Back or Pelvic pain during pregnancy? - Pelvic Girdle Pain explained.

Nov 27, 2015 - 5:46pm

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Many women experience pregnancy-related low back pain and/or pelvic pain. Pelvic Girdle Pain (PGP), also referred to as Pelvic Instability, is pain at the back of the pelvis, and/or pain over the pubic joint. It is important for pregnant women to understand this condition, and be aware of the treatment options, particularly if the pain is severe enough to interfere with their daily activities such as sitting, carrying and walking.

 

What is PGP?

PGP is inflammation of one or more of the pelvic joints. There are two joints at the back of the pelvis (sacroiliac joints) and one at the front (pubic symphysis). Sacroiliac joint (SIJ) pain is generally located between the top of the pelvis and the buttock creases. Pubic symphysis pain is usually located over the pubic bone, groin, inner thigh and/or vaginal area.

What causes PGP?

PGP is very common and

as many as 30% of all pregnant women experience PGP, which usually starts in the second trimester.

The combination of pregnancy hormones, and rapid changes in posture and body weight both contribute to PGP. Genetics and lifestyle factors such as occupation and exercise may play a role too.

Reduced pelvic stability during pregnancy

The pelvic joints are extremely stable before pregnancy and only move by about 2 degrees. During pregnancy your pelvic joints become more mobile and moves up to 4 degrees. The feeling of ‘instability’ during pregnancy comes from suboptimal muscle control or dysfunctional movement patterns.

How do I know if I could have PGP?

You may have pregnancy-related PGP if you experience pain during daily activities listed below:

• Pain in one or both sides of the lower back/pelvic area
• Pain over the pubic bone
• Pain with rolling in bed
• Pain with standing up from a chair
• Pain whilst standing on one leg

If you suspect that you may have PGP see your physiotherapist, who will test the stability, movement and pain of your pelvic joints and muscles.

How do I treat it?

RICE management: The use of the following acronym is a helpful tip to remember what may help to decrease your pain.

Rest – horizontal rest is the only way to offload the sore joints

Ice – ice is a natural anti-inflammatory, and has a cumulative effect, so use it a lot!

Compression – support garments such as tubigrip, a pelvic support belt or pregnancy shorts may help. Beware, in some cases these garments may make it worse. Seek advice from your women’s health physiotherapist first.

Education – Talk to your physiotherapist for advice on changing your daily activities, exercise and posture to help decrease your pain. For more information, Fitwise Physiotherapy have an e-book on: PGP during pregnancy and as a New Mum: Management and Solutions 

Additional techniques that may help:

• Manual therapy from your physiotherapist
• Decrease the amount of walking you are doing
• Avoid standing on one leg i.e. sit down to get dressed, avoid pushing things out of the way with your foot
• Clinical pilates to address your biomechanics

Can I still exercise?

YES! Exercise during pregnancy is good for you and your baby. Keep it low impact and pelvis friendly and your options could include:

• Pilates
• Stationary cycling
• Swimming (avoid breast stroke kick)
• Light weights sitting on a fitball or with weight even through both feet (avoid lunges or single leg movements)

Will it go away after I give birth?

Usually the pain improves when the cause (pregnancy) has been taken away. However, the higher the pain during pregnancy, the more likely the woman will have pain after pregnancy. Therefore, it is best to see a physiotherapist as soon as you can to help keep the pain at a low level during pregnancy. Research shows that functional rehabilitation (Pilates) after birth improves your post-natal outcomes, and decreases the change of PGP with subsequent pregnancies.

Credit image: onedollarphoto.com

Article written by: Caitlin Fris, Caitlin@fitwisephysio.com.au

Caitlin is a physiotherapist with post-graduate training in pelvic floor physiotherapy and exercise for women. She works with pregnant and post-natal women at Fitwise Physiotherapy in East Melbourne and Armadale where she loves to promote fun and safe exercise. Caitlin spends time on the maternity ward at Epworth Freemason's hospital, treats patients at Fitwise and runs exercise classes including pilates and pregnancy spin classes. Caitlin also works at the continence clinic at St Vincents public hospital. To keep fit, Caitlin enjoys yoga and running, so understands the importance getting back into exercise during and after pregnancy. For more information, visit: www.fitwise.com.au

What treatment measures have you found the most useful in the management of PGP?

Varicose veins management in pregnancy

Nov 18, 2015 - 3:13pm

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Varicose veins are one of the most frequent complaints during pregnancy. They occur due to many changes that take place in the woman’s body: the presence of pregnancy hormones, an increased blood volume and a compromised venous return. The most common and visible place for varicose veins are the legs, however they can also occur around vagina (vulval varicosities) and anus (haemorroids).

 

 What is the function of veins?

Veins are responsible for carrying deoxygenated blood back to the heart. To complete this task they have valves that stop the returning blood flowing backwards. If these valves develop weakness, or fail to work, the blood starts to pool in the veins distending them, particularly in places affected by gravity.

How do varicose veins develop during pregnancy?

Pregnancy predisposes women to varicose veins due to multiple reasons that include:

1) Your growing belly puts pressure on the veins in your pelvis and slows down the circulation.

2) Simultaneously, you are carrying extra blood volume during pregnancy, as well circulating progesterone hormone, that relaxes your blood vessels walls.

Varicosities in the legs

Your legs is the most common place to get varicose veins. Pregnant women often complain of increased discomfort caused by blood pooling associated with prolonged standing.

Haemorrhoids

Varicose veins around the anus, are called haemorrhoids or piles and could be coupled with constipation.

Vulval varicositites

One in ten of pregnant women develop varicose veins in and around the vagina, particularly in the second half of their pregnancy.

Vulval varicosities are distressing since they cause swelling around the vagina and make sitting uncomfortable.

What are the symptoms of varicose veins?

As well as being visible under the skin, varicose veins can also cause:

• Swollen feet and ankles.
• Muscle cramps at night.
• Heavy, aching legs.
• Dry skin and eczema over the area of varicose veins.

What can I do to treat and prevent varicose veins?

• After 20 weeks avoid lying on the back. Sleep on the side and elevate your feet on a pillow above the heart.
• Avoid prolonged standing whenever possible. Move around at least once every 30 minutes.
• Use muscle pump activity exercises to stimulate blood circulation. For example, a short burst of calf raises with weight or without.
• Get moving. Moderate physical exercise such as walking and swimming is great for circulation as well as helping you with a healthy weight and life-style.
• Avoid crossing your legs and put your feet up as much as possible. For example, at work you can place your feet on a box or a step.
• Avoid constipation and do not strain on the toilet to assist with haemorroids. Opt for a high fibre diet and drink plenty of water. Most cases of haemorroids can be effectively managed with over the counter treatments from the pharmacy.
• Stay comfortable. Wear comfortable shoes, particularly if the ankle swelling is a problem. In the case of vulval varicosities, supportive undergarments may provide relief.
• Compression maternity stockings are a good option for all types of varicosities, since they promote venous blood return back to the heart and may ease some discomfort associated with varicous veins. Graduated compression hosiery provides the strongest pressure at the ankles that decreases as it goes up the leg. Such garments come in various compression levels, designs and colours. Brands of graduated compression stockings that we recommend are: Solidea. Sigvaris and Jobs. Another option is compression maternity leggins: SRC leggings.

On the positive note …

Varicose veins developed during pregnancy usually disappear completely once you have your baby.

Credit image: onedollarphoto.com

What measures have you found most effective to manage varicouse veins in pregnancy?

Common childbirth myths addressed

Jul 19, 2015 - 3:18pm

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It has been 9 months of pregnancy and now your bundle of joy is about to arrive. You may start hearing lots opinions from friends and mothers, as well as reading information on the internet. It is easy to get overwhelmed, confused and misinformed when it comes to delivery. This article will dispel some of the most common myths about childbirth.

Drinking castor oil can be used to bring on my labor if overdue:

Castor oil is an old-school remedy to induce labor in a woman. The idea is that castor oil stimulates the bowel, which in turn stimulates contractions of the uterus. However, it can lead to unpleasant side effect such as nausea and diarrhea and is not recommended in modern obstetric practice.

Women with wide hips have an easier delivery:

While it seems like the baby would have more space passing through a woman with wide hips it is not an accurate assumption. The external shape of your curves is not related to the pelvis proportions inside. During birth, baby’s head molds to fit into the vaginal canal and mother’s hips widen to accommodate the baby. The ease of delivery does depend on the size of the woman’s pelvis, but many other factors play a role, which include baby’s size and position.

If I have written a birth plan I know exactly what will happen during my delivery:

Having a birth plan ahead of time is a great idea, but there is no way to predict how your labor will proceed. Whilst doctors and midwives will respect your wishes, giving birth can be unpredictable and certain factors are outside your control. For example, a woman may plan a vaginal delivery but may need an emergency c-section due to a complication.

An Epidural and a Spinal anaesthesia are the same:

Epidural and Spinal anesthesia are procedures that numb parts of your body to give pain relief, which are given by your anesthesiologist. They are both administered via injections in your lower spine and allow you to stay awake. Whilst there are some similarities between the two procedures, is important to understand the differences:

An epidural involves injection of medication into a space between the vertebrae and the spinal fluid, called the epidural space. Pain relief effect takes 10 to 30 minutes and used for longer procedures such as natural childbirth. There is usually a small tube, called catheter, left in place to allow a top up of medication.

A spinal is an injection of medication directly into the spinal fluid. This is done as one shot of medication and takes effect right away. This is used for shorter procedures such as elected C-section delivery.

There is also a technique called Combined Spinal Epidural (CSE), where both anaesthesias are used together. This technique offers the rapid onset of pain relief of a spinal and the continuous long-lasting relief of an epidural.

Epidurals and Spinals are given with a big needle and it’s painful:

Before Epidural and Spinal blocks are administered you are given a local anesthetic into your lower back, which is not painful but may feel like a sting for 10 seconds. Spinal needle is the width of a thick piece of hair.  Epidural needle is the size of a pencil lead. Local anesthetic is in place before Epidural and Spinal needles go in, so there is no pain but you may feel pressure.

Epidural and Spinal anaesthesia are dangerous:

Epidural and Spinal anesthesia are very reliable and safe, but they do have some risks. Your anesthesiologist will take you though the complete list of side effects and possible complications. To ensure safety, during the delivery the anesthesiologist will be monitoring your pulse, blood pressure and oxygen levels in your blood.

Epidural during labor increases your chances of doctor intervention delivery:

It is true, that epidural can, slow down the second stage of labor and make it harder to push the baby. Nevertheless, a 2005 study (by Northwestern University in Chicago) have shown that there is no increase in the risk of cesareans when epidurals are administered during labor. In addition, the epidural dose can be lowered to make it easier to push, thus, reducing the likelihood of forceps or vaccum-assisted delivery.

A Cesarean-section is less painful than a vaginal birth:

C-section a major abdominal surgery, and whilst you may not feel any pain during the delivery there is discomfort afterwards. In addition, c-section carries the risk of complications associated with surgery as well as post-operative recovery time and a scar, which is not the case with the vaginal birth.

My stomach will flatten immediately after birth:

For most women this is not the case. After delivery, women have a round, soft stomachs also referred to as ‘mummy tummys’. Even when the baby is out the uterus only shrinks to about 60% of its size post-birth. It takes 6 to 8 weeks for the hormonal changes to take place and for the uterus to return to its pre-pregnancy size.

Kate Middleton was praised for showing her post-baby tummy after both of her deliveries.

Image credit: dollarphotoclub.com

Have you got a question about childbirth that we have not addressed in this article? We would love to hear from you.

Free Whooping Cough vaccination in pregnancy

Jul 9, 2015 - 6:45am

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Whooping cough (pertussis) is a highly contagious respiratory infection caused by the bacterium Bordetella pertussis. It is spread by airborne droplets from the upper respiratory tract when the infected person coughs or sneezes.

In young babies it is particularly dangerous due severe symptoms and life-threatening complications. Infants have small airways and the pertussis infection in their lungs causes uncontrollable coughing fits. This may lead to potentially fatal complications such as septic shock and suffocation. Statistically 1 in 200 babies under the 6-month, who contract the infection, will die (betterhealth.vic.gov.au). The best way to protect newborns from this deadly respiratory infection is vaccination.

Symptoms of whooping cough:

• Severe coughing fits
• Characteristic ‘whoop’ sound at the end of a bout of coughing due to a deep breath
• Vomiting after coughing

The cough may last up to 3 month, even after the infection is treated with antibiotics. Important: If the child develops blue colour in the lips or skin or has difficulty breathing, seek urgent medical attention.

Recently, there has been a dramatic spike in whooping cough cases in Australia. Based on the Global Pertussis Initiative, from June 1 Victorian State government made a step towards preventing whooping cough by providing a free vaccine. This vaccination would be supplied via the state's government program through immunisation providers such as GPs, maternity hospitals, obstetricians and local councils.

All pregnant women are eligible for the free vaccine during every pregnancy along with all the immediate family members, caregivers and anyone else who has close contact with the newborn. This minimises the risk of whooping cough circulating in the family and at schools. The vaccination provides cover for 10 years after that a booster dose is required.

In addition, Pertussis vaccine is safe and effective for pregnant women in the third trimester. This is the optimal time to administer the vaccination since the boosted immunity from the mother transfers to the baby providing 90 % effectiveness in preventing the infant from contracting the whooping cough.

Vaccinations are given Intra-Muscularly and are very well tolerated. Side effects and allergic reactions are rare.

Brands of Whooping cough vaccinations available in Australia:

• Boostrix®
• Adacel®

 

 

Morning sickness - what are my options?

May 31, 2015 - 8:23pm

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Early weeks of pregnancy may be perceived as a blooming period for a woman. The reality: a large proportion of women in the first trimester will suffer from an unpleasant sign of pregnancy – morning sickness.

 

Why does it happen?

Morning sickness is nausea and vomiting in pregnancy that frequently occurs in the morning, but may also continue during the day. In most cases, the baby is not affected unless symptoms are severe and persistent.

Although not a pleasant symptom, morning sickness is a sign of a healthy pregnancy. The exact mechanism is unknown, but it is thought to be caused by a rapid rise of pregnancy hormones: human Chorionic Gonadorophin (hCG) and oestrogen.

 

What are some of the dietary and lifestyle measures I could try?

 

1) Keep hydrated:

- Aim to drink at least 2L of fluids per day in small amounts throughout the day. Dehydration can make nausea and vomiting worse.

- Try fluids other than water. Options may include: flat lemonade, diluted fruit juice, weak tea, clear soup, electrolyte replacement drink.

- Try chilled drinks or sucking on icy poles. - Ginger may help with nausea. Try making ginger tea: soak few slices of ginger in boiling water for five minutes.

- Ginger may help with nausea. Try making ginger tea: soak few slices of ginger in boiling water for five minutes.

 

2) Measures to reduce nausea:

- Avoid being hungry. Eat small amounts but more often during the day. Have snacks between your meals. - Morning nausea may be improved by snacking on a cracker before getting out of bed.

- Avoid nausea triggers. Eg. If a smell of hot food makes you ill try having cold food instead.

- Avoid fatty, and spicy foods.

- Avoid caffeine drinks. Ie. coffee and cola.

- Get plenty of rest.

 

3) Foods that help to settle nausea:

- Toast with jam

- Low fat soups

- Yoghurt

- Boiled rice

- Mashed potato

- Eggs boiled and scrambled.

 

What’s available over-the-counter for my morning sickness?

You may want to try the following supplements in addition to your dietary and lifestyle measures:

Pyroxin® 25mg tablets : (Pyridoxine/Vitamin B6): 25-50mg up to 4 times a day.

Elevit Morning Sick Relief tablets: Vitamin B6 and Ginger. 

I have tried all the treatments at home with no results, what do I do?

If nausea and vomiting persists after taking all of the conservative measures, the next step is to discuss further options with your obstetrician and/ midwife. Depending on the severity of your nausea and vomiting, the doctor may prescribe anti-nausea medicine. These include:

- Metoclopramide (Maxolon®)

- Ondansetron (Zofran®)

Hyperemesis Gravidarum – what is it?

Hypermesis Gravidarum is severe nausea with a continuous vomiting that may lead to the loss of weight and dehydration, putting the health of the baby and the mother at risk. This form of morning sickness is rare and may require admission to the hospital, where anti-nausea medicine, fluids and nutrients may be given via a drip.

Fact: Kate Middleton suffered from Hyperemesis gravidarum in both of her pregnancies.

Image credit: bigstock.com

Have you suffered from morning sickness during your pregnancies? What measures did you find most useful?

 

Magnesium supplements – can it help with cramps in pregnancy?

Jan 30, 2015 - 5:06pm

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Magnesium supplementation in the reduction of muscle cramps in pregnancy - is there evidence supporting its use? Dosages recommended. What supplement brands to use?

Up to half of pregnant women in the second and third trimester complain of leg cramps particularly at night. There have been various mechanisms postulated for this effect, some of which are due to deficiencies caused by the growing fetus: low potassium, calcium and magnesium (Mg) levels. By far the strongest evidence involving pregnancy related cramps is pointing towards the link with Mg deficiency. This article summarizes the current evidence available for treating muscle cramps in pregnancy with Mg supplementation. (2)

What is the role of Magnesium?
Mg is the forth most abundant essential mineral in the body. It is involved in activation of over 300 different enzymes in the body and is an important player in metabolism, hormonal reactions and muscle contraction. (3)
More than half of the Mg in the body is distributed between muscles and soft tissues. This means that the other 50% of Mg is stored in the bones and very small amount will be in the blood. For this reason Mg deficiency can be difficult to diagnose with a blood test. The test result will not reflect of what levels are in the tissues. (3)
In skeletal muscle, Mg plays a role in relaxation. So when there is a deficiency the muscle will not be able to relax causing a cramp. (1)

What is a muscle cramp?
Cramps are an involuntary, sudden, uncomfortable squeezing or contraction of a muscle (1).
The two most common places for pregnancy cramping are the calf and the inner thigh (adductor muscle). In addition, to Mg deficiency, the latter, is most likely due to the muscle fatigue from carrying around the extra weight around the pelvis.

How does Mg help with cramps in pregnancy?
Due to the growing fetus, the Mg requirement increases during the pregnancy. Additionally, there are changes in the metabolism of the mother, and Mg excretion via the kidney goes up. Towards the second half of pregnancy Mg requirement is difficult to obtain from food alone. Typical symptoms of Mg deficiency might develop as pregnancy progresses: eg. Calf cramps, muscle tension.
Hence, there are extensive studies showing that therapeutic benefit of Mg in pregnancy related cramps. (3)
Given that Mg is well tolerated it can be safely used in most cases. Some of the side effects may include diarrhea and nausea, which can be avoided by building up the dose gradually.

Magnesium is available in oral supplements that include tablets and powders. It also can be absorbed via the skin and some of the other products available are creams and a bath soak salts.

Which form of Mg should I use?
Different forms of Mg influence its absorption. Inexpensive salts of Mg include Mg oxide. Another is Mg citrate, which is better absorbed then the oxide salt (4). The best bioavailability comes from the chelated form of Mg such as Magnesium aspartate or bisglycinate.

What brand of supplements do I take?
Recommended dosages to take for cramps in pregnancy vary.

Here is what we recommend:

Brand name	Ingredients	Quantity	Price $
Blackmores MagMin	Magnesium aspartate dihydrate (Magnesium 37.4mg) 500 mg	250	39.95 (0.16/tablet)

Dosage recommended: Take 3-6 tablets with meals or as directed by your doctor.




A more convenient dose may be in a powder form. Our pick:

Brand name	Ingredients	Quantity	Price $
Mega Magnesium Powder	Magnesium diglycinate 3g equiv. elemental Mg – 300mg + Other ingredients	200g	27.69 (1.2/scoop)

Dosage recommended: Take 1 scoop (8.7g) in 200ml of water twice daily.



Another product that we would strongly recommend to use in conjunction with supplements is Epsom salts:

Brand name	Ingredients	Quantity	Price $
Faulding Epsom salts	Magnesium sulphate salt	1kg	2.99 (~1/bath)

Directions: Dissolve 375g in an average size bath of warm water.



Are there other measures I can do?
Stretch the affected calf by flexing at the ankle so that your toes are pointed towards your head. Do not point your toes as this may aggravate your cramp.

If you get a cramp in your calf or the inner thigh try the following:

• Wear support hosiery, such as compression stocking that are graduated (meaning that they are tighter at the foot and looser near the knee).
• Drink plenty of fluids throughout the day and evening.
• Massage the affected muscle.
• Apply local heat.
• While holding on, squat down to the floor.
• Daily soak in a warm bath with Epsom salts.

What foods contain Mg?
Dietary sources of magnesium include whole grain cereals, green leafy vegetables, legumes, soybeans, nuts, dried fruit, animal protein and seafood. (4)

Main image credit: Bigstock.com

Have you experienced cramps in pregnancy in the past or do you have it now? What treatment did you find the most useful?

References:
1. Nguyen V. Magnesium supplementation in the reduction of muscle cramps: A systematic literature review. The Australian Journal of Pharmacy. Nov 2013. P80-83.
2. Young G, Jewell D. Interventions for leg cramp in pregnancy. Cochraine Database Systematic Review CD000121 2002.
3. Dahle L; Berg G; Hammer M, Hurtig M; Larsson L. The effect of oral magnesium substitution on pregnancy-induced leg cramps. American Journal of Obstetrics and Gynecology 1995 Jul; 173(1) 175-80.
4. Wu J; Carter A. Magnesium: the forgotten electrolyte. Australian Prescriber. Vol 30: 4. Aug 2007. P102-105.
5. Linberg JS; Zobitz MM; Pintdexter JR; Pak CY. Magnesium bioavailability from magnesium citrate and magnesium oxide. J Am Coll Nutri. 1990 Feb; 9 (1): 48-55.
6. Sebo P, Cerutti B, Haller DM. Effect of magnesium therapy on nocturnal leg cramps: a systematic review of randomized controlled trials with meta-analysis using simulations. Fam Pract 2014; 31:7-19.