Symphysiolysis is pain in the area of the pubic symphysis during pregnancy and after childbirth, with or without evidence of separation (diastasis) of the pubic bone. Pain in the symphysis represents a major problem for some pregnant women (Depledge et al., 2005). Findings show that the width of the symphysis diastasis does not coincide with the clinical picture of this syndrome (Lebel et al., 2010). Due to the high concentration of progesterone and relaxin in pregnancy, the ligaments in the pelvis physiologically soften, naturally preparing the birth canal for delivery. Severe pain in the pelvic girdle that occurs during pregnancy or labor and causes functional limitations requires special attention from healthcare professionals (Pires et al., 2015). Wellock and Crichton (2007) presented the interactions between healthcare professionals and pregnant or postpartum women with symphysis dysfunction in their article. The purpose of the study, which took place between March 2003 and February 2005 in a maternity hospital in northwest England, was to determine women’s experiences with healthcare professionals when diagnosing symphysis dysfunction. Interviews were conducted with 28 women at the time of diagnosis, at 36 weeks of pregnancy, and 6 weeks after birth. The focus was on the midwife, doctor, and physiotherapist. In all cases, the women expressed both positive and negative opinions. Most were bothered by the underestimation of pain and the lack of an empathetic approach by all the listed healthcare professionals. Most agreed with the statement that symphysis dysfunction profoundly affects their ability to perform daily activities. Some felt that healthcare professionals lacked knowledge in treating women with symphysis dysfunction (Wellock and Crichton, 2007).

Early recognition of symphysiolysis is crucial in preventing complications and improving clinical outcomes.

Most women first complain of a burning and stabbing pain that radiates into the thigh (Crichton and Wellock, 2008). An appropriate medical history and clinical examination of the pregnant woman play an important role in this (Pires et al., 2015). A midwife is the person who helps with the early recognition of symphysiolysis and directs the woman to a specialist, as correct treatment helps slow down the further development of problems (Jain et al., 2006).

Incidence of symphysiolysis

The incidence of symphysiolysis varies between 1/569 to 1/30,000 births (Cicek et al., 2015). The true incidence of symphysiolysis in the general population of pregnant women in Slovenia is not known; severe forms probably represent only the tip of a relatively common condition in pregnancy. Many cases go unrecognized (especially mild forms), perhaps also due to little interest from the professional public in this problem (Kobal, 2009). Howell (2012) states that the incidence of pelvic girdle pain is recorded between 48‒71%, with 31.7% of pregnant women reporting pain in the symphysis area. Lebel et al. (2010) believe that the number of reports of symphysis dysfunction is increasing today mainly due to poor reporting in the past, and healthcare professionals are also better at recognizing it today. The results of a study (Lebel et al., 2010) conducted at the Soroka University Medical Center between 2000 and 2007, covering 80,898 pregnant women, showed that symphysiolysis was diagnosed in 154 (0.2%) pregnant women. Symphysiolysis during labor is rare, occurring in 0.005 to 0.8% of births, especially in women over 35 years of age (Pires et al., 2015).

Symptoms and signs of symphysiolysis

The severity of symptoms in symphysiolysis varies from mild discomfort to debilitating pain (Howell, 2012). The midwife plays an important role in recognizing symphysiolysis during pregnancy, as well as in further treatment, where she collaborates with the doctor and physiotherapist (Clark, 2010).

She must be particularly attentive to symptoms such as:

• stabbing pain in the symphysis area;
• pain radiating to the lower abdomen, lower back, groin, perineum, thigh, and/or leg;
• pain when walking, bending the leg, or putting weight on one side of the body;
• presence of pain during daily activities, when bending over, getting up from a sitting position, walking up stairs, and turning in bed;
• occasionally, a movement of the pubic bone can be heard or felt;
• dyspareunia;
• occasional problems with urination;
• exhaustion (Howell, 2012). The condition can also manifest with other signs:

• pain over the pubic symphysis and/or in the sacroiliac joints;
• waddling gait;
• a gap in the symphysis area that can be felt;
• edema and swelling in the joint area.

The condition can be assessed with Patrick’s test: the woman lies on her back with one leg bent so that the heel touches the knee of the opposite leg. If severe pain occurs in the femur, inguinal area, and symphysis and/or if it is impossible to touch the knee of the other leg with the heel, the test is positive and indicates symphysis dysfunction (Albert et al., 2000). For this purpose, the Trendelenburg test is also performed: when a woman stands on one leg while the other is lifted off the ground, normal abductor strength keeps the pelvis in a horizontal position, and the Trendelenburg sign is negative. If the pelvis sags on the non-weight-bearing side and is higher on the weight-bearing side, this is a positive Trendelenburg sign (Albert et al., 2000).

Risk factors

Clark et al. (2013) state that the midwife’s task during the care of a woman in pregnancy is also to check if pelvic girdle pain is present and to explore how the pain affects her daily life and well-being. She must know the risk factors to recognize and assess the level of risk for the pregnant woman.

Leadbetter et al. (2004) divide risk factors into two parts: risk factors during pregnancy and during labor. Risk factors during pregnancy are:

• a family history of pelvic girdle pain (mother, sisters);
• symphysis pain in previous pregnancies;
• early menarche;
• oral contraceptives;
• number of births;
• lower back pain;
• previous pathological events in the pelvic area or pelvic injuries;
• lack of regular exercise;
• hypermobility of the pelvic joints.

  Risk factors during labor include a large fetus and post-term pregnancy. Pires et al. (2015) state that risk factors during labor can include previous pelvic girdle injuries, shoulder dystocia, complicated labor – vacuum-assisted delivery, epidural anesthesia, and associated hyperabduction of the hips during the pushing stage.

Diagnostics

Pain in the symphysis area and sacroiliac joints is the most common sign of symphysis dysfunction in pregnancy (Jain et al., 2006). A history of previous illnesses and the symptoms reported by the woman are important in diagnosing symphysis dysfunction or symphysiolysis. X-ray imaging is not a suitable technique during pregnancy due to radiation exposure. Diagnosis can be made with ultrasound, which is considered a safe imaging technique in this case (Leadbetter et al., 2004). Swedish studies state that ultrasound represents a safe, simple, and inexpensive method for proving symphysis separation (Herren et al., 2015). There is no correlation between the severity of symphysiolysis symptoms and the degree of symphysis separation. Measuring the symphysis gap is important for understanding and treating this phenomenon, while also helping to exclude differential diagnoses such as symphysis diastasis (Leadbetter et al., 2004). Jain et al. (2006) explain that a doctor can determine symphysis separation by palpation, but emphasize that the woman’s own description of her discomfort is sufficient for diagnosing symphysis dysfunction. Leadbetter et al. (2006) present a screening test to help doctors manage women during pregnancy. Among them are five essential symptoms that require attention: pain in the pubic symphysis while walking, pain when standing on one leg (while dressing), pain when walking up stairs, pain when turning in bed, and a history of pelvic injuries. By presenting the screening test, they hope it would contribute to the appropriate treatment of pregnant and laboring women with symphysiolysis.

Due to the pain present during contractions and the pushing stage, symphysiolysis is often an overlooked phenomenon (Demirkale et al., 2007). Various imaging techniques play a role in making a diagnosis after birth. X-ray imaging is used after birth to diagnose symphysis diastasis. Computed tomography (CT) is used to examine the symphysis after birth, primarily for research purposes. Although magnetic resonance imaging is a less accessible and more expensive imaging technique in medicine, it offers more information about soft tissue damage in symphysis separation and therefore plays an important role in investigating symphysis dysfunction or symphysiolysis (Leadbetter et al., 2004).

THERAPY AND THE ROLE OF THE MIDWIFE IN TREATING A WOMAN WITH SYMPHYSIOLYSIS

In treating a pregnant woman with symphysiolysis, mutual collaboration between the midwife, doctor, and physiotherapist is crucial. If the midwife is the one the woman confides in about pelvic girdle pain, it is essential that she recognizes the discomfort and refers her to a specialist. Early detection of symphysiolysis and the implementation of therapy are of utmost importance to prevent further complications during pregnancy, labor, and the puerperium (Shepard, 2005). Recognition and treatment of symphysis separation during pregnancy or after birth require a fast and consistent approach (Herren et al., 2015).

Therapy during pregnancy

It is important for the midwife to know the possible causes of pelvic girdle pain; this way, she can correctly advise women and direct them to the appropriate specialist (Richens et al., 2010). Jain et al. (2006) state that when pelvic girdle pain occurs, the pregnant woman should be provided with an examination by a physiotherapist, who will advise her on appropriate movement and rest to prevent further complications. The advice offered to the woman includes:

• avoiding activities that cause discomfort (lifting and carrying heavy things, standing for too long, walking, and strenuous exercise);
• frequent rest;
• moderate exercise to strengthen the pelvic floor;
• avoiding squats;
• avoiding straddling when getting in and out of a car or entering a bathtub;
• analgesic therapy (paracetamol) is necessary in the presence of pain;
• applying a compress to the painful area (maximum 5 minutes at a time);
• using a pelvic belt.

Pain control is extremely important in preventing chronic symphysis pain (Keriakos et al., 2011). Acute pain during pregnancy is alleviated with paracetamol (Jain et al., 2006).

Women can also help themselves with complementary treatment methods. Chiropractic has proven effective in managing pelvic girdle pain (Keriakos et al., 2011). A survey conducted among women with symphysis dysfunction showed an improvement in the condition after chiropractic treatment in all respondents. Public health services have limited access to chiropractic treatment, although interest is growing, especially in primary healthcare (Jain et al., 2006). Pregnant women need a gentle approach to alleviating pelvic girdle pain, and chiropractic care offers them a safe and effective way of treatment, which includes the use of a pelvic belt, compresses, and stretching exercises. At home, moderate activity, Kegel exercises, and using a pillow between the knees while sleeping are recommended (Howell, 2012).

Women suffering from symphysis dysfunction or symphysiolysis are encouraged to join various groups led by volunteers with their own experience of symphysis pain, as the condition is also mentally exhausting for the woman. They offer personal support, provide information, and organize meetings with women who have also faced symphysis dysfunction and can help them with practical advice on solving daily obstacles (Jain et al., 2006).

Labor and perinatal therapy

Jain et al. (2006) state that for most women with symphysis dysfunction or symphysiolysis, a spontaneous vaginal birth is recommended. In some pregnant women who suffer from severe symphysis pain that hinders their daily activities and movement, labor is induced before the expected due date. There is no evidence to support cesarean section as a more favorable mode of delivery for women with symphysiolysis. Nevertheless, it is an interesting fact that women who gave birth by cesarean section express less discomfort in the symphysis area than women after vaginal birth. Rather than the mode of delivery, regular application of analgesia probably contributes more to less discomfort and pain.

Before labor, the range of pain in the lower back, hips, and symphysis during free movement should be assessed and documented. When choosing positions, it is important not to restrict the laboring woman’s movement or cause her discomfort. A birth plan that takes into account the woman’s mobility and her ability to change positions during labor is recommended (Fishburn and Cooper, 2015). Symphysis pain worsens with inappropriate and forced positions and lasts longer even after birth. The leg spread during the pushing stage should be minimal (Jain et al., 2006). Excessive and forced hip abduction, which stresses the symphysis, should be avoided (Fry et al., 1997). The midwife encourages the woman to find her most comfortable position (Robson and Waugh, 2013). Epidural anesthesia is not recommended because it may mask signs of symphysis diastasis, although there is no existing evidence to support this claim (Jain et al., 2006).

Postpartum period and therapy

Postpartum women with symphysiolysis need more help with care after birth; continuous support from the midwife, doctor, and physiotherapist must be ensured. A daily check-up is important, through which the midwife assesses the improvement or worsening of the condition. The hospital stay is prolonged in the case of symphysiolysis. When moving, the woman should use a pelvic belt, which gives a sense of pelvic stability, and she can use crutches when walking. For severe pain that does not subside despite analgesics, an X-ray is needed to exclude or confirm symphysis diastasis, along with a consultation with an orthopedist (Jain et al., 2006). In the postpartum period, the woman must also be provided with support in caring for the newborn. Regular application of painkillers helps with pain control (non-steroidal anti-inflammatory drugs). Due to severe pain and immobility, the postpartum woman feels considerable helplessness, so attention to signs of depression is also necessary (Robson and Waugh, 2013). Surgical correction of diastasis is rarely performed, and only when conservative treatment is unsuccessful. It should be performed by an orthopedist with appropriate experience (Kobal, 2009). It is difficult to predict the recurrence of symphysis dysfunction in subsequent pregnancies, but there is a 68‒85% chance of recurrence in the next pregnancy (Jain et al., 2006).

In the thesis, the author presents the case of a 32-year-old woman with a confirmed mild form of symphysiolysis after birth. The candidate joined the research process through a third party, with the assurance that she would remain anonymous.

Case presentation

A 32-year-old woman conceived spontaneously. Both she and her partner accepted the news of the pregnancy positively. This is her first pregnancy, which proceeded without problems until the 23rd week (except for nausea, which was present until the 20th week of pregnancy but did not threaten the health of the pregnant woman). Her lifestyle changed only in terms of diet up to that point (avoiding cured meat products or food that increases the risk of toxoplasmosis). She continued with her daily activities. She wanted to be active during pregnancy, as she realized that a woman’s good psychophysical condition is very important during labor.

She regularly visited the gynecological clinic. The pregnancy proceeded without complications. In the 23rd week, the first pains appeared, which she initially felt after a long walk. Rest reduced the pain. The level of pain was not high; on a scale of 1 to 10, she would rate it a 2–3. From the first appearance of pain in the symphysis area, the problems never disappeared. Pain also began to appear when walking short distances (500 m–1 km), and turning in bed and getting out of bed also presented a problem. The pain was still rated at level 2–3. The next check-up at the gynecological clinic was performed at 24 weeks and 3/7 days. She mentioned the new problems to the midwife at the clinic. However, she did not want to exaggerate, so she did not mention the problems later in the conversation with the obstetrician-gynecologist. No description of the problems is recorded in the maternity book. As the weeks of gestation increased, the pain became stronger and by the 30th week of pregnancy already represented an obstacle in daily activities (walking, visiting the store, cleaning the apartment). She rated the level of pain at this point as 3–4. Rest alleviated the pain. Another gynecological examination was performed at 30 weeks and 2/7 days, where she again mentioned the pain in the symphysis area to the midwife; there are no notes about the mentioned problem in the maternity book. In the 35th week, the pain level was rated 4–5. Despite the pain, the pregnant woman wanted to remain active, but with excessive effort (cleaning the apartment, a long walk), the pain level escalated (7–8), sharp pain appeared in the symphysis, there was a sense of pelvic instability, the pain radiated to the thighs, and walking was not possible. Rest stabilized the condition. Turning in bed began to represent an increasing problem due to the pain, as did lifting her legs when sitting up in bed. In the remaining weeks of pregnancy, the patient still reported problems during check-ups, but because she felt that similar problems happen to all pregnant women, she did not pay excessive attention to them herself.

At 41 weeks and 2/7 days, she was admitted to the high-risk pregnancy ward at 1:00 PM due to a suspicious CTG (cardiotocogram) recording, with the admission diagnosis: pregnancy 41 weeks 2/7, suspicious CTG, for monitoring and possible induction. Upon admission, while filling out the documentation, she reported severe pain in the symphysis area to the midwife. There was no record of this. On the ward, labor was induced with prostaglandin at 7:00 PM; due to another suspicious CTG recording, she was then admitted to the delivery room at 11:00 PM, where she slept through the night. The obstetrician inserted a second prostaglandin vaginal tablet at 7:00 AM the next day. Contractions began at 9:00 AM, and at 10:00 AM, there was a spontaneous rupture of the membranes. As the contractions intensified, the pain in the symphysis area also increased, hindering the woman’s walking. Despite the fact that it is easier to endure a contraction while standing and despite the midwife’s encouragement to walk, the woman could no longer stand during a contraction due to the symphysis pain. She rated the pain on the scale as 9–10. At the same time, a sense of pelvic instability was present. The sitting position also presented a problem. With epidural anesthesia, the symphysis pain decreased, as did the pain of the contractions; the pain level was 1–2. The woman was in the lithotomy position during the pushing stage. Due to a weaker contraction and a drop in the fetal heart rate, pressure on the uterine fundus was necessary. At 6:04 PM, a healthy boy was born in the vertex position with a birth weight of 3740 g, length of 53 cm, and head circumference of 36 cm. Upon discharge from the delivery room, the symphysis pain began to intensify, movement was impossible due to the pain, so additional help was needed; the woman was transferred to a ward bed. Lying on her side eased the pain; three nurses assisted in turning her to the other side. The pain was rated 10.

In the morning, the head nurse suspected symphysiolysis, so the woman was taken for an X-ray. Pelvic X-ray with hips (performed the next morning after birth): the symphysis width is 8 mm, which means a mild degree of symphysis diastasis. Otherwise, the skeleton of the pelvis and both hips is radiologically within normal limits. A consultation with an orthopedist stated that the X-ray showed symphysis diastasis; clinically, it is grade I symphysiolysis. The orthopedist further advised avoiding forward bends in a lying position, keeping the legs together when getting up, and recommended physiotherapy.

The woman got up for the first time on the second day after birth with the help of a physiotherapist, who first put a pelvic belt on her. The pain was severe (10), and she could not walk. During the next eight days of hospitalization, the patient got up with the help of staff and had physiotherapy treatment in the morning. When turning in bed, which caused her the worst pain, the midwives helped her by having one midwife hold her ankles, another her knees, and a third provide support to the pelvis. They performed the maneuver simultaneously, either to the left or right side. When breastfeeding the newborn, the midwives or nurses on the ward helped the woman, and they also took care of the newborn. The woman reported a sense of helplessness and expressed mental distress because she could not take care of herself and her child. With daily analgesia (Analgin 5 ml/ 12 h i.v., Tadol 2 ml/ 8 h i.v., Paracetamol 100 ml/ 6 h i.v.), the pain decreased slightly. On the eighth day after birth, the woman was able to get up on her own and walk with the help of crutches, so she was discharged to home care.

Walking without crutches was possible 4 weeks after birth, but full recovery took a further 6 months. The pain in the symphysis area has not completely disappeared even 3 years after birth; it is present when getting up suddenly if the legs are not together, during long walks, especially when walking uphill, and when running.

A review of the literature shows that pelvic girdle pain and with it symphysiolysis are common occurrences that are often underestimated or not recognized when treating pregnant women. For most women, however, it can significantly affect their maternal role and quality of life before and after birth (Clark et al., 2013).

Due to poor recording, it is difficult to speak about the exact number of these occurrences. The incidence of symphysiolysis varies between 1/569 to 1/30,000 births (Cicek et al., 2015). The author did not find data on the incidence of symphysiolysis in Slovenia during the literature review. Terminology also presents a problem; recently, the term “pregnancy related pelvic girdle pain” or the abbreviation “PRPGP” has been used. The term covers pelvic girdle pain, which includes symphysis dysfunction, symphysiolysis, and symphysis diastasis (Robson and Waugh, 2013). Jain et al. (2006) strive for standardization of terminology, as this would enable higher quality care for women during pregnancy and labor.

If the midwife in the clinic listens to a woman reporting symphysis pain during pregnancy and is attentive to the risk factors for symphysiolysis, she can help her with advice on correct posture and movement (she should avoid carrying and lifting heavy loads, straddling when getting in and out of a car and when getting out of bed, and advise frequent rest and the use of a pelvic belt). In this regard, there is a possibility that the symptoms subside and later complications are avoided (Robson and Waugh, 2013). In Slovenia, pregnant women less frequently encounter midwives in primary healthcare, with some meeting a midwife for the first time only upon admission to the maternity hospital. Upon admission to the delivery room, a midwife can assess whether a normal birth can be expected based on the medical history and by reviewing the maternity record book (Lavrič, 2016). In the case report, the pregnant woman mentions that she repeatedly reported symphysis pain to the qualified midwife at the gynecological outpatient clinic, but these issues were not noted in her maternity record book. It can often happen that problems reported by a woman during pregnancy are not recorded in the maternity record book, so the midwife, upon admission to the maternity hospital, should carefully listen to the symptoms reported by the laboring woman experiencing symphysis pain. If the laboring woman reports severe pain during contractions, making her unable to sit or walk, the midwife must consult with a doctor. Similarly, the choice of analgesia during labor should be discussed with both the doctor and the laboring woman. Robson and Waugh (2015) state that epidural anesthesia can mask the signs of symphysiolysis or symphysis diastasis, but they do not advise against it. If the laboring woman opts for epidural analgesia, caution is needed when she is in the lithotomy position; the legs should be placed back on the support simultaneously. They recommend that this position be maintained for the shortest possible time. The midwife should also pay attention to the condition of the postpartum woman. If she complains of severe symphysis pain, the midwife should document the issues and mention them to the doctor, who will then order further examinations. In any case, the midwife plays an important role in the care of the postpartum woman, as she attends to all daily activities that are impaired in women with symphysiolysis.

When diagnosing symphysis dysfunction in pregnancy, there are tests that help determine the state of the symphysis, for example, Patrick’s and Trendelenburg’s tests (Albert et al., 2000). These tests could also be performed by a midwife on a woman reporting symphysis pain, either in the clinic or upon admission to the maternity hospital. Ultrasound is used to diagnose symphysiolysis in pregnancy, which is considered a safe and reliable imaging technique (Herren et al., 2015). In the case presented by the author in the thesis, an ultrasound to diagnose symphysiolysis during pregnancy was not performed. An X-ray was performed after birth, which showed a symphysis diastasis of 8 mm, indicating mild symphysiolysis. However, it is important to emphasize here that the width of the gap does not coincide with the pain (Lebel et al., 2010). Despite the minimal symphysis diastasis, the postpartum woman was immobile and suffered severe pain.

Symphysis dysfunction is a treatable condition that can be managed at any stage of pregnancy. The problems that arise include symphysis pain, difficulty moving, and emotional consequences due to restricted movement and difficulties with daily tasks. Timely recognition of symphysiolysis leads to faster recovery and prevention of complications (Fishburn and Cooper, 2015). Mutual collaboration between the midwife, doctor, and physiotherapist is important to prevent further complications during pregnancy, labor, and the puerperium. All healthcare professionals should strive to improve the situation in this field with appropriate care for the woman during pregnancy, labor, and in the postnatal period. A woman should have the opportunity to express her problems and fears to the midwife, who should listen to her problems and seek further solutions. As can be seen from the case report, the pregnant woman warned about pain in the symphysis area already during pregnancy, but the midwife did not listen to her enough. Based on the literature review, the author believes that these are often ignored problems; most healthcare professionals treat pelvic pain as a physiological phenomenon in pregnancy and do not pay enough attention to it, as they are convinced that the problems will disappear after birth (Fishburn and Cooper, 2015). With an appropriate medical history, we can determine the risk factors for symphysiolysis and ensure appropriate care for the pregnant woman when symptoms or signs appear. Here, the author especially emphasizes the importance of midwifery care during pregnancy, as the midwife is the person a woman meets more often during pregnancy than a physiotherapist who could offer her therapy. Therefore, knowledge of the signs and symptoms of symphysis dysfunction is important in care, so that early recognition, advice, and referral can alleviate problems and prevent complications.

Foreign authors present many suggestions in their literature for preventing and alleviating problems that arise with symphysiolysis, with particular emphasis on the role of the midwife, who should be attentive to risk factors and symptoms.

It is necessary to raise awareness among midwives about the possibilities of preventing symphysiolysis and measures to improve the condition. Interprofessional collaboration between the midwife and the physiotherapist is key.