Pelvic girdle pain (PGP) in pregnancy

This leaflet is for women who think they may be experiencing pelvic girdle pain (PGP) relating to their pregnancy. PGP is a term for any pain experienced in your pelvis, including pain in your hips and sacroiliac joints in your back. Pain is commonly felt in the symphysis pubis, at the front just below your tummy, or one side or both sides of your back. About one in five women will experience PGP in their pregnancy.

Women with PGP often have:

• difficulty walking
• pain when standing on one leg, such as when getting dressed or climbing the stairs
• pain when turning in bed
• pain during normal activities in life

The pain may be intermittent, irritating and can be very tiring and upsetting.

What causes PGP?

It was thought that the hormone relaxin caused PGP by making pelvic joints loose and the pelvis unstable. It is now known that the pelvis remains strong and stable in pregnancy and birth. As your pregnancy progresses, you will experience many changes in your body. Some of these changes will naturally ‘turn up the volume’ on your nervous system. This can make us more alert to the changes happening and make our body behave in a protective way. Muscles can feel tight and movement can be difficult, restricted and painful.

Will my pain go away?

The sooner PGP is identified the better it can be managed. Women might experience different symptoms and these can be more severe in some women. If you understand what PGP is and how you can reduce it this might speed up recovery and help manage the pain. Having some symptoms does not mean that the pain will get worse as your pregnancy progresses. Once they have given birth most women find the symptoms settle. Seven per cent of women will have some discomfort after giving birth. If this happens and the pain does not settle down in two weeks seek a referral for a physiotherapist (see ‘Treatment’ below).

Risk factors

Women with PGP may have experience of:

• a previous history of lower back or pelvic pain
• injury to the pelvis
• having a physical job
• PGP in a previous pregnancy
• joint hypermobility (excessive flexibility in the joints in the body)
• having a high body mass index (BMI)

Risk factors not associated with PGP:

• length of time between pregnancies
• age and height
• breastfeeding
• the contraceptive pill
• pelvic joint changes

Treatment

In Cambridge University Hospitals NHS Foundation Trust we invite women to attend the virtual PGP class. This is taught by an experienced physiotherapist and provides information and advice on PGP, exercises, posture, lifestyle and equipment, including maternity belts. Please complete the PGP class self-referral form (available from the ‘Pelvic health and obstetric physiotherapy’ page on our website) or ask your midwife to refer you.

Many women find attending the virtual PGP class very helpful, and improves PGP. If, however, if the class is not appropriate for you or has not helped you, we encourage you to get in touch with your local pelvic health and obstetric physiotherapy provider to request a one-to-one assessment.

General advice

Listen to your body - if an activity hurts you should consider whether you are doing it correctly and whether you should be avoiding it.

Work

• If you have a job that involves sitting a lot ensure your workstation is correctly set up for you. The computer screen should be at eye level. You may need to lower your chair or raise the desk. Ensure you can rest both feet flat on the floor or on a foot stool, rather than crossing your legs. Consider asking your employer for a detailed risk assessment.
• If you are on the phone make sure it is easily accessible and you do not have to stretch too much for it.
• Regular breaks can help reduce pain. Try to get up every 20 minutes to change position.

Home

• If you have to do heavy chores in your house avoid these if they increase your pain; for example try to vacuum one room a day rather than the whole house.
• When picking up items from the floor or lifting toddlers try to keep a straight back. Reduce the frequency of lifting, encourage your toddler to climb onto you for cuddles, or ask for help when needed. Try to avoid carrying a toddler on one hip.
• Try to plan your day by bringing down a few items at a time from upstairs rather than consistently using the stairs.
• If pushing a large shopping trolley increases your pain, try a smaller trolley or try online grocery shopping.

Night time

• If you find you cannot get comfortable at night, try sleeping on your side with a pillow between your legs. If this does not help try resting your top leg on two pillows in front of you, allowing the other leg to be straight in the bed.
• If turning in bed is uncomfortable try turning a different way. Try turning underneath you or turning with your knees together with your buttocks clenched.
• A duvet or thick mattress topper underneath your top sheet can be comfortable.

Exercising

If you have been advised by an obstetrician or midwife to restrict your physical activities, please seek further advice before exercising.

• It is important to move. Some activity or exercise may aggravate your pain so try to concentrate on things that do not.
• Try a short walk every day if this does not increase your pain. You may find slowing down your walking speed or wearing supportive shoes helps.
• Attending yoga or a pilates class can also be helpful, as can swimming. Some women find breast stroke increases their pain; if it does, try front crawl or swimming on your back. You do not need to avoid this movement if it does not increase your pain.

Pelvic floor muscle exercises

The pelvic floor muscles lie at the bottom of your pelvis. Exercising them encourages circulation in the pelvis which will reduce the pain response. The muscles also help in labour, improve the control of your bladder and bowel and can help prevent a pelvic organ prolapse. We know these muscles can get weak in pregnancy.

Pelvic floor muscle

The pelvic floor muscle is like a hammock made of muscle and connective tissue (ligaments). The muscle is attached from the pubic bone at the front to the coccyx at the back. The pelvic floor muscle is the muscle you would use if you are trying to stop yourself from passing urine or wind.

You can exercise the pelvic floor muscles in any position, but sitting is a good position to start in. Sit upright on a firm chair with your weight evenly on the sitting bones in your bottom cheeks. It is important to work all parts of the pelvic floor muscles and to do this you need to practise both short and long contractions.

Try to ‘squeeze and lift’ the pelvic floor muscles. Start gently and rhythmically. You may not feel that much is happening at first but keep trying.

Short squeezes – Aim to get to 10 contractions.

Try the action above, pulling the muscles up strongly and then letting go completely.

Long squeezes – Build up to 10 seconds x 10 times.

Try the action above and hold whilst still breathing for as long as you can, which may only be a few seconds to begin with. Build this up gradually to a maximum of 10 seconds. You should be able to control the release of these muscles. Repeat until the muscles tire.

For more information, please see the ‘Pelvic health and obstetric physiotherapy’ page on our website for the pelvic floor muscle training leaflet and the pelvic floor muscle exercise video.

Other exercises

Tummy muscle exercise

This exercise can be done sitting, standing or lying on your side.

Breathe in gently. As you breathe out, gently pull in the lower part of the stomach (about 30% of the total pull in you could do), drawing your ‘bump’ in towards your spine. Don’t move your back. Aim to hold for five breath cycles (normal breathing in and out).

Back muscle stretch/side bends

Stand with your feet shoulder-width apart and approximately 10 to 15cm from the wall. Flatten your back to the wall and place your hands on the back of your head. Keeping your back flat on the wall, side bend until you can feel a stretching sensation. Hold for 10 seconds, then return to an upright position. Repeat on the other side.

These side bends can also be done whilst sitting on a chair or a gym ball.

Pelvic tilt standing

Stand with your feet hip-width apart. Keep your knees as straight as possible and, by tightening your buttocks and pulling your abdominals in, roll your pelvis backwards (round your lower back). Return to starting position.

Pelvic tilt sitting

Sit upright on a chair or gym ball. Keep your hips higher or at least level with your knees, and your feet flat on the floor. Slide your hips forward to flatten your lower back. Allow your pelvis to tilt backwards and tuck your tailbone underneath you. Keep your head up. Return to starting position.

Cat arch

Start on your hands and knees. Ensure that your knees are directly below your hips, hands directly under your shoulders, head and spine in a natural posture. Tuck your chin into your chest and draw your tummy in towards your spine as you gently round your lower back. Hold for five seconds. Return to starting position.

Child pose

On all fours, engage your lower tummy muscles and round your lower back like the cat arch (above). Part your legs a little if necessary to allow space for your bump. Lower your bottom towards your ankles until you feel a nice stretch in your lower back. Hold for 10 seconds. Return to starting position.

Will having PGP affect my delivery?

Most women with PGP can deliver their baby vaginally, and a caesarean section is not normally recommended. Women are commonly anxious about the possibility that their pain will increase during labour, but this is not always the case. You may want to think about positions that are comfortable for you, record these in your delivery plan and consider a water birth as the water allows you to move freely. During labour, think about the use of gravity to help. You may find standing and leaning through a raised bed, or being on your hands and knees, helps.

Resources

• Pelvic girdle pain and other common conditions in pregnancy booklet, available from Pelvic, Obstetric and Gynaecological Physiotherapy (POGP) website (opens in a new tab).
• The Squeezy app (opens in a new tab) – designed by physiotherapists to help people with their pelvic floor muscle exercise programmes.
• Gym Balls – check guidance on sizing and choose a burst-resistant ball.
• Spiky Massage Balls – about 9cm diameter with a little give (not rigid) or a tennis ball for massaging the back and buttocks.
• Maternity Support Belts – wide range available, for example Promedics and Emma Jane Maternity support belts.
• Elasticated Bandage – often known as Bump or Belly Bands. Tubigrip size L or K (L is bigger) is one example.
• Crutches – can be borrowed from CUH Physiotherapy Outpatients, Monday to Friday 08:30 (8:30am) to 16:30 (4:30pm).
• The physiotherapy self-referral form for CUH pelvic health physiotherapists is available from ‘Pelvic health and obstetric physiotherapy’.
• Physiotherapy self-referral Community based NHS service Dynamic Health offers physiotherapy self-referral (opens in a new tab) for patients living in Cambridgeshire or Peterborough.
• The Chartered Society of Physiotherapy has a ‘Find a physiotherapist (opens in a new tab)' service.

For further physiotherapy advice you can leave a message for the CUH pelvic health physiotherapists on 01223 217422.