Pregnancy: What is Normal & What is NOT When it Comes to Body Changes
During pregnancy, some things are a given – hello BELLY! – and other changes may come as a surprise. Specific anatomic and physiologic changes occur with every pregnancy, however the majority of aches and pains that may accompany these changes are NOT normal and can be addressed or prevented with a little more knowledge and a bit of guidance. The following outline highlights a small portion of the body’s transformation; but it is by no means exhaustive:
Let’s start off here with the proverbial meat n’ potatoes of the physical changes in pregnancy: changes in the MUSCULOSKELETAL SYSTEM. While all of the changes and happenings described below are part of the normal progression of the very natural process of pregnancy, they nonetheless are changes that can be smartly managed to minimize any adverse effect on mom and optimize her physical function during pregnancy AND postpartum! You’ll see some tips sprinkled throughout, but the most important take home here is to be as mindful about taking care of and living in your body during pregnancy as you are about what is going on inside with the growth of your baby(-ies)! Certainly this includes nutrition and sleep, but also includes using good body mechanics when you change positions and lift bags of groceries, and exercising in ways that will help you have the strength for caring for your new baby (and schlepping all their things!) and in ways that generally keep you as strong and functional as possible during the entire pregnancy.
- Typical weight gain is equivalent to a 20-25% increase in body weight – which may increase forces on the joints by as much as 100%. Recommended amount of weight gain is based on pre-pregnancy weight, and varies if pregnancy is singleton or multiples.
- As the uterus enlarges, the Round Ligaments become elongated and may cause sharp lower quadrant or groin pain.
- Postural Changes: As the uterus and breasts enlarge, a pregnant
woman’s center of gravity moves forward causing an increased curve in
the lower back, the pelvis to tip forward, and a compensatory wider base
of support (standing with the feet wider apart than “normal”).. Studies
suggest decreased postural stability is most notable in later trimesters
and up to eight weeks postpartum.
- These postural changes can - among other things -lead to muscle strains and create nerve irritation, resulting in pain, burning, numbness, pins and needles, and/or decreased muscle strength and function.
- 80% of pregnant women will experience swelling, known as edema, especially in the last weeks of pregnancy. This may increase the likelihood of nerve entrapment in various areas of the body. Carpal tunnel syndrome, for example, results from compression of the nerve on the palm side of the wrist. Symptoms are characterized by numbness and tingling in the palm, thumb and first two fingers, a weak grip and difficulty carrying objects in the hands. It usually resolves after delivery or once a woman stops breast-feeding, but it may be problematic enough that waiting on one of these events isn’t acceptable. In such cases, conservative management, including physical therapy, can be very helpful to reduce or resolve the symptoms and restore function.
- The Pelvic Girdle (put your hands on your
hips...when we reference the “pelvic girdle”, we mean the bones on which
your hands are resting and everything in between!) commonly demonstrates
decreased stability, which increases the likelihood of malalignment issues and may predispose to separation of the joints.
- ***All of the following pelvic girdle issues can be successfully treated through some combination of physical therapy, support belts, and modifications to activities and posture. No pregnant woman needs to “just wait until the baby is born” to wait for symptoms to resolve - that may be months away!!
- Pubic Symphysis: This joint is at the center front of the pelvis. Separation of up to 12mm (1.0-1.5inches!) to accommodate for delivery is normal. However, a larger separation may lead to pain during position changes or standing on one leg, increased strain to surrounding musculature (adductors, abdominals and round ligament of the uterus), or create referred symptoms into the hip or perineum.
- Sacroiliac Joint: There is a right and a left sacroiliac joint, formed by the meeting of the right and left pelvic bones with the broad edge of the sacrum (the bone at the bottom of the spine). Malalignment is common and involves the surrounding muscle and ligamentous attachments.
- Coccydynia: This is a fancy word for “tailbone pain.” It is characterized by pain with sitting, transitional movements (sit to stand), sexual activity or defecation
- Diastasis Rectus Abdominis (DRA) is a thinning or separation of
the connective tissue in the midline of the abdomen, connecting the left and
right muscle bellies of the rectus abdominis (aka, the 6-pack muscle).
- This separation may occur during pregnancy due to the weakening of the connective tissue, or during the stress of labor/delivery. It is usually first seen during the 2nd trimester with incidence peaking during the 3rd trimester.
- While the overall prevalence of DRA is estimated at ~60% by the time of delivery, research indicates a higher incidence of DRA in non-exercising pregnant women than exercising women.
- The pelvic floor is comprised of eight layers, and during pregnancy these muscles work harder than ever to support the increasing load from above as the uterus enlarges. The nerves that supply these muscles can be stretched during delivery, sometimes leading to lasting decreases in nerve supply to the muscles of the pelvic floor, which means that the muscle or muscle group can’t function optimally. Trauma from episiotomy or perineal tears (which can affect the skin tissue and/or the pelvic floor muscles) may contribute to incontinence and pelvic pain. As many as 50% of women will develop SUI during pregnancy and delivery; incontinence commonly lasts through the first 4-12 weeks postpartum. This is thought to be because of tissue disruption, swelling and weakness, but - GOOD NEWS! - all of these can be addressed by positioning, postural, and activity modifications, appropriate use of ice and rest, and gentle exercises, respectively. We encourage you to look for guidance from a knowledgable healthcare provider, such as a physical therapist or midwife, who can help you be PROACTIVE during the early stages of recovery.
- Back and Peripheral (non-spinal) Joint Pain
- The combined effects of hormonal changes, increased weight, and postural changes may cause pain in the back as well as joints of the wrists (carpal tunnel, tendonitis), knees, ankles (sprains) and feet.
- One study found that 37%
of women reporting back pain in pregnancy still reported back pain at 18
- Our suggestion: don’t ignore back pain! Physical therapists and other healthcare professionals can be very helpful to reduce or minimize pain during pregnancy - which should not only make the pregnancy more enjoyable, but decrease the risk of falling into the group of women who still had back pain a year and a half after having their baby!
- Relaxin works to relax ligaments and connective tissue throughout
the body, thereby preparing for delivery of baby by altering stiffness of
the pelvic ring – both widening the pubic symphysis (front) and increasing
the mobility of the sacroiliac joints (back). Concentrations are highest
during the first trimester, and then decrease by 20% for the duration of
pregnancy. It decreases to pre-pregnancy levels by three days postpartum.
- Even with this increased joint laxity, research indicates that increased levels of relaxin do not correlate with pelvic or pubic symphysis pain during pregnancy
- Ovarian Hormones:
- Estrogen contributes to connective tissue changes and assists in both uterine and breast growth.
- Progesterone contributes to rises in core temperature (1/2 degree for the entire pregnancy) and increases both respiratory rate and fat storage. It also reduces the tone in smooth muscles, which are found throughout the digestive and urinary systems, so this may provide some explanation for changes in how your stomach, bowels, and bladder seem to be functioning.
- The growing uterus displaces the heart upward, forward and to the left. Blood volume and flow both increase, with heart rate increasing on average 10-15% (from 72bpm to 80-90bpm). Cardiac output, the amount of blood pumped by the heart with each beat, increases by 40% during pregnancy, though blood pressure decreases slightly until the final month of pregnancy. As the uterus grows, its increased size puts pressure on the veins to the lower body, creating increased pressure and decreasing the rate of venous blood flow. This has the potential to cause edema, hemorrhoids, or varicosities.
- The rib cage is displaced upwards and expands. Shortness of breath on exertion is reported in up to 75% of pregnant women by 31 weeks gestation. Pregnant women breathe more deeply and frequently with 20% increased oxygen consumption.
- Intestinal motility decreases secondary to increases in the hormones estrogen and progesterone – leading to increased constipation.
- There is a general increase in overall volume of body fluid, as well as increased urinary frequency - in early pregnancy this is caused by hormonal changes, in late pregnancy by the bladder being moved up and flattened by the growing uterus.
- Overall incidence of Stress Urinary Incontinence (SUI – any loss
of urine occurring with an increase in abdominal pressure such as coughing,
sneezing, laughing, active exercise or lifting) during pregnancy varies
widely in the literature, anywhere from 12-49%.
- Research found 2/3 of women with SUI during pregnancy still had the issue 15 years postpartum (it only resolved for 1/3 of the women surveyed).
Though largely determined by genetics, some common changes in the INTEGUMENTARY SYSTEM are minimized by keeping weight gain within your provider’s recommendations and performing resistance exercises that keep muscle tone from diminishing during pregnancy, including the abdominals! Remember, as with cardiovascular exercise, if you aren’t sure what to do, don’t do nothing! Many healthcare and fitness professionals are available and happy to help!
- Striae Gravidarum (stretch marks) may affect the skin of the breasts, abdomen, buttocks, and thighs.
HORMONAL CHANGES are truly part of the deal and there is nothing to do to change that they are occurring. However, the following few points may give you a little more context - primarily that we can’t outright blame hormonal changes for pain in the pelvic joints, but we can lean on them to explain some of the changes in digestion and bowel/bladder habits!
Growing a little person (or persons!) inside your own body is a lot of work! The CARDIOVASCULAR SYSTEM has to step up its game to - quite literally - keep pace! Apart from being aware of these changes, & assuming they remain medically clear to do so, the best thing a pregnant woman can do is to continue to engage in cardiovascular activities. Intensity, duration, and activity type may need to be modified from pre-pregnancy and to be modified further as the pregnancy progresses, but try to find something fun to keep you moving throughout! Swimming, walking, stationary equipment, etc - anything non-impact (no downhill skiing or boxing, for example!). If you are unsure of what to do, it is worth it to meet with a physical therapist or fitness professional who can help!
You could be convinced that that flight of stairs you climb every day just doubled in steepness and length...but NO, it’s just that the RESPIRATORY SYSTEM is also working a lot harder during pregnancy. Part of this has to do with the body’s need for more oxygen, and part is a very mechanical adjustment to the changing anatomy of a progressing pregnancy. As with other things, continuing to challenge the system through regular and appropriate exercise will make these respiratory changes easier to manage. It is also crucial to essentially undo some of these adaptations postpartum, consciously drawing your breath back into the lower ribs and lower belly and letting your diaphragm move through its normal range of motion - something a 9-month gestation uterus prevents it from doing!! (We’ll talk more about this next week...)
Back to those hormones...the changes they cause in the GASTROINTESTINAL SYSTEM frequently result in constipation. Boo. Fortunately, we put out a piece last week with great tips on diet and fluid intake to address constipation - all tips that remain valid for pregnancy-related constipation. One key thing, however, for pregnancy-related constipation - it is more important than ever to avoid straining! The pelvic floor and pelvic organs, as well as the abdominal wall, are working harder than normal and are under near-constant stretch and stress. This means that they are more vulnerable to bearing down and straining. And what does vulnerable mean...? It means that it is more likely that the additional stresses they experience could contribute to longer-term problems like pelvic organ prolapse, urinary or bowel incontinence, and loss of muscle function in the abdominal wall.
Everyone has heard of the “in the bathroom all the time” pregnant woman stereotype. Frequent urination can truly be a problem for many women but there is treatment available! This should not be ignored and allowed to have a detrimental affect on quality of life! See our previous post and visit Take The Floor PFD for additional information and resources. Certain pregnancy-related changes in the GENITOURINARY SYSTEM contribute to bladder changes in this timeframe.
While pain or other issues affecting function are not altogether surprising given the extra stress your body is responsible for - pregnancy and childbirth is a monumental and monumentally-physical undertaking after all! - you do not have to dismiss it as part of the deal and passively wait until baby arrives, hoping improvement will come then! Tell your physician if you notice any pain symptoms, particularly if they are affecting your ability to do the things you need to do in daily life, and ask them to point you toward providers who can help! There are often ways to treat, and even prevent dysfunction during pregnancy including: modifying posture and body mechanics, adding specific flexibility and strengthening exercises, and occasional use of external supports (belts and binders).
In conclusion, even this lengthy post doesn’t do adequate justice to the important physical changes experienced during pregnancy, nor to the equally important ways that pregnant women and their providers can proactively engage with and manage these changes! A natural process (yes, pregnancy is!) does not inherently mean we passively let it take it’s course. The collective “we” of culture, moms, healthcare providers are learning more and expecting more of ourselves and our function all the time - as well we should! Let’s work together to keep spreading this message - a message of empowerment for moms, really - that all of us can deal honestly with the physical changes and challenges of pregnancy and childbirth AND rise together to meet these challenges with appropriate education, care and action.
(This text was completed in the waning minutes of Mother’s Day 2012...how fitting!)