Pelvic Girdle Pain (SPD) in Pregnancy

What pelvic girdle pain is

The RCOG defines it clearly: "The pelvic girdle is a ring of bones around your body at the base of your spine. PGP is pain in the front and/or the back of your pelvis that can also affect other areas such as the hips or thighs."

The NHS describes the mechanism as "a stiffness of your pelvic joints or the joints moving unevenly" at the front or back of the pelvis. The RCOG says the same: "PGP is usually caused by the joints moving unevenly, which can lead to the pelvic girdle becoming less stable and therefore painful."

You will still see it called symphysis pubis dysfunction, or SPD. Both the RCOG and Tommy's note that PGP is the current term, and it is a better one — the problem is not confined to the pubic joint at the front.

How common it is

Common enough that you are not unlucky, and common enough that services exist for it.

• The RCOG: "PGP is common, affecting 1 in 5 pregnant women, and can affect your mobility and quality of life."
• The NHS: "PGP affects up to 1 in 5 pregnant women to some degree."
• Tommy's: "Around 1 in 5 women and birthing people have pelvic pain in pregnancy."
• The HSE puts it higher: "About 1 in 4 pregnant women experiences pelvic girdle pain."

The spread between 1 in 5 and 1 in 4 reflects different definitions and thresholds rather than a disagreement about the condition. Either way, it is not rare.

What it feels like

Pain may be felt over the pubic bone at the front, across one or both sides of the lower back or buttocks, in the groin, hips, thighs or knees, and in the area between the vagina and anus. The NHS and RCOG both mention "a clicking or grinding in the pelvic area", which people often find alarming and which is a recognised part of the picture.

It is characteristically movement-triggered. The movements named across the NHS, RCOG, Tommy's and HSE guidance are consistent: walking, especially long distances or on uneven ground; going up or down stairs; standing on one leg — getting dressed, for instance; getting in and out of a car or bath; turning over in bed; moving your knees apart; and having sex.

Severity varies enormously. The HSE notes that people may struggle with walking, dressing and lying on their back or side. Tommy's acknowledges that severe cases may need crutches or a wheelchair.

One thing to hold on to: Tommy's states directly that "PGP does not harm your baby". It is painful and it limits what you can do, but it is not a risk to the pregnancy.

Who is more likely to get it

The NHS lists a history of lower back or pelvic pain, a previous pelvic injury, PGP in a previous pregnancy, physically demanding work, and being overweight. The RCOG adds hypermobility syndrome. The HSE adds gestational diabetes and low fitness before pregnancy.

None of these are things to blame yourself for, and none of them predict severity well.

What actually helps

Here is what the guidance recommends, and how strong the evidence behind it is.

Physiotherapy referral — the recommended first step

NICE's antenatal care guideline (NG201, recommendation 1.4.15) says: "For women with pregnancy-related pelvic girdle pain, consider referral to physiotherapy services for: exercise advice and/or a non-rigid lumbopelvic belt."

The RCOG's instruction to patients is equally direct: "Tell your midwife or doctor about your pain. You should be offered an appointment with a physiotherapist who will make an assessment to diagnose PGP." Its list of what physiotherapy may include: advice on avoiding aggravating movements, exercises to relieve pain, manual (hands-on) therapy, heat therapy, hydrotherapy, acupuncture, and support belts or crutches.

The NHS makes the timing argument: "Getting diagnosed as early as possible can help keep pain to a minimum and avoid long-term discomfort." This is the single most actionable sentence on the page. PGP is frequently dismissed as an inevitable part of pregnancy, and it is not.

What the trial evidence shows

The Cochrane review of interventions for low-back and pelvic pain in pregnancy pooled 34 randomised trials with 5,121 women. It is worth reading its findings precisely, because they are more mixed than most summaries suggest:

• Moderate-quality evidence that an eight- to 12-week exercise programme reduced the number of women reporting combined low-back and pelvic pain (risk ratio 0.66, 95% CI 0.45 to 0.97; 1,176 women, four studies).
• Moderate-quality evidence that land-based exercise reduced pain-related sick leave (RR 0.76, 95% CI 0.62 to 0.94; 1,062 women).
• For pelvic pain specifically, two studies (374 women) found no significant difference between group exercise plus information and usual antenatal care (RR 0.97, 95% CI 0.77 to 1.23) — low-quality evidence.
• Single studies suggested acupuncture or craniosacral therapy improved pelvic pain more than usual care, and that osteomanipulative therapy or a combined manual-therapy, exercise and education package may help. These are individual studies, not pooled results.
• "When reported, adverse effects were minor and transient."

The reviewers' honest caveat: "Further evidence is very likely to have an important impact on our confidence in the estimates of effect and change the estimates." Tommy's notes that NICE found insufficient evidence to support acupuncture, heat or ice packs, or painkillers specifically for PGP. So exercise is the best-supported option, the evidence is stronger for back-and-pelvic pain together than for pelvic pain alone, and anyone promising you a cure is going beyond what has been shown.

Pain relief

The RCOG says: "Paracetamol is safe in pregnancy and may help if taken in regular doses." NHS guidance elsewhere is to take paracetamol at the lowest effective dose for the shortest possible time, and to avoid ibuprofen and other NSAIDs, and codeine-containing painkillers, unless a doctor has specifically prescribed them.

Day-to-day self-help from NHS guidance

• Do keep active, but avoid the things that make the pain worse.
• Do wear supportive shoes.
• Do sleep with a pillow between your legs.
• Do keep your knees together when getting in and out of a car.
• Do not sit or stand for long stretches, use stairs more than you need to, or lift heavy things.

What it means for birth

Less than people fear. The NHS: "Many women with pelvic pain in pregnancy can have a normal vaginal birth", and a water birth may ease discomfort by taking the weight off the joints. The RCOG goes further and addresses the question people are really asking: "there is no evidence that a caesarean section helps women with PGP."

What is worth doing in advance is discussing positions with your midwife or physiotherapist — knowing your comfortable range of movement for your legs before labour starts is more useful than deciding on the day.

After the birth

The RCOG: "PGP usually improves after birth although around 1 in 10 women will have ongoing pain." Tommy's gives the same figure. If you are in that group, that is a reason for continued physiotherapy referral rather than something to put up with.

When to call

• Tell your midwife or doctor at your next contact if you have pelvic pain at all — the RCOG expects this to trigger a physiotherapy assessment.
• Ask to be seen sooner if, as the HSE puts it, the pain "interferes with your normal daily life" or "does not improve within 1 to 2 weeks."
• Contact your maternity unit the same day if pelvic or back pain comes with vaginal bleeding, regular cramping or tightenings, unusual discharge or fluid leaking, pain when you pee, or pain that is severe or does not settle after 30 to 60 minutes of rest.
• Before 37 weeks, backache that is not usual for you is on the NHS list of premature labour signs. If your pelvic pain changes character or becomes rhythmic, ring.

Call your local emergency number (999 in the UK and Ireland, 911 in the US and Canada, 000 in Australia, or 111 in New Zealand) if you collapse or have sudden severe abdominal pain with heavy bleeding.