Women's Health Physiotherapy
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Direct answer
From the second trimester, the hormone relaxin plus a shifting centre of gravity conspire against the pregnant spine and pelvis: up to half of pregnant women report low back pain, and a substantial minority develop pelvic girdle pain — pain over the symphysis pubis or sacroiliac joints, with the classic pattern of pain on standing on one leg, turning in bed, and walking. Physiotherapy answers this with pelvic belt fitting, specific stabilising exercises for gluteals and deep abdominals, movement modification (sitting to dress, log-rolling in bed, avoiding single-leg stance) and, in the postnatal period, graded return to loading. Diastasis recti abdominis — separation of the rectus bellies along the linea alba, assessed by finger width or caliper at, above and below the umbilicus during a head-lift, with a commonly used threshold of about two centimetres — is treated with progressive deep abdominal and oblique training rather than crunches. Exercise in an uncomplicated pregnancy is encouraged to the tune of 150 weekly minutes, modified to avoid supine exercise after about the mid-second trimester, contact risk and altitude.
What you must remember
- Pelvic girdle pain pattern: location (symphysis, unilateral or bilateral sacroiliac), provocation (single-leg stance, turning in bed, stairs, stride), and validated tests — the active straight leg raise, posterior pelvic pain provocation test (P4) and modified Trendelenburg; a pelvic stabilization belt trial often aids diagnosis itself.
- PGP management package: education and reassurance, pelvic belt, gluteal and deep abdominal retraining, symmetrical posture habits, log-rolling, sit-to-dress, avoid prolonged single-leg stance and heavy unilateral carrying.
- Diastasis recti assessment: supine, knees flexed, head lifted to tense the recti; inter-recti distance palpated or measured by ultrasound at 4.5 cm above, at and below the umbilicus — roughly 2 cm or more, or visible doming/bulging on the task, is the commonly applied threshold; prevalence is high in late pregnancy and persists postnatally in a minority.
- Diastasis rehabilitation: transversus abdominis and pelvic floor activation first, loaded progressively with oblique-biased and anti-extension work; avoid sustained breath-holding and ballistic sit-ups until control returns.
- Pregnancy exercise rules (ACOG-aligned): at least 150 minutes of moderate activity weekly in uncomplicated pregnancy; avoid supine exercise after roughly the second trimester if symptomatic, contact sports, scuba diving and altitude; stop signs include vaginal bleeding, painful contractions, dizziness, headache and fluid leakage.
One pregnancy, start to postnatal
A 31-year-old teacher, second pregnancy, presents at 30 weeks unable to turn in bed or walk to the staffroom without sacroiliac pain; the active straight leg raise is heavy and positive on the right, and P4 reproduces her pain. Session one delivers explanation (the joint, not the baby, is the problem), a fitted pelvic belt worn for load tasks, and the movement script: log-roll with elbows, sit to put on salwar bottoms, legs together before rising from bed or car, no standing on one leg to dress. Her exercise ladder begins immediately — side-lying gluteal strengthening, transversus abdominis draws on the outbreath, quadruped hip extension avoiding lumbar sag. She delivers at term; at the six-week check a two-finger diastasis with doming on head-lift redirects the programme: dead-bug progressions and oblique work replace any sit-up instinct, pelvic floor training runs in parallel, and walking extends weekly. At three and a half months she retests single-leg bridges and jogging intervals against symptoms — postnatal return is criteria-led, the criteria being continence, pelvic stability and load tolerance, not just the calendar.
Exam framing and Indian practice notes
BPT question banks frame this as "physiotherapy management of pregnancy-related low back pain and pelvic girdle pain" and "diastasis recti abdominis — assessment and management" as long answers, with the assessment numbers (finger widths, landmarks, threshold) and the belt-plus-exercise package as the mark carriers. Indian practice specifics earn credit: floor-level living — cross-legged sitting, squatting, bucket bathing — are functional patterns to train into and around; and postnatally, the 40-day confinement tradition plus early resumption of lifting older children shape realistic progressions. Culturally sensitive pelvic floor education matters: postnatal incontinence is under-reported in India and most women never volunteer it unless asked in privacy, ideally by a female therapist — ask directly, because silence is the biggest barrier to treatment.
Frequently asked questions
How is pelvic girdle pain diagnosed clinically?
By symphysis or sacroiliac pain provoked by standing on one leg, turning in bed and walking, supported by the active straight leg raise and posterior pelvic pain provocation tests.
How is diastasis recti abdominis assessed?
With the woman supine and knees bent, lifting her head to tense the recti while inter-recti distance is palpated or measured above, at and below the umbilicus — about 2 cm or more, or doming on the task, is the commonly applied threshold.
What exercise precautions apply in pregnancy?
Avoid supine exercise after about the mid-second trimester if symptomatic, contact sports, scuba diving and altitude; stop for vaginal bleeding, painful contractions, dizziness, headache or fluid leakage.
Why are crunches discouraged postnatally?
Repeated spinal flexion increases intra-abdominal pressure and bulging through a diastasis; progressive deep abdominal, oblique and anti-extension training rebuilds tension across the linea alba instead.
When can a postnatal woman return to running?
Commonly around three months after a vaginal or uncomplicated delivery, guided by pelvic floor control, continence, diastasis management and graded impact tolerance rather than the calendar alone.