Pelvic Pain in Pregnancy: SPD Symptoms, Causes & Relief

What Is Symphysis Pubis Dysfunction (SPD)?

Symphysis pubis dysfunction (SPD) is a condition where the ligaments that normally keep the pelvic bones aligned become too relaxed and stretchy during pregnancy. This causes instability and pain in the pelvic joints, particularly at the symphysis pubis (the joint at the front of the pelvis) and the sacroiliac joints at the back. It is also commonly referred to as pelvic girdle pain (PGP).

The pelvis is a ring-shaped structure made up of three bones held together by strong ligaments. At the front, the two pubic bones meet at the symphysis pubis, a cartilaginous joint that normally allows very little movement. At the back, the sacrum connects to the two iliac bones at the sacroiliac joints. During pregnancy, the hormone relaxin is released in increasing amounts to prepare the body for childbirth by softening these connective tissues.

In most women, this natural loosening causes no significant problems. However, in approximately 20-25% of pregnant women, the increased laxity leads to instability and pain in one or more of these pelvic joints. The condition can range from mild discomfort that is easily managed to severe pain that profoundly affects daily activities, work, and quality of life. Research published in the European Spine Journal has established that around 5-8% of pregnant women experience symptoms severe enough to significantly limit their mobility.

SPD is not a dangerous condition and does not harm the baby. However, the pain can be debilitating and should not be dismissed as a normal part of pregnancy. With proper diagnosis and treatment, the vast majority of women experience meaningful relief and can continue to function throughout their pregnancy.

What Causes Pelvic Pain During Pregnancy?

Pelvic pain during pregnancy is primarily caused by the hormone relaxin, which softens ligaments and joints in the pelvis to prepare for childbirth. Combined with the growing uterus shifting the center of gravity and increasing weight load, this puts excess strain on the pelvic joints, leading to instability, inflammation, and pain.

The exact pathophysiology of pregnancy-related pelvic girdle pain involves a complex interplay of hormonal, biomechanical, and sometimes metabolic factors. Understanding these underlying mechanisms can help explain why the condition occurs and inform more effective treatment strategies.

Hormonal Changes

From early pregnancy, the body produces increasing levels of the hormone relaxin, primarily from the corpus luteum and later the placenta. Relaxin acts on collagen fibers in ligaments and connective tissue, increasing their elasticity and water content. This is an essential biological adaptation that allows the pelvis to expand during childbirth. However, the degree of ligament softening varies significantly between individuals, and some women experience excessive laxity that destabilizes the pelvic ring.

Research has shown that relaxin levels peak during the first trimester and again near delivery, but interestingly, there is no consistent correlation between relaxin blood levels and symptom severity. This suggests that individual tissue sensitivity to relaxin, rather than the absolute hormone concentration, plays a crucial role in determining who develops SPD.

Biomechanical Stress

As pregnancy progresses, the growing uterus shifts the body's center of gravity forward, increasing the lumbar lordosis (the inward curve of the lower back). This altered posture places increased mechanical load on the pelvic joints and the muscles that stabilize them. The pelvic floor muscles, abdominal muscles, hip muscles, and back muscles all work together to maintain pelvic stability. When the ligaments become too lax to hold the joints firmly, these muscles must compensate, leading to fatigue, spasm, and pain.

Weight gain during pregnancy further compounds this biomechanical challenge. The average weight gain of 10-15 kg places additional vertical load through the pelvis, which the already-softened joints must bear. Asymmetric loading, such as carrying a toddler on one hip, climbing stairs, or standing on one leg, can cause uneven forces across the pelvic joints and trigger or worsen symptoms.

Risk Factors

Not all pregnant women develop pelvic girdle pain, and several factors have been identified that increase susceptibility. Understanding these risk factors can help with early identification and preventive strategies.

• Previous PGP in earlier pregnancy: The single strongest risk factor. Women who experienced pelvic pain in a previous pregnancy have up to an 85% chance of recurrence
• History of lower back pain: Pre-existing back problems suggest underlying musculoskeletal vulnerability
• Previous pelvic trauma or injury: Fractures, falls, or other trauma to the pelvis can weaken the structural integrity of the joints
• Multiparity: More common in second and subsequent pregnancies, possibly due to cumulative ligament stretching
• High BMI: Additional weight increases mechanical stress on the pelvic joints
• Physically demanding work: Occupations involving heavy lifting, prolonged standing, or repetitive bending
• Hypermobility: Women with naturally flexible joints (joint hypermobility syndrome) may be more susceptible to excessive pelvic laxity

What Are the Symptoms of Pelvic Girdle Pain?

The main symptoms of pelvic girdle pain include pain over the pubic bone at the front of the pelvis, pain in the lower back or sacroiliac area, pain in the hips and groin, difficulty walking, a clicking or grinding sensation in the pelvis, and pain when turning in bed, climbing stairs, or standing on one leg.

Pelvic girdle pain can manifest differently from woman to woman, both in location and severity. Some women experience pain primarily at the front of the pelvis (symphysis pubis), while others feel it mainly at the back (sacroiliac joints). Many women have pain in multiple locations simultaneously. The onset can be sudden, perhaps triggered by a specific activity like stepping off a curb, or gradual, worsening over weeks as the pregnancy progresses.

The severity of symptoms varies widely. For some women, the discomfort is mild and manageable with simple lifestyle adjustments. For others, the pain can be so severe that it significantly affects mobility, sleep, work capacity, and emotional wellbeing. Studies have shown that women with severe PGP are at increased risk of anxiety and depression, highlighting the importance of taking the condition seriously and seeking treatment early.

Common Symptoms

The following symptoms are characteristic of pelvic girdle pain and SPD. Women may experience some or all of these, and the pattern can change throughout pregnancy.

• Pain over the pubic bone: Tenderness and aching at the front of the pelvis, which may radiate to the inner thighs
• Lower back and sacroiliac pain: Deep aching pain in the lower back, buttocks, or at the dimples above the buttocks
• Pain when walking: Difficulty walking, often with a waddling gait. Pain typically worsens with longer distances
• Clicking or grinding sensation: An audible or palpable click in the pelvic area during movement
• Pain when turning in bed: Difficulty and pain when rolling over at night, which can significantly disrupt sleep
• Difficulty climbing stairs: Pain when lifting one leg, particularly going up stairs
• Pain standing on one leg: Activities like getting dressed require balancing on one leg, which can be very painful
• Groin pain: Pain radiating into the groin and inner thigh area

Activities That Typically Worsen Pain

Certain movements and activities consistently exacerbate pelvic girdle pain. Recognizing these triggers is essential for symptom management and helps guide the lifestyle modifications that form a core part of treatment.

Severity Levels

Healthcare providers often classify pelvic girdle pain severity to guide treatment decisions. Understanding where your symptoms fall can help you and your healthcare team determine the most appropriate intervention.

Mild: Occasional discomfort during specific activities. Manageable with simple lifestyle modifications. Minimal impact on daily routines. Most women with mild symptoms can continue working and exercising with minor adjustments.

Moderate: Regular pain during multiple activities. Disrupts sleep and limits certain movements. May require a pelvic support belt and regular physiotherapy. Some work modifications may be necessary, such as reduced standing time or ergonomic workplace adjustments.

Severe: Constant or near-constant pain. Significant limitation of mobility. May require walking aids such as crutches or a wheelchair. Sleep is severely disrupted. Work may not be possible. This level of severity affects approximately 5-8% of women with PGP and requires intensive multidisciplinary management.

How Is Pelvic Girdle Pain Diagnosed?

Pelvic girdle pain is primarily diagnosed through clinical examination by a healthcare provider or physiotherapist. The assessment includes provocation tests that reproduce pain in specific pelvic joints, evaluation of gait and mobility, and ruling out other conditions. Imaging such as ultrasound may be used in severe cases to measure the width of the symphysis gap.

Diagnosis of pelvic girdle pain is predominantly clinical, meaning it relies on the patient's history and a structured physical examination rather than laboratory tests or imaging. The European guidelines for pelvic girdle pain, published in the European Spine Journal, provide a standardized diagnostic framework that most clinicians follow. A thorough assessment is important not only to confirm the diagnosis but to determine the severity of joint instability and guide appropriate treatment.

During your appointment, the clinician will first take a detailed history of your symptoms, including when they started, what activities provoke or relieve them, and how they affect your daily life. They will ask about previous pregnancies, any history of back or pelvic problems, and your general health. This information is essential for developing an individualized treatment plan.

Clinical Examination and Tests

The physical examination involves several standardized provocation tests designed to stress specific pelvic joints and reproduce symptoms. These tests are performed gently and the clinician will stop immediately if they cause excessive pain.

The active straight leg raise (ASLR) test is one of the most reliable diagnostic tests for PGP. You lie on your back and lift one leg slightly off the bed while the examiner assesses how difficult this is and whether it reproduces your pain. The posterior pelvic pain provocation test (P4 test) applies gentle force through the hip to compress the sacroiliac joint. The Gaenslen test and Patrick test (FABER) also assess sacroiliac joint involvement. For the symphysis, direct palpation over the pubic bone and the modified Trendelenburg test evaluate anterior pelvic joint dysfunction.

In cases of suspected severe diastasis (actual separation of the pubic bones), an ultrasound examination may be performed to measure the width of the symphysis gap. Normally, this gap measures 4-5 mm. During pregnancy, it naturally widens to up to 9-10 mm. A gap exceeding 10 mm is considered a diastasis and may require more intensive management. In rare cases, an MRI may be ordered to assess for other conditions such as avascular necrosis of the femoral head or stress fractures.

How Is Pelvic Pain in Pregnancy Treated?

Treatment for pelvic pain in pregnancy focuses on physiotherapy, pelvic support belts, lifestyle modifications, and safe pain relief medication. Physiotherapy with targeted exercises to strengthen the pelvic floor and stabilizing muscles is the most effective evidence-based intervention. A pelvic support belt provides external stability and immediate pain relief for many women.

The management of pelvic girdle pain in pregnancy requires a multimodal approach combining physical interventions, lifestyle modifications, and when necessary, medication. The Cochrane systematic review on interventions for preventing and treating pelvic and back pain in pregnancy has established that physiotherapy and exercise are the cornerstones of effective treatment. The earlier treatment begins, the better the outcomes, so it is important not to wait until symptoms become severe before seeking help.

Treatment plans should be individualized based on the severity of symptoms, the stage of pregnancy, and the impact on daily function. A skilled physiotherapist with experience in pregnancy-related conditions is the ideal healthcare professional to guide your management. Most women will use a combination of the approaches described below.

Physiotherapy

Physiotherapy is the first-line treatment for pelvic girdle pain in pregnancy and has the strongest evidence base of all available interventions. A physiotherapist specializing in women's health or musculoskeletal conditions during pregnancy can provide a comprehensive assessment and develop a tailored exercise program.

Treatment typically includes manual therapy (gentle mobilization of the pelvic joints to improve alignment and reduce pain), soft tissue techniques (massage and trigger point release for tight muscles), stabilization exercises (progressive strengthening of the muscles that support the pelvis), and education about pelvic mechanics and ergonomic strategies for daily activities. Studies have demonstrated that physiotherapy can reduce pain scores by 50-70% and significantly improve functional capacity.

Pelvic Support Belt

A pelvic support belt (also called a maternity support belt or sacroiliac belt) is a simple but often highly effective intervention. The belt is worn around the hips, below the bump, and provides external compression that stabilizes the pelvic joints. Many women report immediate relief when wearing the belt, particularly during weight-bearing activities like walking and standing.

The belt should be positioned correctly to be effective: it should sit across the greater trochanters (the bony prominences at the sides of the hips) and be snug but not uncomfortable. Your physiotherapist can show you the correct positioning. While the belt is helpful during activity, it should be removed during rest to allow the muscles to remain active and not become dependent on external support.

Pain Medication

Acetaminophen (paracetamol) is considered safe throughout pregnancy and can be used for pain relief as needed. It can be particularly helpful for managing nighttime pain that disrupts sleep. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen should generally be avoided during pregnancy, particularly in the third trimester, as they can affect the fetal cardiovascular system.

In cases of severe pain that does not respond to standard measures, your healthcare provider may discuss other options on a case-by-case basis. Any medication decisions during pregnancy should always be made in consultation with your prescribing healthcare provider who can weigh the individual risks and benefits.

Complementary Therapies

Acupuncture has shown promising results for pregnancy-related pelvic pain in several clinical trials. A systematic review published in the BMJ found that acupuncture was more effective than standard treatment alone for pelvic girdle pain. It is generally considered safe during pregnancy when performed by a qualified practitioner who has experience treating pregnant women.

Aquatic therapy (exercising in warm water) is another beneficial option. The buoyancy of water reduces the gravitational load on the pelvis while allowing gentle strengthening exercises. Water temperature should be below 35°C (95°F) during pregnancy. Many hospitals and physiotherapy clinics offer prenatal aquatic exercise classes specifically designed for women with pelvic pain.

What Exercises Help with Pelvic Pain in Pregnancy?

Pelvic floor exercises, deep core stabilization, gentle hip strengthening, and swimming are the most beneficial exercises for managing pelvic pain in pregnancy. These exercises strengthen the muscles that support the pelvis and improve joint stability. Exercises should be pain-free and ideally guided by a physiotherapist.

Exercise is a crucial component of pelvic girdle pain management, but it must be the right kind of exercise. High-impact activities, wide leg movements, and exercises that cause pain should be avoided, while gentle, targeted strengthening is encouraged. The American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant women engage in regular physical activity, with appropriate modifications for conditions like PGP.

The key principle is to strengthen the muscles that stabilize the pelvic ring without placing additional stress on the already-loose ligaments. This means focusing on exercises that keep the legs parallel and close together, avoid asymmetric loading, and progressively challenge the deep stabilizing muscles of the core and pelvis.

Pelvic Floor Exercises

Pelvic floor exercises (Kegels) are fundamental for pelvic stability during pregnancy. The pelvic floor muscles form the base of the pelvic ring and play a critical role in supporting the pelvic organs and maintaining joint alignment. Strengthening these muscles can directly reduce PGP symptoms and also prepares the body for labor and postpartum recovery.

To perform a pelvic floor contraction, imagine stopping the flow of urine and holding in wind simultaneously. Hold the contraction for 5-10 seconds, then relax fully. Aim for 3 sets of 10 repetitions throughout the day. It is important to fully relax between contractions and to breathe normally during the exercise. If you are unsure whether you are performing the exercises correctly, a women's health physiotherapist can assess your technique.

Core Stabilization

Deep core activation involves gently engaging the transversus abdominis muscle, the deepest layer of abdominal muscle that wraps around the torso like a corset. This muscle works together with the pelvic floor to provide stability to the pelvis and lower back. To activate it, gently draw your lower abdomen in toward your spine (as if bracing for a cough) without holding your breath. This subtle contraction can be practiced in any position and should become an automatic part of movement throughout the day.

A useful exercise is the four-point kneeling stabilization: on hands and knees, engage the deep core and pelvic floor, then gently extend one arm forward while maintaining a stable pelvis. Hold for 5 seconds, return, and repeat on the other side. Progress to extending one leg backward (keeping it hip height) as strength improves. This exercise specifically targets the muscles that stabilize the pelvic ring.

Safe Exercises for PGP

• Swimming and aquatic exercise: Buoyancy reduces pelvic loading while providing gentle resistance for strengthening. Avoid breaststroke kick as it can worsen symphysis pain
• Stationary cycling: Low-impact cardiovascular exercise that keeps the legs parallel
• Prenatal yoga (modified): Gentle stretching and strengthening, avoiding wide-legged poses and deep squats
• Walking (short distances): Keep strides short and use flat, even surfaces
• Seated exercises: Upper body strengthening and gentle hip exercises while sitting reduce pelvic load
• Pelvic tilts: Lying on your back (early pregnancy) or standing against a wall, gently flatten your lower back to strengthen deep stabilizers

How Can You Manage Pelvic Pain at Home?

Effective self-care strategies include keeping your knees together during movements, sleeping with a pillow between your knees, wearing a pelvic support belt, avoiding prolonged standing, sitting down to get dressed, using ice or heat on painful areas, and planning activities to minimize triggers. These simple modifications can significantly reduce daily pain levels.

Self-management is a critical component of living with pelvic girdle pain during pregnancy. While professional treatment provides the foundation, the day-to-day lifestyle modifications you make have an enormous impact on your symptom levels. Many women find that once they learn to move differently and avoid specific triggers, their pain becomes much more manageable.

The overarching principle of self-care for PGP is to keep the pelvis as symmetrical and stable as possible during all movements. This means avoiding activities that create asymmetric or twisting forces through the pelvic ring. With practice, these movement modifications become second nature.

Sleep and Rest

Nighttime pain and difficulty sleeping are among the most distressing aspects of PGP. Improving sleep quality can significantly reduce overall pain levels and improve wellbeing. The most recommended sleeping position is on your side with a firm pillow between your knees and ankles. This keeps the pelvis aligned and reduces strain on the pelvic joints. A full-length pregnancy pillow can provide additional support along the body and behind the back.

When turning in bed, the key technique is to keep your knees together. Squeeze the pillow between your knees, engage your pelvic floor and core, then roll your whole body as one unit rather than twisting at the waist. Using satin or silk bedsheets can reduce friction and make turning easier. Some women find that placing a flat, folded sheet under their body as a "turning sheet" helps them roll more smoothly.

Daily Activities

Many everyday activities require small but important modifications when you have pelvic girdle pain. These changes may feel awkward at first but become habitual with practice.

• Getting dressed: Sit on the edge of the bed or a chair to put on underwear, trousers, shoes, and socks rather than standing on one leg
• Getting in and out of a car: Sit on the seat first, then swing both legs in together. Reverse the process when getting out. A plastic bag on the car seat can help you swivel
• Climbing stairs: Go one step at a time rather than alternating feet. Lead with your less painful leg going up, and your more painful leg going down. Use the handrail for support
• Shopping: Use online delivery services when possible. If shopping in store, use a trolley for support and take frequent sitting breaks
• Housework: Avoid vacuuming and mopping if possible (the pushing motion aggravates PGP). Use a long-handled dustpan to avoid bending. Sit down for tasks like folding laundry and preparing food
• Work: Request an ergonomic assessment if you work at a desk. Take regular movement breaks. Avoid prolonged standing. Your healthcare provider can support a request for workplace accommodations

Pain Relief at Home

Applying ice packs (wrapped in a towel) to the painful area for 15-20 minutes can help reduce inflammation and provide temporary pain relief, particularly after an active period. Some women prefer heat therapy using a warm (not hot) wheat bag or warm bath to relax tense muscles around the pelvis. Alternating between ice and heat can be particularly effective.

Gentle self-massage to the gluteal muscles (buttock muscles) can help release tension that contributes to pelvic pain. Using a tennis ball against a wall to roll over tight spots in the buttocks can provide relief. Rest is important, but prolonged immobility can actually worsen symptoms by allowing muscles to stiffen, so aim for a balance of activity and rest throughout the day.

Does Pelvic Pain Affect Labor and Delivery?

Pelvic girdle pain does not prevent vaginal delivery, but it may require some planning and communication with your birth team. Most women with SPD can have a normal vaginal birth with appropriate positioning. It is important to discuss your pelvic pain with your midwife or doctor before labor so they can accommodate your comfort needs during delivery.

Many women with pelvic girdle pain worry about how the condition will affect their labor and delivery. The good news is that SPD itself is not a contraindication to vaginal birth. However, it is essential to inform your birth team about your condition so they can plan accordingly and ensure your comfort during labor.

One important consideration is your pain-free range of hip abduction, which is how far apart your legs can comfortably open. During labor, your midwife or doctor will need to know this limit to ensure your legs are not positioned beyond your comfortable range during examinations, pushing, or delivery. It can be helpful to have your physiotherapist measure and document your comfortable range before labor, and to include this information in your birth plan.

Birth Positions for PGP

Upright and forward-leaning positions are generally most comfortable for women with pelvic pain during labor. Kneeling on all fours, kneeling over a birth ball, side-lying, and standing leaning forward on a partner or birth rail are all positions that minimize pelvic strain. The traditional lithotomy position (lying on the back with legs in stirrups) is often the most uncomfortable for women with SPD and should be avoided if possible.

If an epidural is used, it is particularly important to ensure the legs are not positioned too wide apart, as the pain relief may mask the discomfort that would normally signal excessive joint strain. Water birth can also be an excellent option for women with PGP, as the buoyancy reduces pelvic loading during labor.

Does Pelvic Pain Go Away After Pregnancy?

For the vast majority of women, pelvic girdle pain resolves within weeks to months after delivery. Studies show that approximately 93% of women are symptom-free within 12 months postpartum. Recovery can be accelerated with continued physiotherapy and a gradual return to exercise. Around 7% of women may experience persistent symptoms that require ongoing treatment.

The postpartum resolution of pelvic girdle pain is closely linked to the normalization of hormone levels after delivery. As relaxin levels decrease, ligaments gradually regain their pre-pregnancy strength and stiffness, and the pelvic joints become stable again. However, this process takes time, and many women are surprised that symptoms do not disappear immediately after birth.

In the early postpartum period, particularly the first 6-8 weeks, the body is still undergoing significant hormonal and physical changes. If you are breastfeeding, relaxin levels may remain elevated for longer, potentially prolonging some degree of pelvic laxity. However, most women notice a steady improvement in symptoms over the first few months postpartum.

Postpartum Recovery Timeline

Recovery timelines vary, but research provides a general framework for what to expect.

First 2-6 weeks: Symptoms may persist or even initially worsen due to the physical demands of caring for a newborn. Focus on rest, gentle pelvic floor exercises, and continued use of the pelvic support belt as needed.

6 weeks to 3 months: Most women experience noticeable improvement during this period. Gradually increase activity levels. A postnatal physiotherapy assessment around 6 weeks is recommended to evaluate recovery and guide exercise progression.

3-6 months: Significant recovery for the majority. Most women can return to normal activities including exercise, though high-impact activities may still cause discomfort. Continue strengthening exercises.

6-12 months: Full recovery for most women. If significant symptoms persist beyond this point, referral to a specialist physiotherapist or pain management team may be appropriate.

When Symptoms Persist

Approximately 7% of women continue to experience pelvic pain beyond 12 months postpartum. This chronic presentation may require a more intensive, multidisciplinary approach including specialized physiotherapy, pain management strategies, and in rare cases, consultation with an orthopedic specialist. Persistent symptoms are more common in women who had severe PGP during pregnancy, those with joint hypermobility, and those who did not receive adequate treatment during pregnancy.

Can You Prevent Pelvic Pain in Pregnancy?

While pelvic girdle pain cannot always be prevented, regular exercise before and during early pregnancy, maintaining a healthy weight, pelvic floor strengthening, and ergonomic awareness can reduce the risk and severity. Women with a history of PGP in previous pregnancies should seek early physiotherapy in subsequent pregnancies for preventive management.

Complete prevention of pelvic girdle pain is not always possible because it depends partly on individual hormonal responses that cannot be controlled. However, there is good evidence that certain strategies can reduce both the risk of developing PGP and the severity of symptoms if it does occur.

Pre-pregnancy fitness is one of the most effective preventive factors. Women who are physically fit with strong core, pelvic floor, and hip muscles enter pregnancy with a more stable musculoskeletal foundation. This does not have to mean intensive gym workouts; regular walking, swimming, yoga, and Pilates all provide excellent preparation for the physical demands of pregnancy.

Early pregnancy exercise continues to be protective. The ACOG recommends at least 150 minutes of moderate-intensity aerobic activity per week throughout pregnancy for women without complications. Early pelvic floor and core strengthening exercises create a muscular support system around the pelvis before ligament laxity reaches its peak.

For women who experienced PGP in a previous pregnancy, early physiotherapy referral in the next pregnancy is strongly recommended. Starting treatment before symptoms develop, or at the very first sign of discomfort, leads to significantly better outcomes than waiting until the condition has become established.

• Before pregnancy: Build overall fitness, strengthen core and pelvic floor, maintain healthy weight
• Early pregnancy: Continue regular exercise, practice pelvic floor exercises daily, maintain good posture
• If previous PGP: Request early physiotherapy referral, use pelvic support belt from early pregnancy
• Workplace: Request ergonomic assessment early, ensure access to a suitable chair and regular breaks
• Lifestyle: Wear supportive flat shoes, avoid carrying heavy loads, sleep with a pillow between knees from early pregnancy