Laboring with Symphysis Pubis Dysfunction

Wow! I can't believe my first post about SPD during pregnancy has gotten so many views in only one week! Thank you to those who shared your stories about SPD with me in the comments section and through shares on Facebook. Thank you also to those who shared the page with loved ones and other health care providers. I hope in the future the pain from SPD isn't so easily dismissed as just a normal part of pregnancy. If my little ol' blog post can help with that - hooray! In case you missed it, click to read the original post "My pelvis is going to split in half!" about symphysis pubis dysfunction during pregnancy. 

Many pregnant women reached out to me, certain they're experiencing SPD, whether it has been officially diagnosed or not, and wondering what to do about labor. This post is for you!

In an attempt to prevent any further or lasting damage to your pelvic joint, this post is meant to encourage you to speak with your care provider about your concerns and to determine the best positions for labor and pushing. I'll talk about positioning, the use of medication as it relates to SPD, and a few related ideas. I hope it helps. 

Positions for birthing with SPD

Most of the considerations for birthing positions are more relevant to the pushing stage of labor. However, it's important to keep them in mind throughout the rest of your pregnancy and the earlier parts of labor.

First and foremost, listen to your body!

During my first pregnancy, I learned during that squatting helps open up the pelvis nearly 10%. I thought that sounded great and would be awesome during pushing to help my baby come out more easily. I was fully planning on squatting for delivery. I'm grateful I had providers who trusted me to make the best decisions for myself during labor, and didn't try to force me into one position or another. When it came time to push, I felt more like being on hands and knees, so I did that instead. Later, I learned that's one of the better positions for relieving pressure on the pubic bone. Had I delivered in my desired squat, I could have permanently damaged the tissues that support that joint. 

Women are often discouraged from arching their backs while pushing, but some women report feeling the least pelvic pain in this position. Trust yourself and your body to know what's best!

Avoid squatting

The reason why squatting is not a good position when you have issues with SPD has to do with the way the baby passes by the pubic bone, and the position of the pelvis while you are squatting. 

The reason to avoid squatting can be felt by actually getting into a squatting position yourself. The picture below illustrates the type of squat I am talking about:

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You should be able to feel your pelvis opening up when you are in this position - usually, that's great! With SPD, that kind of opening can lead to additional strain on the muscles and tissues supporting the joint.

When you add in the weight of your uterus and baby on top of the already weak pubic joint, excess separation of the pubic joint can occur. During pushing, squatting can also cause the baby's head to put more pressure on the joint from the inside out. All of this additional pressure can lead to a seriously out-of-place joint! If you ignore the pain or try to power through it, you could end up with permanent or very long-lasting damage and pain.

Avoid giving birth on your back or in the 'classic' position

I wish I didn't have to even mention this one, but it seems that many women are still being asked or encouraged by their care providers to birth on their backs. 

The 'classic' position is the one you think of if you imagine pretty much any movie birth: woman sitting on a bed, knees pulled back (or maybe in stirrups, or legs held up by her partner and a nurse). 

Did you know your tailbone can move? Not if you're in bed!

The tailbone, similar to the symphysis pubis, is a joint with limited mobility. However, it is able to move well out of the way during birth, partly because of the pressure of the baby's head as it passes by, and partly thanks to the hormones released during pregnancy allowing it to be looser and more mobile. 

The reason these two positions aren't great for labor, and especially bad when you have SPD, is that they don't allow the tailbone to move. You are not only working against gravity and the weight of your body and baby, but the bed prevents the joint from moving back out of the way. Where does this leave the symphysis pubis joint? With a lot of extra pressure it shouldn't have to bear. 

If you do happen to find yourself in the 'classic' position during pushing, there are a few things you can do to help make sure you don't pull your legs too far to either side:

  • Hold your own legs, or make sure you've discussed how to hold them with your labor attendants. It's hard work to hold your legs up, and as you or your attendants get more tired, it's tempting to let the knees fall out to the sides. Don't let that happen!
  • Put your hands under your knees and lift your elbows until they are pointing straight out to the sides. Now pull your knees towards you. Keeping your elbows up and out naturally prevents you from being able to spread your legs very far apart. Try it for yourself! Pull your knees back with elbows up and out, then try to spread your knees farther apart from each other. Now do the same thing, but with your elbows pointing down toward the ground. Quite a big difference! So remember, elbows up and out.

Avoid stirrups or other positions that unnecessarily stretch your legs apart

Stirrups widen the space between your legs, which puts more pressure on the pubic joint. Couple this with the fact that stirrups typically place you on your back in bed, leaving the tailbone with nowhere to go, and you've got a recipe for pubic joint damage. This image shows the direction of the pressure on the pubic joint when you're on your back, with legs spread apart:

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What's the best position?

From the research I've done, the best position seems to be on all fours, followed by standing or kneeling. These positions make it unlikely you will spread your legs too far apart, and also prevent excess strain on the pubic joint. 

Side-lying could also be a good position, assuming you don't lift the upper leg too far. 

Hands and knees is good for birth in general - it works with gravity to let the baby descend more easily, it allows the tailbone to move up out of the way, and it's a relatively restful position (especially if you use it in conjunction with leaning over a birth ball, chair, etc) compared to other not-laying-on-the-bed positions. 

Medicated birth and SPD

Avoid an epidural

If possible, avoid the use of an epidural or other medications that will not allow you to feel your pubic joint at all. When you are unable to feel what is happening, you may not realize that you are stretching too far, or that your body wants you to be in a different position. You also tend to be on the bed and deliver in a position that doesn't allow for the tailbone to move back, often being coached to push-push-PUSH. If you are able to listen to your body's signals, you are able to ease up on the pushing when you need to, rather than being directed to keep going simply because the monitor says you're having a contraction.

If the idea of birth without pain medication seems scary, consider attending an independent (not hospital based) childbirth class near you. If you happen to live in NE Arkansas, let's talk

With an epidural

If you do have an epidural, it's critical that you speak with your care providers in advance and again in labor to make sure that your pushing position(s) are considerate of SPD. 

Even with an epidural, it's possible to push in positions other than the 'classic' position. With a supportive birth team in place, I've seen all sorts of creative positions for pushing with an epidural, including hands and knees and side-lying.

Is a Cesarean delivery necessary with SPD?

No, not always. I personally have had three un-medicated deliveries, and had SPD during all three pregnancies. Most of my students with SPD have also had medicated and un-medicated vaginal deliveries. In the cases where a cesarean was necessary, it was attributed to something else, not the SPD.

If you are aware of your limits, avoid spreading the legs too far apart, and listen if your body tells you you're putting too much strain, a vaginal delivery is definitely possible. 

I'm pregnant with twins

I imagine that most of the items mentioned above would be applicable for twin pregnancies. However, I have not found anything specifically related to twin pregnancies and SPD. If you happen to know of any articles or research, please share them with me! 

Other considerations

  • Educate your providers as much as possible about SPD.

  • Hire a care provider who does not require the use of stirrups, or routinely perform assisted deliveries (forceps, vacuum) which would typically cause you to need to spread your legs farther than not.
  • Hiring a doula knowledgeable about SPD can be a great idea. Your doula will be able to help you remember which positions are best, and can assist you in and out of them. A doula also encourages you to listen to your body's cues and so is a helpful voice when you're in the midst of labor. If you live in Northeast Arkansas, I'd love to work with you. :)

  • Attend a childbirth class with an instructor knowledgeable about SPD. In my childbirth classes, you receive hands-on instruction about positions for pregnancy and labor that are compatible with SPD. Further, you receive advance guidance for making sure the baby is in a good position for birth - resulting in an easier labor for you, and less chance that forceps, vacuum, or cesarean delivery will be necessary, even with SPD.
  • After delivery, it's common for the SPD symptoms to remain for a number of weeks or even months. If permanent damage occurs, some women report pain for years after their delivery. Continue to maintain good positioning techniques even after delivery, and consider a visit to your chiropractor or osteopath soon after delivery.

In an upcoming post, I will share tips for making SPD less likely in future pregnancies, including how to strengthen your muscles to help stabilize your pelvis. 

Did you deliver with SPD? I'd love to hear from you!

What positions did you use? Did your provider help you with positioning and making sure you didn't pull your legs too far apart? How long after birth did your symptoms last?