubis Dysfunction. It is also sometimes referred to as pelvic girdle pain, or PGP. It affects pregnant women, but can persist beyond pregnancy in a rare few very unlucky ladies. In the simple terms, SPD is a misalignment of your pelvic bones, caused by your body producing too much of a hormone called relaxin during pregnancy. Relaxin is what helps your spine realign to make room for Baby, your hips to expand, and your pelvic bones to separate to allow Baby to be born. It's a good thing -- in proper amounts. When your body produces too much of it, the joints in your body become extra flexible, and much more prone to misalignment. In some women, this doesn't become a problem unless they have some kind of trauma occur, such as a car accident or a fall. We don't exactly have the best of balance when we're carrying an extra 20+ pounds in front of us and our joints are soft, do we? When we fall, especially if we land on our hands and knees, which of course is much better than our bellies, the pelvis can easily become misaligned. In my case, my right hip became tilted backward. The body does not naturally realign itself without proper guidance, so the misalignment, if not corrected, can cause excruciating pain that lasts for a very long time, and only gets worse. In some women, however, SPD can occur without any kind of trauma. The hypermobility in the joints caused by the excess hormone can make it easy for the symphysis pubis to work itself into misalignment over time.

How is it Diagnosed?

It cannot be 100% diagnosed "officially" until pregnancy is over, by doing an x-ray to see if the symphysis pubis is misaligned. It's not that difficult for a chiropractor to recognize it, though. For one thing, most women with SPD have one leg slightly longer than the other, due to the misalignment of the pelvis. 

How Can You Tell if You Have It?

A tearing feeling in the middle of your pubic bone and/or perineum is a pretty strong clue. I'm not talking about the odd twinge here and there caused by stretching during pregnancy. This tearing feeling is different. It feels like you are being ripped in half. While the pain may subside quickly in the beginning, over time (if left untreated), it becomes more constant, and spikes with every movement, rather than just walking. It may hurt when rolling over in bed, or when sitting in a bad position. The pain usually subsides for the most part when sitting or laying down, at least until the condition progresses very far. Taking long strides when walking, going up and down stairs, and standing or walking for very long also causes great pain. This pain can also be felt in the hips, usually one side more than the other, or only on one side. The pain can be in different areas for different women, and may feel a bit different because everyone perceives pain differently, and the misalignment can go in various directions and affect different places. 

Clicking, cracking, and popping noises and feelings in the pelvic region and hips are also very common with SPD. Sometimes they can be so loud that others hear them, and sometimes they just feel like they are. Sometimes these pops can bring relief, other times they can make the pain worse. It just depends on whether or not your body is adjusting itself in the right direction.

How is it Treated?

There is no one-size-fits-all treatment. A combination of stabilization exercises, ice, positioning, and manual therapy is the most effective. Stabilization exercises reduce stress on the joint and improve stability. Stabilization exercises include strengthening the abdominals, pelvic floor, gluteals, latissimus dorsi and hip adductors. Chiropractic care is the most highly recommended component of treatment by those that have tried it. It is certainly what I recommend over anything else. Physical therapy is common in the UK, and sometimes attempted in the US, as well. Swimming is a good option, especially in conjunction with specialized physical therapy (in the water) if you can find a therapist trained in treating SPD. 

Many doctors will simply tell women to take acetaminophen (paracetamol), and if the pain gets bad enough, give them crutches, or in rare cases, a wheelchair. This isn't really treating the problem, however, only the symptoms. There are also a couple of different types of surgery that can be performed to try to repair it if it persists after delivery, but they have very low success rates, and sometimes can actually make the pain worse. One type involves fusing the pubis together with a metal plate. Another involves binding it with something else, like thread or ligaments from a donor (like a pig) or another part of your body. These surgeries also make future pregnancies highly inadvisable, since they immobilize the pubis, and make future vaginal delivery impossible. They can also come undone if you do become pregnant again because it will try to separate anyway to make room for Baby. I do not personally recommend these procedures at all, based on their outcomes, unless everything else has failed and you are desperate enough to risk it.

What Can You do to Minimize the Pain?

⬨When getting in and out of a car or getting up from a chair or bed, keep your knees together. Do NOT do extreme stretches, especially one-sided ones. DON'T do lunges or squats. These kinds of stretches have the ability to cause irreparable damage to the symphysis pubis that simple chiropractic care cannot fix, and then your only hope left would be the dismal chance of successful surgery. It is important that any stretching you do be symmetrical, to avoid exacerbating the misalignment, and that it be done while sitting or lying down, to avoid pressure on the pubis. 

⬨Sleeping with a pillow between your knees also helps to stabilize the pubis at night. If you are the type that likes to sleep with one knee drawn upward and the other leg straight like I am, I'm sorry to inform you that this can worsen the misalignment and cause you much more pain, despite being comfier for sleeping. It might take some getting used to and a lot of training yourself to be able to sleep in a different position, but it is well worth it. 

⬨Sit down to put on socks, shoes, underwear, and pants. 

⬨Take stairs one step at a time if you cannot avoid them altogether. A good phrase to remember is "up with the good foot, down with the bad foot," meaning that you lead with your least painful side when going up steps, and your most painful when going down. 

⬨Take small strides when walking, trying to keep your knees as close together as possible, and don't walk for too long at a time. 

⬨Rest frequently. 

⬨Do not cross your legs while sitting.

⬨Limping actually makes the pain worse, so try to avoid it if at all possible. 

⬨Keep your knees together when rolling over in bed, or with the pillow still between them. 

⬨Try sitting in a tall chair if you do the dishes or cook. 

⬨Anything you can do to take pressure off of your pelvis will help. 

⬨Change positions and shift your weight frequently when standing. Try not to favor one side when doing this, as this helps further the misalignment.

What Should You Do if You Think you Might Have SPD?

If your insurance will cover it, or you can afford it, don't wait for the pain to become unbearable. Get an adjustment from a knowledgeable chiropractor at the first sign of trouble and see a physical therapist to instruct you in stabilization if at all possible. This makes it much easier to treat, and increases your chances of a full recovery. The longer you wait, the worse the damage becomes. Many chiropractors have a self-pay option for $25-50 per visit, and some give discounts for those on Medicaid or who are uninsured or have no or low income. Reach out in your local community and ask for help. If you are in the US, call 211 to ask for referrals to resources that may be able to help. Start a GoFundMe. Do whatever you can to take care of yourself. Don't let yourself suffer.



What is Good to Keep in Mind During Delivery With SPD?

The best position for delivery with SPD (and one of the best for all women in general) is on all fours. It is the most natural, and allows more room for the pelvis to expand, while actually taking pressure off of the pubis. In this position, the tailbone has room to move to make more space in the birth canal. It is much more comfortable during contractions for most women, as well.

Squatting has been recommended by some providers. I have not heard any accounts from women with SPD that have delivered in this position, though, and since it still puts so much pressure on the pelvis, and stretches it so much, I am personally a bit hesitant to try it, but I would definitely try it before the lithotomy position if I needed an alternative to being on all fours. 

Waterbirth is also a really good choice. This is when you actually deliver Baby in a pool or tub of water. It helps to decrease tearing of the perineum, and decreases the pain of contractions, as well. This is not always possible, but is becoming increasingly more available of an option across the world. It is most common in birthing centers, but some hospitals do offer it. Homebirth with a midwife or freebirth (without any medical professional in attendance) also makes this possible. 

What is the Most Important Thing to Know About SPD?

You have to be careful during delivery when you have SPD. If Baby is in a funny position, such as with their arm up by their head, during delivery, most doctors/nurses will forcefully grab your legs and push them up to your shoulders. This is one of the absolute worst things that can be done to a woman with SPD, and almost always results in irreparable damage to the symphysis pubis, which can cause her extreme pain for the rest of her life. Like with the stretching I warned against, this can actually cause severe tearing of the ligaments and in some cases, the muscles around the pubis. 

The lithotomy position (lying on your back on a bed or table during delivery) is the worst possible position for a woman to give birth in. Not just women with SPD, but all women. The World Health Organization cautions against this position. Despite the fact that the US uses this position almost exclusively, it has been banned in many countries. It compresses the birth canal and slows labor. It also increases the chances and degree of tearing that may occur during birth. It may even increase the chances of needing an emergency C-section and the use of other interventions, such as forceps or venthouse. The common use of stirrups in this position is one of the dangers to women with SPD, as it can also cause tearing of the ligaments in the pubis.

Having an epidural or spinal block also increases your chances of permanent damage due to SPD. Because it numbs you, your body can't tell you when you are in a position that is putting too much stress on the pubis. You won't be able to feel it if your ligaments or muscles do begin to tear. 

It is very important that you make sure the doctor/nurses/midwife present at your delivery know that you have SPD, and know not to force your legs apart or to put you in stirrups. Some doctors will try to tell you that you cannot have a vaginal delivery if you have SPD. This is simply untrue. While there may be more risks to the pubis with a vaginal delivery than with a C-section, there are still more risks in general with a C-section, so it is still no more advisable over a vaginal delivery for a woman with SPD than a woman without it, unless there are other issues present that make a C-section a safer option.

Again, don't ever let a doctor blow you off if you are having extreme pain. Trust your body. If something doesn't feel right, then it probably isn't. You know your body better than anyone else. Doctors may have lots of knowledge about lots of things, but they are not omniscient. They do not know everything. The best doctor can admit that sometimes the patient does know better than they do. If your doctor is unwilling to listen to your complaints, or is refusing to investigate your symptoms, please don't hesitate to find another doctor that will listen to you and CARE. Many doctors think of patients as just numbers -- money in their pocketbook. A truly good doctor will actually care about you as a person.

Where Can You Find More Information on SPD?

You can find further information on Wikipedia, Physio-Pedia, Healthline, and the NHS, but the best information by far that I have come across in my research came from Plus Size Pregnancy.