What is Diastasis of the Pubic Symphysis?
The pubic symphysis is the midline joint that connects the two sides of the pubic bone. Diastasis, by definition, is the dislocation of two joints or the separation of a bone without a fracture. Therefore, diastasis of the pubic symphysis the separation of the pubic bone from either side without completely fracturing. Most women experience a separation of their pubic symphysis in the late stages of pregnancy in order to help the body prepare for childbirth. Normally, the pubic symphysis only allows movement of about 0.5 mm to 1 mm. In the late stages of pregnancy, it can sometimes expand up to 3 to 4 mm. Many women experience extreme amounts of pain at just 3 to 4 mm separation. However, in extreme cases, some diastasis of the pubic symphysis can go up to 15 mm separation.
Symptoms of Diastasis of Pubic Symphysis
Diastasis of the pubic symphysis is fairly common for women who are about to give birth or who are newly postpartum. One in four women is affected by diastasis of the pubic symphysis either through reasons of childbirth or because of unrelated trauma. The hormone relaxin causes the pubic bone to separate up to 3 to 4 mm. In diastasis of the pubic symphysis, the pubic bone can be separated by 10 mm to 15 mm, causing extreme amounts of pain and immobility for the patient. Some of the most common symptoms of diastasis of the pubic symphysis include:
- Pain in the pelvis while walking
- Pain to the pubic region, groin or the inside of the thigh
- Clicking or grinding in the pelvic area
- Pain with weight-bearing
- Reciprocal activities or pain inter vaginally
- Pain in the front center of your pubic bone
- Pain in your lower back on one or both sides
- pain in the area between your anus and vagina (the perineum)
Diastasis of the pubic symphysis is often diagnosed using images from radiographs, CT scans, or an MRI the latter two which often provide more detailed information about the degree of severity of the diastase of the pubic symphysis.
Diastasis of the pubic symphysis is often treated at home using a brace or pelvic belt to help bring together the public bones and joints as well as muscle strengthening exercises. Oftentimes anti-inflammatory medications and analgesics will be prescribed. Some women find that attending physical therapy or seeing a chiropractor helps in their treatment. IN the most severe cases, women may need to have orthopedic surgery to fix the pelvic surgically. There is a very high reoccurrence rate in subsequent pregnancies of about 65% to 85%.
This is a version of a post originally published on More Green for Less Green, which includes more about Pamm Fontana's personal journey with this Symphysis Pubis Dysfunction.
I was 24 weeks pregnant with my oldest son (I'll refer to this as PG1) when I woke up one morning and felt like someone had kicked me between my legs. I felt bruised from the inside and outside. It was painful to walk but also painful to lay down on my side. I made an appointment with my OB practice and I was diagnosed with diastasis of the pubic symphysis, a more extreme version of the symphysis pubis dysfunction (SPD) that many women experience late in pregnancy.
Diastasis symphysis pubis (DSP) is such an extreme separation of pubic bones that they are considered dislocated. For simplicity, I am going to refer to all of these as SPD in this post, but for the record: SPD can also be referred to as pelvic girdle pain (or PGP), pubic symphysis pain, and a few other names that may refer to the same specific issue or some broader ones, like pelvic instability, which may also refer to issues with the sacroiliac joint (naturally, when the front of your pelvis spreads the rear pelvic joint is impacted, too).
The pelvis naturally widens during pregnancy, especially in late pregnancy, to accommodate for delivery. This increased pelvic girth and flexibility are part of a woman's amazing ability to birth a baby. But for me, it happened too much and too soon. The obstetrician (OB) I met with at the time told me that my diastasis was the most extreme case he'd seen in over twenty years of practice, but there was nothing to be done, save for taking pain medication and making some small comfort measures.
Getting a second OB opinion didn't yield me any additional hope. From a physiological standpoint, the doctors were correct- the gap wasn't going to close itself during pregnancy. But, there is more to health and healing than mainstream western medicine's focus on medication, surgery, or bust. For my next pregnancy, where SPD became intensely painful at just 20 weeks, I knew better and utilized many strategies to make the pregnancy considerably healthier and happier. So, here's what I know now through two pregnancies and four years* of pelvic instability.
*Something like 93% of people who have SP loosening during pregnancy heal quickly and easily after delivery. I am one of the 7% who didn't.
DISCLAIMER: This post is based on my lay-person's understanding and my personal experience. It should not be construed as medical advice. Please consult medical professionals about your particular course of action.
Pursue Healing Help
Chiropractic care is something that entered my life only after PG1 when I didn't get better. For whatever reason, I was afraid of chiropractic care, didn't believe it could be beneficial, and couldn't comprehend paying out-of-pocket for it. When I finally reaped the benefit of chiro care (postpartum PG1 and then throughout PG2), I shed many tears that I didn't recognize as an option before things got so bad. I was very angry that the OBs I'd consulted hadn't recommended this (or even an adjustment with a physical therapist). I was distraught to remember that I actually had booked a chiro visit late in PG1 out of desperation and then chickened out. I so wish that I'd been more open-minded! Here's what I now understand:
- Chiropractic care from a practitioner who specializes in pregnancy is safe, gentle, and highly effective. Ask questions ahead of time to gauge how much experience a practitioner has with pregnancy-related care.
- If the chiro is certified in the Webster Technique, that is a good sign that they have put in extra time in the area of pregnancy care (but you don't have to rule out someone just because they don't.)
- A chiro can actually put things back in place. Even if the ligaments don't hold for long, it provides some relief. I saw a chiro though all of PG2 and it made a HUGE difference. I would feel some relief right after the adjustment, then increased soreness (like how muscles feel after a good workout), and then 1.5 days after the adjustment I would feel amazing. Not all adjustments took. Sometimes my body was just too loose and one of my ilia would torque right away. But, it did work most visits. I went one time per month early in the PG and moved to one time per week at the end.
- If you try one chiropractor and it isn't a fit, try another. The first guy I went to was clueless about pregnancy and asked it was healthy for me to lose five pounds in a week at five weeks postpartum. That was my clue to cancel my follow-up appointment.
- If your insurance doesn't cover alternative treatments or doesn't have a chiro who specializes in pregnancy, don't rule out paying out-of-pocket. The cost may not actually be much higher than a copay. Budgets and costs vary, but if $50 meant the difference between pain and relief, wouldn't that be worth skipping a dinner date or getting a used stroller instead of a new one to allow you to function for the next several weeks or months?
- When it comes to professionals, get a second, third, even fourth opinion. Chronic pain can make you very angry. You have the right to be angry, sad, and depressed and you also have the right to a caregiver who can help you. Even if you've never done anything but mainstream Western medicine, give something else a try: chiropractic, acupuncture, working with herbs and vitamins to help your body (Vitamin D, magnesium, and fish oil are all helpful when facing inflammation). You have everything to gain!
For me, being active was good my overall body, health, weight, etc. It was tough to find the balance of gentle activity vs. pain, but every woman's body will give her different cues on where the line falls.
- In PG1, I lived in relentless chronic pain until delivery. Although every, single step was a challenge, I chose to walk, work, etc. until baby was born at 40+ weeks. Walking was painful, but sitting or lying for too long also caused pain. So, it was mentally healthier for me to keep moving around and stay busy.
- In pelvic physical therapy (PT) between my pregnancies, I learned that though the pain can be intense with activity, it doesn't cause damage to my body unless I over-spread my legs (like with getting in and out of the car or bed and climbing things taller than stairs). In pregnancy 1, I was afraid of hurting my body through too much movement. With pregnancy 2, I felt empowered to stay active-and even grow in strength- knowing that movement was only good for me.
- Exercise comes into play with pelvic stability. Strong muscles in the thighs, stomach, and pelvis all help to hold the ligaments in place. Walking is nature's perfect exercise. Hold your abs in (like a string in pulling your belly button in) as much as possible when walking to support the lower back, also, practice Kegels while walking. This will help keep things strong down there.
- Swimming and soaking in the tub also feel great. Swimming and water walking are not advisable for all people with this, so talk to a professional and listen to your body. The resistance of the water can be too much for some people. In that case, my PT suggested treading water using the arms and not the legs for exercise. The flip-side is that swimming is incredible for strengthening the body. In my second pregnancy swimming was like magic. I stuck to flutter kicks (versus froggy-legs which spread the legs) and water-walking and it made a huge difference.
- The action of pushing, like with a stroller or heavy grocery cart, can make SPD pain intensify. If your children will be closely spaced, consider babywearing. I am an avid babywearer, so my muscles were strong enough to continue wearing my older son through PG2, which actually was easier on my body than holding him. I wore my older son until a few days before the birth, which served as weight-bearing exercise to keep me strong (and had other benefits).
- PG1 I slept on my side with a pillow between my knees, per my doctor. I think the pillow was too wide, as knees should be no more than hip-width apart.
- For PG2 I used a thick blanket when I slept on my side, but I slept on my back as long as possible. My midwife for PG2 was a proponent of back sleeping until my body told me not to.
- In PG1, I wore a Prenatal Cradle Plus V2. On desk workdays I skipped it because it was uncomfortable to sit in. For days at work when I was on my feet a lot (and on unyielding flooring of carpet over concrete slab) the belt was helpful.
- For PG2, I sometimes bound my hips with a woven wrap for babywearing (with or without the Prenatal Cradle under my clothes) because the wrap gets so much snugger and gives a custom fit.
- Mostly I did not bind at all in PG2. I would have the chiro get me back into place and then I use my natural strength to cope. In pelvic physical therapy between PG1 and PG2 the PT also encouraged not relying on a belt to allow the muscles to do the work. Conversely, my chiro saw no harm in recommending an SI belt sometimes, namely at night. So, obviously opinions vary.
- Your pain may vary based on flooring: the floors at my home are wood and springy and gentle on my body-especially when I wear shoes. At work, the concrete was unyielding and hard in me. Good shoes really help cushion things and keep the pain away for longer. I now exclusively wear Naot or Sanita shoes.
As you enter the late third trimester, be aware of baby's position in the uterus. SPD is associated with non-optimal fetal positioning which leads to a higher chance of c-section. You also influence baby's position, though. Spinning Babies has many tips for this.
Chiropractic adjustment (including that Webster technique I mentioned above) is helpful. Moxibustion (acupuncture) is also an option I tried. Some OBs will default to recommending a c-section for SPD, so ask many questions about your options because the other side of the camp is that unmedicated vaginal delivery is highly recommended for SPD. The unmedicated part is because you will remain aware of SP pain if spreading the legs and can adjust, and you preserve your ability to birth in a variety of ways (water birth, on all-fours, etc.). With an epidural, the typical birth position is flat on the back with feet in stirrups (or legs otherwise pulled apart) which can force over-spreading, and you can not feel the over-spreading which means you cannot adjust.
With PG2, an OB mentioned bed rest and a c-section because of SPD to me at just seven weeks pregnant! Needless to say, I switched to a delightful, supportive professional midwifery practice and had a lovely delivery despite the baby being occiput posterior (back of the head facing my back) well into pushing.
Encouragement & Resources
It is common in pregnancy to have pelvic loosening and feel it in the pubic symphysis or sacroiliac joints. It generally happens closer to delivery, but it happening earlier is not necessarily a sentence for bigger pain. It is very possible that the extent of discomfort that a woman feels earlier in pregnancy is as bad as it will get. If you are looking for more information, Relieving Pelvic Pain During and After Pregnancy: How Women Can Heal Chronic Pelvic Instability is the go-to book on this.
Additionally, this website has wonderful tips on keeping legs together when getting in and out of the car and bed, sitting when putting on pants, etc. are little things that make a big difference.
This is a version of a post originally published on More Green for Less Green, which includes more about the author's journey with this condition.
Top Image:Kjetil Kolbjornsrud/Shutterstock