1. Overview of the Spine in Pregnancy
We see lots of patients who are concerned about how their spines will hold up during pregnancy. For some, previous problems have made them wary before they become pregnant, for others their problems present for the first time in pregnancy. The overall advice is very reassuring. There is no reason why most people with pre-existing spinal problems can’t successfully manage during pregnancy, labour and delivery, although a few may require specialist input. In addition, contrary to popular belief, not everyone who becomes pregnant gets back pain – indeed, some people’s back pain actually improves during pregnancy.
Firstly, to dispel a few myths…
- “I am pregnant, therefore I will get back pain” – this doesn’t necessarily happen
- “If I have pre-existing spinal problems they will get worse during pregnancy” – this is often not the case
- “All I can take for pain relief during pregnancy is paracetamol” – there are other options, under your doctor’s advice as well as non-pharmacological options
- “Physiotherapy and massage type treatments aren’t safe during pregnancy as they might cause early labour” – there are lots of non-pharmacological treatments for spinal problems in pregnancy and as long as you see a practitioner who is used to treating pregnant women then manual therapy approaches are safe
- “I can’t have an epidural for pain relief during labour if I have had previous spinal surgery” – this is rarely the case.
And some top tips to get you started…
- Exercise is good for spines during pregnancy, just like when you are not pregnant; if you are used to exercising then stick to what you know but adapt what you do according to how you feel. You’ll need to reduce the intensity and impact as you progress through your pregnancy.
- If you are not used to exercising then it’s not too late to start; regular walking is a first option (start with 10 minutes at a time, walking at an intensity that leaves you slightly out of breath and build up to 30 minutes, five times a week), as is swimming (watch out for breaststroke in your third trimester as it can aggravate symphyseal pubis dysfunction)
- For more detailed advice about exercise in pregnancy see here and if you are not sure about how to exercise safely during pregnancy then do make an appointment to us
- Pilates and yoga can be useful forms of exercise to help you prepare for labour and delivery, as well helping you to look after your spine during pregnancy. However, make sure you go to an instructor who specialises in pregnancy as the exercises are often modified from standard classes.
2. Pregnancy & The Thoraco-Lumbar Spine (Lower Back) and Pelvis
Why may back pain occur in pregnancy?
There are many reasons why back pain may occur in pregnancy, just as back pain is a multifactorial condition in the rest of the population. However, there are two contributing factors which are unique to pregnancy; change in posture and weight, and change in ligamentous laxity. The body produces hormones which soften the ligaments allowing your uterus room to expand and for your pelvis to open slightly, preparing for the passage of your baby through the birth canal. In addition to these softened ligaments, the load which they need to support gradually increases – most women put on around 12-14kg during pregnancy. This increase in load tends to increase your lordosis (the natural curve in your lower back) putting more pressure on the structures at the back of your spine and on your pubic symphysis (the joint at the front of your pelvis). These two factors, either individually or in combination, can relate in an increased incidence of back and pelvic pain.
In addition, you may find your thoracic spine (upper back) stiffens up in compensation; this is a kind of ‘protective’ mechanism where your body tries to take the load off the lumbar spine. Unfortunately, this tends to create pain and aching in your upper back and doesn’t actually help the lumbar spine. As you may imagine, what is more helpful, is to keep the thoracic spine mobile so the lumbar spine doesn’t have to move so much. If you have bad morning sickness and spend much of your first trimester (or longer!) curled up on the sofa this also increases thoracic stiffness.
As your baby starts to grow, you may also experience rib pain; sometimes from kicking, other times from the more sustained pressure of your expanding uterus. Rib pain is also exacerbated by thoracic stiffness.
Of course, there are other causes of back pain in pregnancy (like disc prolapses) but these aren’t much more likely to occur than they are in the non-pregnant population.
Prevention of back pain in pregnancy
The description above might sound a bit depressing – like back pain is an inevitability; it really isn’t and there is lots you can do to keep your spine healthy during pregnancy. If you are fit and active before you become pregnant then you will have better muscle support for your spine (which helps to compensate for the laxity in your ligaments). Any form of regular exercise is good and it’s even better if you mix it up a bit eg some aerobic exercise (walking, cross-trainer, rowing, cycling, swimming), along with workouts that help build strength, flexibility and core stability (pilates, yoga, specifically designed circuits in the gym). So if you are planning to get pregnant and aren’t exercising regularly, this is probably the single best thing you can do to help prepare your spine (and exercise has lots of other benefits for pregnancy too, see our article on ‘Exercise in Pregnancy’).
Once you are pregnant, try and maintain some regular exercise. You may not feel like much during the first trimester due to sickness and tiredness – that’s fine – just do what you can. If you’re pretty much bed-bound due to sickness then make sure you change position regularly and spend some time sitting more upright. You can see a physiotherapist for advice about stretches to help maintain your spinal mobility during this time and they can also give you soft tissue treatment to release any spinal tightness. As soon as you start to feel better then get out for some short walks and gradually build back up to being more active. In general, if you are used to exercising then most exercise is safe (and beneficial) to continue during pregnancy, certainly for the first and second trimesters. There are a few exemptions and times to be cautious; for more information see our article on ‘Exercise in Pregnancy’. If you aren’t used to exercising, then it’s still safe to start but build up gradually and avoid high impact activities like running. Good exercises for during pregnancy (especially if you aren’t used to exercising) are; walking, cross-trainer, swimming, pilates and yoga.
Importantly, if you manage to exercise regularly during your pregnancy this may help to prevent excessive weight gain and further limit the extra loading on your spine.
3. Managing Back and Neck Pain in Pregnancy
What is safe to take or try myself?
In terms of painkillers, paracetamol is absolutely safe to take in pregnancy (as per the dosing instructions on the packet). Other painkillers can be taken but you should talk to your doctor about what might be safe for you as it varies depending on your stage of pregnancy and the severity of your symptoms.
Non-drug treatments that may be useful are:
- Warm bath (not too hot: remember that if you are feeling uncomfortably hot in the bath then your baby will be even more warm so don’t stay in if this is the case). A hot water bottle or wheat packs (link to shop item) placed over the sore area can be helpful.
- Swimming or walking in the water – helps you to mobilise stiff areas and to take the load of your joints and ligaments as most of your body weight is supported by the water.
- Self-massage or asking your partner to gently massage the aching area.
- Specialist pregnancy pilates or yoga classes.
Another useful option for some women is an SIJ belt. This is special support belt that helps to offload the sacro-iliac joints, helping with pelvic pains (at the back and the front). However, it is best to see a specialist physiotherapist before considering one of these are there are different types and they need to be specific to your needs. They work best in combination with other treatment and exercises.
When should I see a specialist?
If your pain persists more than a few days, or is severe, or if the above first aid measures aren’t helping then you should seek further advice. A good place to start is with a physiotherapist that specialises in the care of pregnant women. The physiotherapist will ask you lots of questions and examine to see what is causing your pain. They may do some hands on ‘manual’ treatment to release stiff joints and muscle spasm and will probably give you some exercises to do to help support your back. Some physiotherapists may also use acupuncture or ‘dry needling’ type techniques.
Alternatively, or again, if things aren’t improving after a few treatments, then you may want to see a specialist spinal doctor. All of us here at Spine Surgery London are used to treating women in pregnancy and you can make an appointment here. Sometimes we will arrange a scan to help with the diagnosis, but we will make sure any investigations are safe for you and your baby. Physiotherapy treatment helps in the vast majority of cases, but occasionally if the symptoms are severe then we have to think about other treatment. This may be stronger painkillers, injections and, very occasionally, operations. These can be undertaken safely in women who are pregnant but obviously this will only be done if there is no other option and after careful discussion between you, your spinal specialist and your obstetrician.
The take home message should be that even if you do develop neck or back pain whilst pregnant, there is lots that can be done to help you without putting your baby at risk.
Advice for those with previous spinal problems
Often patients we see with spinal problems express concern that their symptoms will become worse if they get pregnant and commonly ask if they should put off trying to get pregnant until their back pain improves. The answer to this is almost always ‘no’. There can be enough challenges to getting pregnant sometimes without adding in needing to have a painfree spine as well. So, unless you are needing to take regular strong painkillers or anti-inflammatories to control your symptoms or you have been recommended to have surgery, then there is no reason why you shouldn’t crack on! The advice about preventing back pain in pregnancy is just as relevant too. Of course, if you are worried, do come and speak to one of us and we will give you more individualised advice.
4. Spine in Labour
Preparing your spine and pelvis for pregnancy
By following the advice on how to prevent neck and back pain you are already most of the way to there! By maintaining your fitness as well the physical demands that labour presents will hopefully be a bit easier to cope with too.
In addition, all pregnant women will benefit from pelvic floor exercises – started during pregnancy and continued on afterwards. The pelvic floor is formed from a group of muscles that separate the pelvic cavity from the perineal area. The muscles create a sling between the coccyx (sitting bone) and pubic bone and play an important role both in the birth process and in both urinary and faecal continence.
How to manage back and pelvic pain during labour
Many women, especially first time mums, are anxious about how they are going to cope with pain during childbirth and any potential exacerbation of their spinal and pelvic pains. The pain relief options for your back pain are the same as for labour pains. Below are some examples you may want to consider but it is not an exhaustive list so do discuss your options with your midwife and specialists if you are concerned. The last thing to say is that although after reading this you may feel you know exactly what you would like try to stay flexible (in your mind!) as childbirth is unpredictable and sometimes plans have to change.
During labour and delivery there are lots of different positions you can try to see which is more comfortable. Remember your preferred position may change as labour progresses. Usually women find it easier if they stay upright and active rather than lying flat. A few examples of positions are; sitting on a gym ball, squatting, leaning forward onto a bed or table or being on all fours.
- Relaxation aids
Staying calm is key to managing birth pain, as anxiety will tend to tense up the body further. With this in mind, some women use aromatherapy, massage, hypnotherapy and meditation, often in conjunction with more formal pain relief, to help manage their labour.
A water birth is another option as the warmth and buoyancy of the water can help the mother relax and move around a bit. They are common among women who choose home births as small birth pools can easily be set up in the living room, but most hospitals will now have several pools available to labouring women.
An electrical current or, to use its full name, transcutaneous electrical nerve stimulation (TENS), can also help. A TENS machine is easy to use. You tape small electrodes on to your back and administer the currents as and when you feel you need them. The theory is that the currents encourage your body to produce endorphins, which are its own natural painkillers. There are no known side effects for the mother or the baby, but consensus is that TENS is only really effective in the early, less painful stage of labour.
- Gas and air
Gas and air, a mixture of nitrous oxide and oxygen, doesn't so much cut the pain as help you to relax and disassociate from it. You breathe in through a mouthpiece as a contraction starts and, all being well, zone out a little as it reaches its peak. It can make some women feel a little sick or sleepy, but is safe for the baby.
- Injected Painkillers
Injectable analgaesics such as pethidine are also commonly used. They are effective and safe but can cause some nausea or vomiting.
For those women who want to feel nothing or as close to nothing as possible, an epidural is the only real option. A small tube is inserted into your back and a local anaesthetic is delivered to the nerves that carry pain messages from the womb to the brain. For women significant pelvic or back pain prior to labour it can be useful to consider.
Epidurals after previous spinal surgery
There is a myth that women that have had previous spinal surgery are unable to have epidurals. This is rarely the case. The only real contraindication to having an epidural is that you don’t want one! If you have had previous surgery it is worth knowing exactly what it is and discussing this with the anaesthetist. Very occasionally it can be a little trickier to place but in the vast majority of cases it is no different to someone who has not had surgery.
5. Spine After Delivery
When does the spine return to ‘normal’?
It takes about 6 weeks for the body to return somewhat towards ‘normality’ after pregnancy and delivery. However, this timeframe can be affected by the method of delivery, whether you breast feed and how much weight you gained. After a vaginal delivery the soft tissues around the pelvis which form part of the stabilising mechanism for the low back are further stretched which can contribute to back pain. This is why vigorous exercise during the first 6 weeks is best avoided – until everything has started to ‘tighten up’. If you are breast feeding then the hormones produced continue to maintain some ligamentous laxity – though your back and pelvis will be more stable than they were during pregnancy. Following a caesarean-section, it’s your stomach muscles that will be temporarily compromised. Again, it takes around 6 to 12 weeks to recover from a c-section but whether you delivery vaginally or via c-section, the muscles in relevant area will need some attention to re-strengthen afterwards. Lastly, the weight gained during pregnancy and carrying around your baby will also increase the load on your spine. Most women will say that, in reality, it is somewhere between 6 to 12 months before there body really feels ‘normal’ again.
How to manage back pain after delivery
Unless you have severe pain (which is unlikely), this will probably be the last thing on your mind, at least for the first few weeks. Initially focusing on pelvic floor exercises and getting out for short walks with you baby every day (either in a carrier or a pram) is the best starting point. If your pain doesn’t start to improve as you become more active and your body starts to feel more normal then see your physiotherapist or a spinal specialist.
6. When to seek urgent attention
Very occasionally, serous spinal problems such as cauda equine syndrome, can develop during pregnancy just as they can in anyone with back pain. You can find out more about cauda equina syndrome here.
Symptoms of cauda equine syndrome:
- Severe and worsening sciatic pain in both legs
- Numbness or tingling in both legs or over a wide area of one leg
- Weakness in one leg that is worsening or weakness in both legs
- Numbness around the buttock and perineal area (the bits you sit on)
- Loss of control of your bladder or bowel function – this may take the form of incontinence or being unable to open your bowels or pass urine.
If you experience any of the following symptoms you should seek urgent medical attention via A+E if necessary.
This information is based on a series of articles originally written with my colleague Dr Polly Baker who is a Consultant in Sport and Exercise Medicine in Brighton.