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Birth Trauma to Pelvis back |
There are many variants which can cause trauma to the pelvis during delivery. For women
with pelvis instability or dysfunction the risks can become even greater.
Some of the risks are:
Cephalopelvic disproportion, small maternal stature, maternal pelvic anomalies, size and shape of the
maternal pelvis.
Deep transverse arrest of descent of presenting part of the fetus.
Trauma caused by excessive or forced abduction of the maternal thighs during delivery.
Hypomobility and segmental hypermobility, greater joint laxity, slower healing response.
History of pubic symphysis pain/ sacroiliac pain/ back pain in a previous pregnancy.
Very low birth weight infant or extreme prematurity.
Multiparity (women who have been pregnant before).
Prima gravida.
Prolonged or rapid labour.
Abnormal presentation (breech).
Versions and extractions.
Fetal macrosomia.
Large fetal head.
Use of midcavity forceps or vacuum extraction.
Increasing maternal age.
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Symphysis Pubis back |
Hormones and enzymes work together to produce ligamentous relaxation and
widening of the symphysis pubis during the last trimester of pregnancy. The physiologic changes of pregnancy
are superimposed by the trauma of birth. During delivery, the ligaments stretch and tearing in the fibro cartilage
occurs, this tearing can be in any direction, progressively loosening the symphysis, producing cartilage nodules,
cysts and reactive bone formation.
Although fibrous scar tissue usually restores stability, permanent laxity and
continues shear stress sometimes results in eventual narrowing of the symphysis pubis and/or degeneration.
Ongoing instability, degeneration and/or trauma of the pelvic joint accelerates the aging process and lead to
early degeneration and loss of function.
Symphysis Pubis During Pregnancy and Delivery
back
The fibro cartilaginous disc tears.
Fibrous tissue (scar tissue) fills the tears and restores stability for most women.
Resorption of bone amounts to 7mm widening of the symphysis pubis.
Hormones such as relaxin and estrogen add another 3-5mm.
Delivery always causes some traumatic damage; the worse damage is from cephalopelvic disproportion and
multiple pregnancies.
Permanent laxity can lead to degeneration of the symphysis pubis.
Symptoms occur with a width of more than 10mm or vertical displacement of 5mm.
Laxity of the symphysis pubis causes pain in the back, groin, hip and neck.
A diastasis greater then 2.5cm signifies there is damage to the sacroiliac joints.
Lying in any particular angle that transfers a lot of stress to the sacral area.
Further stresses to the symphysis pubis during a mid to high forceps delivery or delivery of a large baby.
The amount of symphysial separation, hormone levels, fetal size, maternal weight/age/ height, x-rays,
or ultrasound does not always correlate with the severity of the symptoms, or the degree of disability, nor
does it appear to predict the postnatal outcome. The non-pregnant gap is 4-5mm but in pregnancy there will
be an increase of at least 2-3mm, therefore, it is considered that a total width of up to 9mm between the two
pubic bones is normal for a pregnant woman. This natural extra gapping decreases within days following the
delivery, although the supporting ligaments will take three to five months to fully return to their normal state.
An abnormal gap is considered to be 1cm or more, sometimes with the two bones being slightly out of alignment.
If there is a complete separation, that is, a traumatic tear, and the joint will be completely unstable.
This tear can be felt and sometimes heard by the woman. There will be intensive pain followed by swelling
and inflammation. The woman is unable to move her back, trunk, hips and legs without causing severe pain.
When laying on her back her legs involuntary move apart and without the ability to close them together.
This type of pelvic fracture needs to be treated as such and investigations into possible involvement of the
sacroiliac joints should be addressed. It is important to note that the same can happen to the sacroiliac joints,
and could lead to laxity and even inflammation. The involvement could involve one or both sacroiliac joint(s).
A separation or diastasis can also be the result of traumatic forces from either an incident during the pregnancy
or delivery.
Symptoms back
Pain is usually felt low down over the Symphysis Pubis joint, which may be extremely tender to the touch. Pain may also be felt in the hips, groin and lower abdomen and can radiate down the inner thighs. You may waddle or shuffle, and may be aware of an audible ‘clicking’ sound coming form the pelvis.
Pain may remain static, i.e. in one place such as the front of the pelvis giving the feeling of having been
kicked, in other cases it may start in one area and move to other areas, you may experience a combination of the
symptoms. Any weight bearing activity has the potential of aggravating an already unstable pelvis, and daily
activities such as turning over in bed, getting in and out of a car or bath and climbing the stairs can all prove
potential problems. Some women find they need referral to a physiotherapist in order to obtain crutches, a
Zimmer frame or in more severe cases a wheelchair to help them get about. For any woman who was physically
active prior to pregnancy to suddenly be grounded by her pelvic pain can be very frustrating and this may cause
her to feel angry or resentful towards her baby. This is a normal reaction, but it is advisable to talk to your
Health Visitor about you feelings and if necessary gain referral to a counsellor to help you come to terms with
your feelings.
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| Sacroiliac Joint (SIJ)
back |
| The sacroiliac joints are two of the most important support
centres of the body, positioned
where the body’s weight transfers from the spine obliquely through the pelvis to the legs.
During pregnancy, the SI joints can cause discomfort both from the effects of the hormones that loosen the joints,
and from the stress of carrying a growing baby in the pelvis.
The female hormones that are released during pregnancy allow the connective tissues in the body to relax.
This relaxation is necessary so that during delivery, the female pelvis can stretch enough to allow birth. This
stretching results in changes to the SIJ's, making them hypermobile - extra or overly mobile. Over a period
of years, these changes can eventually lead to wear-and-tear arthritis. As would be expected, the more
pregnancies a woman has, the higher her chances of SI joint problems.
Sacroiliac Joints and Birth
back
Birth trauma may tear the joint capsule, tear the long posterior sacroiliac ligament,
loosens the Iliolumbar ligaments and destabilizes the disks. When the front part of the pelvis moves down, the
hip joints move down in relation to the SIJ and causes the legs to appear to get longer, sometimes one side more
than the other. Also, when the front part of the pelvis moves down relative to the spine, it stretches the psoas
muscle. The hormonal changes of menstruation, pregnancy, and lactation can affect the integrity of the ligament
support around the SIJ, which is why women often find the days leading up to their period are when the pain is at
its worst. The ligaments helping to stabilize the SIJ can become lax and this, together with increased load on the
spine due to the pregnancy, can cause altered SI joint mechanics and pain. Women are eight to 10 times more
likely to suffer from sacroiliac pain than men, mostly because of structural and hormonal differences between
the sexes. Her anatomy allows one less sacral segment to lock with the pelvis and this influences instability.
Signs and Symptoms
back
Mechanical SIJ dysfunction usually causes a dull ache.
The pain may become worse and sharp whilst doing activities such as standing up from a seated position, or
lifting the knee up to the chest during stair climbing.
The pain in your buttocks and low back and will often radiate to the front into the groin.
Typically the pain is felt in the low back and/or on the same side as the SIJ problem.
Noticing frequent changes in body posture to avoid prolonged tension on the SIJ and ligaments.
When SIJ joint dysfunction is severe, there can be referred ligament and joint pain into the hip, groin and leg.
Pain can be referred from the SIJ down into the buttock or back of the thigh.
Rib or mid back pain that increases with arm movement or prolonged sitting.
Loss of bowel and/or bladder control.
Pain during sexual intercourse.
Occasionally there may be referred pain into the lower limb which can be mistaken for sciatica.
Difficulty turning over in bed.
A higher level of physical fitness before pregnancy does not protect patients with posterior pelvic pain
during pregnancy nor does a fitness program benefit until the moderate to severe pain has diminished.
The most accurate way of determining whether the SI joint is causing pain is to perform a diagnostic injection
of the joint. Because the joint is so deep, this must be done using X-ray guidance with a fluoroscope
(a type of real-time X-ray) .
Once the doctor places a needle in the joint, an anaesthetic is injected into the joint to numb the joint. If your
pain goes away while the anaesthetic is in the joint, then your doctor can be reasonably sure that the pain you
are experiencing is coming from the SI joint.
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| Back Pain & Pregnancy back |
Back pain is common during pregnancy. Most pregnant women have some
component of back pain during pregnancy. Back pain in pregnancy is
most commonly either lumbar pain or posterior pelvic pain other
types are high back pain, sciatica, and night time-only.
About 50% of woman experience low back pain during pregnancy.(23)
Back pain in pregnancy may be severe enough to cause significant pain and disability and pre-dispose patients to
back pain in following pregnancy. No significant increased risk of back pain with pregnancy has been found with
respect to maternal weight gain, exercise, work satisfaction, or pregnancy outcome factors such as birth weight,
birth length, and Apgar scores.
Biomechanical factors of pregnancy that are shown to be associated with low back
pain of pregnancy include abdominal sagittal and transverse diameter and the depth of lumbar lordosis.(22) Typical factors
aggravating the back pain of pregnancy include standing, sitting, forward bending, lifting, and walking. Back pain in
pregnancy may also be characterized by pain radiating into the thigh and buttocks, night-time pain severe enough
to wake the patient pain that is increased during the night-time, or pain that is increased during the daytime.
The avoidance of high impact, weight-bearing activities and especially those that asymmetrically load involved
structures such as: extensive twisting with lifting, single-leg stance postures, stair climbing, and repetitive motions
at or near the end-ranges of back or hip motion.
Additional advice includes:
Adoption of lower impact exercise routines abdominal and low back muscle conditioning within tolerance.
Maintenance of good postures.
Use of mechanical supports and lumbar rolls.
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Increased Weight of Pregnancy back |
The weight gained during a normal pregnancy is generally around 10 to 13kg.
That works out at approximately 3kg of baby, 1kg for the uterus, 0.5kg for the placenta, 4kg for the increased
blood supply and around 4kg for the increased tissue and fat stores in anticipation for breast feeding. Of course,
these are average figures and will vary according to the individual.
The Weight Gained During Pregnancy Will Increase:
Demand and fatigue on spinal and pelvic muscles.
Stress on spinal and pelvic ligaments.
Joint stress and thus occurrence of vertebral and sacroiliac joint misalignments.
Demand and fatigue on spinal and pelvic muscles.
Stress on spinal and pelvic ligaments.
Increase in lumbar and thoracic spinal curves which further increase the above.
Joint stress and thus occurrence of vertebral and sacroiliac joint malalignment.
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Symphysiotomy back |
| Symphysiotomy results in a temporary increase in pelvic diameter (up to 2 cm) by surgically
dividing the ligaments of the symphysis under local anaesthesia. This procedure should be carried out only in
combination with vacuum extraction. Symphysiotomy in combination with vacuum extraction is a life-saving procedure
in areas where caesarean section is not feasible or immediately available.
Symphysiotomy leaves no uterine scar and the risk of ruptured uterus in any future labour is not increased.
These benefits must, however, be weighed against the risks of the procedure. Risks include urethral and bladder
injury, infection, pain and long-term walking difficulty. Symphysiotomy
should, therefore, be carried out only when
there is no safe alternative.
Abduction of the thighs more than 45 degrees from the
midline may cause tearing of the urethra and bladder.
Give appropriate analgesic drugs.
Apply elastic strapping across the front of the pelvis from one iliac crest to
the other to stabilize the symphysis and reduce pain.
Leave the catheter in the bladder for a minimum of 5 days.
Encourage the woman to drink plenty of fluids to ensure a good
urinary output.
Encourage bed rest for 7 days after discharge from hospital.
Encourage the woman to begin to walk with assistance when she is ready to do so.
If long-term walking difficulties and pain are reported (occur
in 2% of cases), treat with physical therapy. A symphysiotomy is
only carried out as a last resort if there is no other means of
safe delivery e.g. C-section. It is advised that this procedure
should not be repeated due to the risk of the woman developing
long term walking problems and continued pain.
[Information From the
World Health Organization, Reproductive Health, Managing Complications in Pregnancy and Childbirth.]
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