Guidance for Mothers-to-be and New Mothers

Pelvic Girdle Pain and other common conditions in pregnancy

Your health carer has given you this leaflet to explain and provide advice about pelvic girdle pain (PGP) related to your pregnancy. The term PGP is used to describe pain experienced in the front and back of your pelvis (you may have previously heard the term symphysis pubis dysfunction [SPD] used; however, PGP is now the accepted name for this condition).

This leaflet has been written both by healthcare professionals who have cared for women with PGP and also by the women themselves. It will help you understand more about PGP, how you can adapt your lifestyle and how you can look after yourself.

There are sections relevant to your health during and after your pregnancy, as well as advice on giving birth and breast- or bottle feeding. 

Introduction

Pregnancy-related PGP is common.

The sooner it is identified and assessed, the better it can be managed.

Around 1 in 5 pregnant women experiences mild discomfort in the back    or front of the pelvis during pregnancy. If you have symptoms that do not improve within a week or two, or interfere with your normal day-to-day life, you may have PGP and should ask for help from your midwife, GP, physiotherapist or other health carer.

Women experience different  symptoms and these are more  severe in some women than others. If you understand how PGP may be caused, what treatment is available, and how you can help yourself, this may help to speed up your recovery, reducing the impact of PGP on your life.

A range of management options is avaliable to you, based on the type of PGP you are found to have.

What is PGP and how is it diagnosed?

PGP    describes    pain    in    the    joints    that    make    up    your    pelvic    girdle;    this    includes    the    symphysis    pubis    joint    (SPJ)    at    the    front    and/or    the    sacroiliac    joints    (SIJ)    at    the    back.

The discomfort is often felt over the pubic bone at the front, below your tummy, or across one side of your lower back, or both sides.

• A diagnosis of PGP can be reached based on certain signs and symptoms that you may experience during the pregnancy or afterwards. Having one or more of them may indicate the need for a physiotherapy assessment followed by advice on appropriate management.

• You    may    experience    pain    in    all    or    some    of    the    areas    shaded    in    the    diagrams    above.

You may also have:

• difficulty    walking
• pain    when    standing    on    one    leg    (e.g.    climbing    stairs,    dressing,    or    getting    in    or    out    of    the    bath)
• pain    and/or    difficulty    moving    your    legs    apart    (e.g.    getting    in    or    out    of    the    car)   
• clicking    or    grinding    in    the    pelvic    area    –    you    may    hear    or    feel    this  
• limited    or    painful    hip    movements    (e.g.    turning    over    in    bed)
• difficulty    lying    in    some    positions    (e.g.    on    your    back    or    side)
• pain    during    normal    activities    of    daily    life
• pain    and    difficulty    during    sexual    intercourse

With PGP, the degree of discomfort you are feeling may vary from being intermittent and irritating to being very wearing and upsetting.

Your doctor, midwife or physiotherapist should always listen to what you say in order to assess the cause of your symptoms and give you advice on how to best manage your symptoms. They will decide if you need further referral to a physiotherapist. Your signs and symptoms should not be dismissed as just ‘the normal aches and pains of pregnancy’. 

How many women get PGP?

This is a common condition affecting about 1 in 5 pregnant women:

• there    is    a    wide    range    of    symptoms,    and    in    some    women,    it    is    much    worse    than    in    others   
• having    some    symptoms    does    not    mean    you    are    automatically    going    to    get    worse
• if    you    get    the    right    advice    and/or    treatment    early    during    pregnancy,    it    can    usually    be    managed well: in some cases, the symptoms will go completely
• in    a    small    percentage    of    women,    PGP    may    persist    after    the    birth    of    your    baby.    Your    midwife or health visitor can refer you to a women’s health physiotherapist for a postnatal pelvic assessment.

What causes PGP?

Sometimes there is no obvious explanation for the cause of PGP. Usually, there is a combination of factors causing PGP including:

• the    pelvic    girdle    joints    moving    unevenly 
• a    change    in    the    activity    of    the    muscles    of    your    tummy,    pelvic    girdle,    hip    and    pelvic    floor,    which can lead to the pelvic girdle becoming less stable and therefore painful
• a    previous    fall    or    accident    that    has    damaged    your    pelvis
• a    small    number    of    women    may    have    pain    in    the    pelvic    joints    caused    by    hormones

Occasionally, the position of the baby may produce symptoms related to PGP.

 Risk factors 

Not    all    women    have    any    identifiable    risk    factors,    but    for    some,    the    following    physical    risks    may apply: 

• a    history    of    previous    low-back    and    pelvic    girdle    pain
• previous    injury    to    the    pelvis
• more    than    one    pregnancy
• a    hard    physical    job    or    workload/awkward    working    conditions/poor    working    postures 
• PGP    in    a    previous    pregnancy
• increased    body    weight    and    body    mass    index    before    and/or    by    the    end    of    pregnancy
• increased    mobility    of    other    joints    in    the    body

Factors not associated with PGP include:

• time since last pregnancy
• age and height
• the contraceptive pill
• smoking
• breastfeeding

Management 

To manage your PGP, you will need general advice (see Section 6a), and may need one or more of the following referrals:

• from    a    doctor    (or    midwife)    to    physiotherapy    for    assessment    of    your    pelvic    joints,    followed by treatment and advice on how to manage your condition 
• to    other    professions,    such    as    occupational    therapy,    for    equipment    to    help    you    to    manage better at home
• to    social    services    for    advice    on    benefits,    or    a    care    package    for    help    at    home,    if    you    have    severe symptoms
• to    the    GP    for    medication    for    pain    relief    Remember to;
• ask    for    help    early   
• ask    whether    you    can    have    your    hospital    appointments    on    the    same    day,    or    whether    your midwife is able to visit you at home. This will assist with day-to-day living, not necessarily with recovery

a. General advice

You should be given advice that is relevant to your current level of function in your daily life and your lifestyle. If your daily activities do not increase your pain, or if you have had some treatment and the pain is controlled, then some of the following advice may not apply.

During pregnancy, DO:

• Walk    in    supportive    footwear,    swing    arms    and    use    a    rucksack,    rather    than    a    handbag    for    symmetry    and    ease    of    movement.    If    walking    is    diffi    cult    and    painful,    try    altering    your    stride length and speed 
• Be    as    active    as    possible,    keeping    pain-free    and    avoiding    activities   
• Be    as    active    as    possible,    keeping    pain-free    and    avoiding    activities    that aggravate your pain
• Accept    help    when    you    need    it 
• Sit    down    to    get    dressed    and    undressed;    avoid    standing    on    one    leg
• Sit    down    to    get    dressed    and    undressed;    avoid    standing    on    one    leg
• Try    to    keep    your    knees    together    when    getting    in    and    out    of    the    car
• Place    a    pillow    between    your    knees    when    sleeping    on    your    side    (diagram), and when turning over, keep your knees together as much as possible 
• Try    getting    into    bed    or    turning    over    in    bed    via    hands    and    knees
• Do    your    pelvic    fl    oor    exercises    and    low    abdominal    exercises    as    advised by your physiotherapist.
• Swimming    may    help,    but    the    breaststroke    kick    may    aggravate    your pain
• Move    from    sitting    to    standing    symmetrically    (diagram)
• Take    the    stairs    one    at    a    time    (lead    with    your    less    painful    leg    when   
• Take    the    stairs    one    at    a    time    (lead    with    your    less    painful    leg    when    going upstairs, and downstairs, lead with the more painful leg) going upstairs, and downstairs, lead with the more painful leg)
• Use    a    small    rucksack    to    carry    things    if    you    need    to    use    crutches
• Use    a    small    rucksack    to    carry    things    if    you    need    to    use    crutches
• Consider    alternative    positions    for    sexual    intercourse    such    as 
• Consider    alternative    positions    for    sexual    intercourse    such    as    side-lying or kneeling on all fours

Where possible, avoid activities that make the pain worse, which may include:

• standing    on    one    leg
• bending    and    twisting    to    lift,    or    carrying    a    toddler    or    baby   
• bending    and    twisting    to    lift,    or    carrying    a    toddler    or    baby    on one hip
• crossing    your    legs
• sitting    on    the    floor
• sitting    twisted
• sitting    or    standing    for    long    periods
• lifting    heavy    weights    (e.g.    shopping    bags,    wet    washing,    vacuum    cleaners    and    toddlers)
• vacuuming
• pushing    heavy    objects    like    supermarket    trolleys
• carrying    anything    in    only    one    hand    

Don’t take up any new high-impact sporting activity

This is not an exhaustive list. 

b. Physiotherapy

The advice and exercises on the previous page may help your symptoms effectively, but some women will need a one-to-one assessment with a physiotherapist. A physiotherapist assesses the effect PGP has on your whole body, your family and your lifestyle, and offers a range of treatment options and advice.

Assessment will include: 

• careful    examination    of    your    pelvic,    back    and    hip    joints,    and    the    muscles    around    them,    looking    at    how    the    joints    move,    and    whether    the    muscles    are    strong    enough    to    support    your pelvis and spine 
• looking    at    how    well    you    move    and    carry    out    everyday    activities

Treatment

The physiotherapist will discuss the plan for treatment with you. Physiotherapy treatment aims    to    improve    your    spinal    and    pelvic    joint    position    and    stability,    relieve    pain,    and    improve    muscle function.

Treatment may include:

• advice,    including:
• back    care 
• lifting   
• suggested    positions    for    labour    and    birth   
• looking    after    your    baby    and    any    toddlers
• positions    for    sexual    intercourse
• exercises to retrain and strengthen your stomach, back, pelvic floor and hip muscles
• manual therapy    to    make    sure    your    spinal,    pelvic    and    hip    joints    are    moving    normally, or to correct their movement.
• other types of pain relief such as acupuncture or transcutaneous electrical nerve stimulation (TENS)
• exercises in water
• provision of equipment (if necessary after individual assessment), such as pelvic girdle support belts and walking aids to be used as directed by your physiotherapist.

How often will you need treatment?

• Your    physiotherapist    will    see    you    during    the    pregnancy    as    necessary.    For    some    women,    the pain gets completely better and no more treatment is needed.
• Not    everybody    responds    completely    to    physiotherapy,    and    you    may    need    repeated    visits    for further reassessment and treatment to keep your pain under control.
• You    should    continue    to    heed    any    advice    given    to    you    by    the    physiotherapist,    and    if    you    have been prescribed exercises as part of your treatment, then these should be carried out regularly.
• Treatment    should    continue    after    you    have    had    your    baby    if    the    pain    persists.    It    is    important to tell your physiotherapist if you feel you have not made a full recovery, and discuss the options for further treatment.

If    an    NHS    physiotherapist    is    not    available    quickly,    you    may    wish    to    see    a    private    physiotherapist (see Section 12) or other professional, including an osteopath, chiropractor, or acupuncturist, who has training and experience in treating PGP. You should check that your    therapist    is    appropriately    qualified    to    deal    with    pregnancy-related    PGP,    and    holds    the    relevant    professional    qualifications.

c. Exercise and sport

Avoid any activity that increases your pelvic girdle pain.

Emotional effects of PGP 

The    discomfort    of    PGP    and    diffi    culty    with    normal    activities    may    make    you    feel    low. Seeking help and advice as early as possible will help your pain, but if you are experiencing any emotional effects of PGP, help and support are available from the medical team looking after you. Do ask.

Labour and birth 

Most women with PGP can have a normal vaginal birth

• Many    women    worry    that    the    pain    will    be    worse    if    they    have    to    go    through    labour.    This    is    not    usually    the    case    when    good    care    is    taken    to    protect    the    pelvic    joints    from    further strain or trauma. You should be able to choose your place of birth as you wish, including birthing centre or home birth options.
• Most    women    with    PGP    manage    to    have    a    normal    delivery    and    a    Caesarean    section    is    not    normally recommended. However, you should discuss this with your midwife or doctor.

Before labour:

• Think    about    and    practice    moving    between    positions    that    are    comfortable for you
• Record    them    in    your    birth    plan    and    discuss    with    your    birthing    partner    and/or    midwife 
• Labour    and    birth    in    water    may    be    appropriate    and    comfortable for you
• Discuss    coping    strategies    with    your    physiotherapist

During labour: 

Use    gravity    to    help    the    baby    to    move    downwards    by   staying    as    upright as possible:

• kneeling
• on all-fours
• standing    

These positions can help labour to progress and avoid further strain on your pelvis.

• try    to    avoid    lying    on    your    back    or    sitting    propped    up on the bed - these positions reduce the pelvic opening and may slow labour
• the    squatting    position    and    birthing    stool    may    be    uncomfortable positions for labour
• moving    between    positions,    and    positions    of    symmetry are often most comfortable

Discuss with your midwife and try these gravity-assisted positions instead of lying on your back or sitting.

Pain-free range of movement

Some    women    have    diffi    culty    or    pain    moving    their    legs    apart.    You    may    fi    nd    that,    following    physiotherapy treatment, you are able to open your legs further. However, if you still have some    restriction    while    pregnant    and/or    after    labour    has    started,    your    physiotherapist,    midwife or birthing partner should measure how far apart your knees can separate without pain (your pain-free range) when lying on your back, or sitting on the edge of a chair with your feet apart. You should take care to keep your legs within your pain-free range of movement    as    much    as    possible    during    labour    and    birth    to    protect    your    joints,    particularly    if    you have an epidural or spinal block. However, in a minority of births it may be necessary to move your legs wider apart in order to deliver your baby safely.

Assisted deliveries (forceps and ventouse)

Where you need forceps, ventouse delivery or stitching in the lithotomy position (i.e. feet up in stirrups), care should be taken by the midwives and doctors to lift both legs up at the same time, and to keep the distance apart within your pain-free range. 

After you have had your baby

If    you    have    pain    or    diffi    culty    moving    after    the    birth    of    your    baby,    do    tell    your    midwife.    

Be    aware    that:

• medication    to    relieve    pain    may    cover    up    the    discomfort    of    your    PGP,    so    be    very    careful about doing things that were painful before you had your baby until after you have stopped taking your painkillers
• you    should    be    referred    to    a    physiotherapist    for    early    assessment    and    treatment    if    you still have PGP pain or are still needing to take painkillers 

After you have had your baby you may need extra help with personal care and caring for your baby. Ask your hospital or community if any extra help is available.

a. Feeding and caring for baby

Feeding:

• When    possible,    sit    in    a    fi    rm    but    comfortable    chair    to    feed your baby.
• Make    sure    your    back    is    well    supported;    placing    a    small,    rolled    towel behind your lower back helps.
• Ensure    your    feet    are    supported    and    fl    at    on    the    floor.
• Stopping    breastfeeding    will    not    speed    up    recovery    of    PGP.
• Change nappies on a surface at waist height.
• Carry    your    baby    in    front    of    you;    do    not    carry    your    baby    on one hip.
• Kneel at the bath side rather than leaning over.
• Lower the cot side when lifting or lowering your baby.
• Keep    your    baby    close    to    you    when    moving    him/her    in    and out of a car seat.
• If you have to carry your baby in the car seat, hold it in front of    you,    not    on    your    hip,    or    put    it    on    a    wheeled    frame/buggy. of    you,    not    on    your    hip,    or    put    it    on    a    wheeled    frame/buggy.
• Do not lift your baby in and out of high shopping trolleys.
• Do your pelvic floor muscle exercises daily.

b. Emotional well-being

It is important that your partner, family, friends and hospital staff give you as much support as possible while you are in hospital and when you get home. This will speed up your recovery and hopefully prevent problems from developing.

Remember:

• if    PGP    persists    after    your    baby    is    born,    it    is    important    that    you    discuss    its    impact    with    your    partner    (and/or    your    family).    In    particular,    you    should    discuss    how    best    to    care    for    your    baby/toddler    and    how    much    help    you    need   
• if    you    are    feeling    low,    it    is    important    to    ask    for    help    from    your    GP,    midwife    or    health    visitor    as    they    may    help    you    to    recover    more    quickly    

c. Physiotherapy referral

You can:

• ask    to    resume    physiotherapy    as    soon    as    you    feel    able    to    attend
• have    a    physiotherapy    reassessment    of    your    spine    and    pelvis,    and    start    treatment    as    needed

d. Sexual intercourse  

• You    may    be    able    to    avoid    discomfort    during    sexual    intercourse    by    considering    alternative positions or other ways to be sexually intimate.
• There    are    sometimes    other    reasons    for    discomfort,    such    as    scarring    from    stitches,    so    if    you are concerned, talk to your midwife, doctor, health visitor or physiotherapist. You may    fi    nd    that    using    a    vaginal    lubricant    might    help.
• Stitches    should    not    be    painful    after    the    fi    rst    few    weeks,    but    if    they    are,    do    not    hesitate    to ask for help.

e. Menstruation

•  A    minority    of    women    report    a    return    of    PGP    symptoms    when    their    monthly    period    returns. For some, this may get better after a couple of months, but for others, it continues. The degree of pain varies considerably.

If this happens to you, you should ask for another assessment of your pelvis. You can take pain relief as necessary.

f. Exercise and sport

• doing    your    pelvic    floor    muscle    exercises    every    day
• keep    up    the    exercises    given    to    you    in    hospital 
• continue    the    gentle    abdominal/tummy    (and    hip)    exercises    given    to    you    by    your    physiotherapist when you were pregnant 
• after    your    baby    is    born,    continue    to    be    careful    when    exercising    until    you    are   symptom-free
• avoid    high-impact    activity,    such    as    aerobics,    for    a    few    months
• avoid    any    activity    that    brings    back    the    pain

Planning your next pregnancy

• Some    women    may    experience    PGP    again    during    their    next    pregnancy.    However,    the    symptoms may not be as severe, especially if it is well managed. 
• Between    pregnancies,    you    should    ensure    that    you    continue    with    the    exercises    given    to    you    by    your    physiotherapist;    in    particular,    pelvic    floor,    abdominal/tummy    and    hip    exercises. 
• If    you    are    considering    a    further    pregnancy    or    if    you    are    pregnant    again,    it    is    worth    asking    your GP if a referral to a physiotherapist is available. If it is, then the physiotherapist can check    your    pelvic    joints    and    make    sure    you    are    as    fit    as    possible    for    another    pregnancy.

There is no particular advantage in leaving a long gap between babies, although some abdominal muscles may not have recovered fully 12 months after the birth of your baby. 

• It is worth considering whether your toddler will be able to walk while you are pregnant in order to reduce the strain on your joints if you do have pain during future pregnancy.
• It might be worth becoming fully fit, losing excess weight and reducing the symptoms of PGP before considering another pregnancy.

Further investigations 

Further investigations should be considered if your symptoms do not improve once the baby is born and after physiotherapy treatment. These may include ‘stork’ X-rays (special X-rays to    show    whether    there    is    any    movement    at    the    pubic    joint),    or    MRI    or    ultrasound    imaging.    There is no recommended time-scale for this, but if you are concerned, talk to your GP.

Remember that:

• is    common,    but    not    normal,    to    have    PGP    in    pregnancy
• every    woman    is    different
• PGP    is    a    treatable    and    manageable    condition 
•   with    a    team    of    health    workers    giving    you    the    information,    advice    and    treatment    you need, your discomfor may be less severe.

As for help as early as possible.

Other common conditions

As well as PGP there are other relatively common uncomfortable symptoms that you may experience during and after pregnancy. Usually, with good advice and education, these symptoms can be kept to a minimum and managed well.

However, if symptoms persist, or you feel like they are affecting your daily activities, then do seek advice and referral to a women’s However, if symptoms persist, or you feel like they are affecting your daily activities, then do seek advice and referral to a women’s health physiotherapist

a. Postnatal backache

A new baby brings new postural challenges to your daily life. This, accompanied by the muscular and hormonal changes that occurred during pregnancy, can sometimes lead to upper    and    lower    backache    during the first few postnatal months.

Usually, these symptoms are uncomplicated, and can be reduced or even eliminated with good postural awareness.

When sitting and feeding your baby, prepare your seating arrangements whenever possible. Position your bottom far back in the chair, and When sitting and feeding your baby, prepare your seating arrangements whenever possible. Position your bottom far back in the chair, and place a small cushion or rolled up towel into the small of your back. You can lean back and your upper back is then also in good postural alignment. It can also help if baby is supported on a pillow on your knee, so that you are able to keep your shoulders back while feeding baby. a pillow on your knee, so that you are able to keep your shoulders back while feeding baby.

When changing your baby, the safe use of a changing table can When changing your baby, the safe use of a changing table can be helpful to avoid low back pain. Curving the spine into fl exion be helpful to avoid low back pain. Curving the spine into fl exion unduly    loads    the    spine    and    back    muscles,    which    can    quickly    cause    unduly    loads    the    spine    and    back    muscles,    which    can    quickly    cause    unduly    loads    the    spine    and    back    muscles,    which    can    quickly    cause    backache.

When    leaning    forwards    over    baby,    try    to    think    about    hinging    from    your    hip    joints    and    gently drawing your tummy button towards your spine. This helps to engage the core muscles that help to support the spine. This posture should also be adopted when lifting baby out of a cot, and as much as possible, when bathing baby.

Other activities that may contribute to postnatal backache are:

• pram    handles    being    too    low    so    that    you    have    to    be    in    a    bent    position    to    walk  
• front    baby    carriers    being    positioned    too    low    and    putting    a    strain    on    the    shoulders
• always    carrying    baby    on    the    same    side

If your backache is persistent and does not settle by correcting your posture, you should speak to your health visitor or midwife, and be referred to a physiotherapist.

The physiotherapist will assess your back pain, advise you regarding helpful exercises and treat your symptoms if necessary.

b. Diastasis rectus abdominis

The rectus abdominis (6-pack muscle) runs down the front of the abdomen. It has two muscle bellies that sit close together, attached to a muscle bellies that sit close together, attached to a fibrous    band    (the linea alba).

During pregnancy, the linea alba becomes thinner, stretches and the muscle bellies move apart to accommodate the growing bump. This increased gap (inter-recti distance) is termed diastasis rectus abdominis (DRA or RAD).

It is very common in pregnancy, (>60% in the 3rd trimester) and can continue postnatally. It is associated with repeated heavy lifting (including childcare), being older, and is much more common in women who do not exercise before, or during, pregnancy.

Symptoms

A    gap    of    around    2    finger-widths    at    the    belly    button    is    considered    to    be    normal.    But    even    more important is whether the muscles can activate well.

The muscles need to be strong enough to help control movement around the pelvis and back to contribute to posture and breathing, and provide abdominal organ support.

With    a    DRA,    you    may    experience    bulging/doming,    or    sagging,    of    the    muscles    when    straining or using your abdominals, such as when sitting up, getting out of bed or lifting the baby. Some women experience stomach or back pain, or pelvic floor problems.

Treatment

Regular exercise can reduce the risk of developing a DRA. For women with uncomplicated pregnancies, 150 minutes per week of moderate exercise is recommended.

Your    physiotherapist    will    also    advise    you    on    specifi    c    core    and    abdominal    exercises    to    strengthen your pelvic fl oor, and appropriate control of the core muscles.

Some    improvement    naturally    occurs    in    the    first    8    weeks    following    delivery.    The    focus    postnatally should also be on activation of the pelvic fl oor and core muscles.

Exercises such as sit-ups, planks and high-impact exercises need to be avoided initially. Also avoid any activities that increase abdominal pressure, or cause doming of the abdominals, such as straining with constipation and repeated heavy lifting.

For some women, compression such as a tubigrip or belly band can help in the early stages, but seek the advice of a physiotherapist regarding this.

c. Carpal tunnel syndrome

The carpal tunnel is an inelastic structure located at the level of the wrist.

Many    tendons    which    move    the    thumb    and    fingers    pass    through    this    carpal    tunnel    on    their    way to the hand. A nerve called the median nerve also sits in this tunnel with the tendons, so there is very little room.

The    nerve    is    responsible    for    giving    you    feeling    in    the    thumb    and    fingers,    and    also    makes    the tendons work properly.

Hormone changes during pregnancy can cause swelling in many parts of your body including the wrist and carpal tunnel.

Any swelling will increase the pressure on the median nerve inside the tunnel. This pressure on the nerve causes the symptoms known as carpal tunnel syndrome. Symptoms are    most    likely    to    occur    from    the    fifth    or    sixth    month    of    pregnancy.

You may feel one or more of the following symptoms:

• pain,    pins    and    needles,    numbness    or    burning    in    the    thumb,    index    middle    or    ring    fingers
• tingling    or    numbness    of    your    entire    hand
• weakness    in    the    hand    and    forearm
• pain    that    shoots    from    your    hands    up    the    arm    as    far    as    the    shoulder
• your    symptoms    are    worse    at    night    or    first    thing    in    the    morning
• you    may    drop    objects
• you    may    have    trouble    performing    dextrous    tasks    such    as    writing    because    of    reduced    grip
• hands    are    swollen,    hot    and    sweaty

Self-management of carpal tunnel syndrome

1. Elevate    your    arms    with    pillows    or    cushions    when    lying    or    sitting    down    –    this    can    help to reduce swelling in the tunnel.

2. Apply ice cubes wrapped in a wet tea towel to the front of your wrist for 10-15 minutes, 3-4 times each day. Do not use ice if you can not tell the difference between hot and cold.

3. Speak to your pharmacist about medication that may help your pain but is safe to take throughout pregnancy.

4. Wear a wrist splint, if supplied by your physiotherapist. Always ensure the metal bar is flat and follow your physiotherapist’s instructions for when and for how long you should use it.

5. Try to keep wrists in a neutral position when undertaking activities of daily living such as writing, eating and washing.

6. Try to limit repetitive activities such as typing or writing for long periods.

7. Avoid any heavy lifting as this will cause the tendons to swell and further reduce space within the carpal tunnel.

8. Avoid placing hands in hot water as this will further increase inflammation.

9. Pace yourself with hand actions or positions that make your symptoms worse (e.g. ironing, driving).

Carpal tunnel syndrome usually improves after your pregnancy ends.

If you do continue to have problems after you have had your baby, contact your physiotherapist or GP for further advice.

d. Varicose veins

Varicose veins are usually caused by weak vein walls and valves. This causes the veins to swell and enlarge, and usually occurs in the legs. The veins may appear blue or dark purple, and are often lumpy or bulging.

Other symptoms include: 

• aching,    heavy    and    uncomfortable    legs
• swelling    in    the    feet    and/or    ankles 
• burning    or    throbbing    in    your    legs
• muscle    cramp    in    your    legs,    particularly    at    night
• dry,    itchy    and    thin    skin    over    the    affected    vein

How do they occur?

Sometimes the walls of the veins become stretched and lose their elasticity, causing the valves to weaken.

If the valves don’t function properly, blood can collect in your veins, which become swollen and enlarged, causing the varicose veins.

During pregnancy, the amount of blood increases to help support the developing baby. This puts extra strain on your veins.

Increased hormone levels during pregnancy also cause the muscular walls of the blood vessels to relax, which also increases your risk.

Vulval varicose veins may also develop as the womb begins to grow and puts increased pressure on veins in the pelvic area.

Although being pregnant can increase your risk of developing varicose veins, most women find    that    their    veins    significantly improve after    the baby is born.

Varicose    veins    are    rarely    a    serious    condition    and    they    don’t    usually    require    treatment.

However, speak to your midwife, GP or obstetrician if:

• your    varicose    veins    are    causing    you    pain    or    discomfort
• the    skin    over    your    veins    is    sore    and    irritated 
• the    aching    in    your    legs    is    causing    irritation    at    night    and    disturbing    your    sleep

How can I prevent and ease varicose veins?

• Use    compression    stockings:    discuss    with    your    midwife,    doctor    or    obstetrician    beforehand.
• Exercise    regularly.
• Avoid    standing    up    for    long    periods. 
• Elevate    the    affected    area    when    resting.

Information taken from NHS choices  -  see    https://www.nhs.uk/conditions/varicose-veins/ for more information.

Websites and contact details

• Pelvic,    Obstetric    and    Gynaecological    Physiotherapy    (POGP)    -    pogp.csp.org.uk   
• Pelvic    Partnership    -    pelvicpartnership.org.uk   
• Chartered    Society    of    Physiotherapy    (CSP)    -    www.csp.org.uk;    tel.    020    7366    6666
• Manipulation    Association    of    Chartered    Physiotherapists    (MACP)    - macpweb.org
• Organisation    of    Chartered    Physiotherapists    in    Private    Practice    (OCPPP)    - www.physiofirst.org.uk
• Acupuncture    Association    of    Chartered    Physiotherapists    (AACP)    -    www.aacp.org.uk
• The    British    Medical    Acupuncture    Society    -    www.medical-acupuncture.co.uk

With help, the woman should not become disabled during pregnancy, but if she does, the following website offers practical advice and support:

• Disability,    Pregnancy    and    Parenthood    International    -    www.disabledparent.org.uk