Relieving the

Discomforts of
Pregnancy(PART1)
SHS.509 LEC-08

DR.TAMKNAT
 Pregnancy is often the first time in a woman’s life that she will
experience so many different ‘feelings’, both physically and
psychologically.
 The vast majority of primigravidae will experience ‘aches and pains’
during pregnancy.
 The majority of these discomforts can be directly related to the physical
changes that take place during pregnancy, and their resultant
biomechanical effects upon functional movement.
 The growing uterus, and its contents, can give rise to experiences of
‘pulling, pressing and pushing’discomfort or pain. Some women
describe ‘sharp stabbing pains’, or‘dropping-out’ feelings.
(I) BACK AND PELVIC GIRDLE
PAIN
 More than one-third of women experience back and pelvic pain
 The intensity and duration of the pain can fluctuate throughout the pregnancy
 Great variation in severity between individuals
 The back pain is made worse by:
 Standing
 Sitting
 Forward bending
 Lifting – particularly when combined with twisting
 Walking
 Coccydynia can also be a problem of antenatally.

 Factors that could account for higher incidence of back pain in pregnant women:

 Fatigue

 Increased mobility of joints

 Weight gain with increased spinal loading

 Adaptations in posture

 Pressure from the growing foetus

 It is also worth noting that back pain before pregnancy does not necessarily lead to back pain
during pregnancy.
 Some women actually experience less back pain than usual whilst pregnant.
PREVENTION OF BACK PAIN
 One of the main aims of the women’s health physiotherapist antenatally is to prevent
back pain.
 To prevent an increase or exacerbation of symptoms
 To educate the woman to ‘manage’ her symptoms
 Antenatal classes should include education in body awareness and back care

(i) Lying
 It can be very uncomfortable during pregnancy.
 Comfortable resting and sleeping positions are essential.
 Additional support may be necessary in the form of pillows, or extra mattress support
 There must be whole body support, with all joints in a position of ‘ease’. A position of
unsupported rotation must be avoided at all costs.
 Comfort in supine lying can be increased with pillows under the thighs, though long
periods in this position should be discouraged later in pregnancy owing to the
increased risk of supine hypotensive syndrome.
(ii) Rolling:
 All human movement is performed more efficiently if it is facilitated as follows:
 Turning the head in the direction of ‘travel’ will facilitate the upper trunk to ‘roll’
 Folding the arms across the chest with the top arm leading in the direction of ‘travel’
will facilitate the mid trunk to ‘roll’
 Slightly flexing the outside knee and laying it on the inside leg (closest to ‘travel’) will
facilitate the lower trunk to ‘roll’
(iii) Sitting:
 The aim of the chair is to be of support to the user with the following criteria:
 Buttocks well back on the seat
 Thighs fully supported, for at least 2/3 of their length, no more than two fingers-
width from the popliteal fossa, and horizontal (i.e. hips at 90°, knees at 90°)
 Feet fully supported and flat on the supporting surface
 Spine fully supported enabling natural spinal curvature – a small pillow in the
‘lumbar hollow’ may be necessary
 Enabling the functional activity, e.g. writing, word processing, watching
television.
 Encouraged not to sit for too long
(iv) Standing & Walking:
 Standing posture can be maintained by the following:
 Weight evenly distributed over both feet
 Feet slightly apart, and slightly angled
 Knees off stretch, ‘soft’
 Spinal curves maintained, and symmetrical
 Environment or tasks positioned to enable good posture, e.g. kitchen work surface at the ‘right’
height
 Standing and walking for long periods should be avoided
 All functional activity in standing should be performed in such a way as to reduce
risk:
 Avoid trunk-on-hip flexion – a ‘top-heavy’ bend taking the trunk outside the base of support
 Avoid twisting repetitively, or whilst carrying a load
 Move about the knees, using the powerful quadriceps muscles to initiate movement
 ‘Move’ up and down the spine, within the base of support
(v) Lifting:
 Heavy lifting should be avoided
 Load carrying must maintain good posture
 Getting something from floor level, the woman should be advised to:
 Avoid squatting unless fitness and stamina ‘prevail’. This is not a stable position unless the
feet are flat on the floor and the weight is within the base of support. The knee extensors are
much less efficient in raising the body up against gravity, when the knees are flexed beyond
90°
 Go down on one knee so that both knees are at 90°, feet on the floor with as large a surface
area as possible, knees in line with hip joints .
 To kneel (with both knees) if staying down there, e.g. cleaning the bath
 Go back to one knee when ready to raise up
 Put the hand to knee/stool/bath and push through at the same time as …
Push through the floor, equally with both legs, to extend the knees.
MANAGEMENT OF BACK AND PELVIC GIRDLE
PAIN
 A reduction in overall activity can be advise

 Maintaining back care and posture

 Gentle heat

 Massage

 TENS/ Electrotherapy
(II) SACROILIAC JOINT
DYSFUNCTION
 Pregnancy could have many possible effects on the sacroiliac joint; for
example joint laxity may allow repetitive new movement at one, or
both,joints causing pain, if combined with sufficient activity.
 The increased weight during pregnancy thrusts the sacrum downwards
between the ilia in all upright postures, and in walking, each sacroiliac
joint alternately transmits the total loading.
 Certainly sclerosis of the sacroiliac joints (e.g. osteitis condensans ilii)
is seen on X-ray after childbirth. Changes in orientation or degrees of
movement at a sacroiliac joint may affect the symphysis pubis, and also
the spine.
Treatment
 Technique 1
 With the woman lying supine, and the knee of the affected
side flexed, the toes are hooked under the lateral aspect of
the straight knee. The therapist passively takes the flexed
knee across the body while holding the shoulder of the
affected side against the plinth.
 Thus tension is applied to the affected sacroiliac joint and
any slack is ‘taken up’; at the end of range a single, gentle
thrust is given.
 The woman may benefit from repeating this position at
home with or without gentle rocking movement but minus
the thrust.
 Technique 6
 Lying with hip at 90 and lower legs supported horizontally on a solid
surface.women presses with her thighs affected side against a firm
surface,holds and release.
 It is essential that the woman has full understanding of her ‘problem’,
and knows how best to maintain the correction and prevent recurrence.
 Side lying is usually the most comfortable resting position with a pillow
between the knees or forward under the top knee. The knees should be
kept together and ‘crooked’ when turning over in bed.
 Work involving leaning forward should be avoided, but when essential,
placing a foot on a low stool, or equivalent, controls the anterior rotation
of the pelvis to some degree (but not if suffering the symptoms of SPD
 A supportive belt applied following a manoeuvre may increase comfort
and help avoid recurrence of the malposition
(III) SCIATICA
 When a pregnant woman complains of sciatica, her obstetrician may possibly suggest
it is the baby sitting on a nerve. However, this, unless the woman is near term, seems
unlikely.
 Sciatica may accompany backache and sacroiliac joint dysfunction; it will rarely occur
alone.
 The L4 and L5 component of the sciatic nerve, due to its course, would become
involved in any dysfunction or inflammatory reaction at this site.
 An increased lumbar lordosis resulting in lying and standing would also change the
lie of these roots.
 Increased loading may result in the spinal foramina being reduced in size with
consequent root compression.
Treatment
 Management of the symptoms is by far the best approach, with
reduced activity levels, within pain-free range.
 Advice from the physiotherapist on
 positioning,
 back care,
 posture correction,
 activities of daily living
 and pain relief can be taken ‘as read’.
(IV) SYMPHYSIS PUBIS DYSFUNCTION
(SPD)
 The width of the symphysis pubis has been shown to increase asymptomatically in
pregnancy from about 4.8 mm to 7–9 mm.
 The pain is described as a ‘burning’ or ‘bruised’ feeling in and around the joint, which
may also radiate suprapubically and to the medial aspect of the thigh(s).
 Pain varies in severity and may be of gradual onset or incidious. It may be linked to a
specific activity or a traumatic incident.
 It is provoked by weightbearing, especially unilateral, and hip abduction.
Difficult activities will include:
 • getting in or out of the car or bath
 • changing position in bed, particularly ‘turning over’
 • dressing
 • walking, which is severely restricted or impossible.
Treatment
 Rest and reduction of non-essential ‘chores’ is vital, as is keeping the legs
adducted and avoiding single leg standing.
 Pelvic support may reduce pain levels, for example a Tubigrip ‘rollon’,
trochanteric belt, SPD belt or maternity support underwear, by helping to stabilise
the pelvic mechanics.
 In severe cases functional aids may be required (e.g. walking aids, a ‘helping
hand’, a slide board or turntable).
 Gentle isometric contraction of hip adductors, in sitting – small cushion between
the knees (whilst maintaining pelvic stability), may relieve adductor tension.
 Supervised exercise in water is a positive approach,though care should be taken
when getting in or out of the pool, and breaststroke must be avoided.
(V) COCCYDYNIA
 Coccydynia, also known as coccygodynia, is characterized by pain in and around the region of the
coccyx.
 The cause is most often of a traumatic nature but it can also be from an infection or tumor. An injury
can result in a bruise, dislocation or fracture of the coccyx bone.
 Previous injury to the coccyx predisposes to this problem in pregnancy, but otherwise this condition is
rare antenatally unless caused by a fall.

 Treatment
 This includes:
 • cushion when sitting, taking pressure through ischial tuberosities and
 thighs
 • gentle mobilisations – grasping the coccyx, using a gloved index finger,
 in the anus, and the thumb, posteriorly
 • ice packs, heat, ultrasound and TENS.
(VI) THORACIC SPINE PAIN
 Some women during pregnancy complain of pain over the thoracic spine. The rib cage
expands during pregnancy as a result of the growing foetus.
 This may well have a mechanical effect upon the costovertebral joints resulting in
pain.
 There may be symptoms radiating to the upper limb as a result. Muscular symptoms
may be the result of the increasing size and weight of the breasts.
 This may also be linked with pain along the anterior margin of the lower ribs (i.e.
costal margin pain (rib ache), and intercostal neuralgia).
 The ‘flaring’ can increase the diameter of the chest by as much as 10–15 cm.
‘Intercostal neuralgia’ is a term sometimes used to describe the intermittent pain,
usually unilateral, which can radiate around the chest and may be referred to the lateral
abdominal wall.
TREATMENT
 • mobilisations may ease costovertebral joint pain, but it is essential to remember that
during pregnancy there is an increase in joint laxity
 • posture correction (taping may assist with proprioception)
 • self-mobilisation techniques
 • exercises, stretching – which may address spasm and stiffness
 • a well-fitting brassiere should also be considered
 • ‘rib lifting’ techniques are helpful in dealing with rib ‘flare’: raise both arms over
the head with the hands clasped side flexion (with arm raised) away from the pain; sit
astride a chair ‘backwards’ (but not if suffering the symptoms of SPD or sacroiliac
joint problems)
 • hot-water bottle or an ice pack.
(VII) POSTURAL
BACKACHE
 Frequently the backache complained of
during pregnancy will be described as a ‘tired
ache’ in the lower back, often at the end of the
day, or after particularly heavy effort.
 There are many comfortable positions to
relieve this sort of discomfort and they can be
demonstrated, and practised during antenatal
classes, for relief at work and at home.
(VIII) PREGNANCY ASSOCIATED OSTEOPOROSIS
(PAO)
 PAO is rare, but maybe underdiagnosed, and therefore misunderstood.
 It is essential that the physiotherapist working in obstetrics is aware of its
possibility when considering particularly back,hip, and rib problems in pregnant
women.
 The highest proportion of fractures are: vertebral compression, rib and pubic ramus
 The symptoms experienced by these women were as follows:
 • backache, sometimes radiating around the chest wall, sudden severe backache,
back ‘spasm’, progressing to severe incapacitating back pain
 • hip/groin pain progressing to an inability to walk or weight-bear
 • vertebral fractures with subsequent loss of height and consequential effect upon
posture. Back pain is a common symptom in pregnancy and therefore osteoporosis
can be missed
 SIJ mobilization linkhttps://www.youtube.com/watch?v=tp36zXhEEz8

 SIJ exs
 https://www.youtube.com/watch?v=mTFxY_HS8OM

 SIJ STRETCHES
 https://www.youtube.com/watch?v=_VGmw3p3BdI&t=12s

 AUTO MOBILIZATION OF SIJ

 https://www.youtube.com/watch?v=iUVY4CpI7vI
 PELVIC ROLLING
 https://www.youtube.com/watch?v=u_w8MHrE_qI

 BACK EXS

 https://www.youtube.com/watch?v=AZwWEjvbnmo
 EXS FOR SCIATICA
 https://www.youtube.com/watch?v=1mNKzIrGZc4

 PIRIFORMIS RELEASE
 piriformis stretch

 CTS EXS
 https://www.youtube.com/watch?v=Q5G916yCyF0