Episode 176 Pelvic Girdle Pain (PGP) - a chat with Sarah - The Obs Pod

Episode Transcript
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Florence (00:00):
Hello, my name's Florence.
Welcome to the OBSPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife.
Maybe birth fascinates you, oryou're simply curious about what
exactly an obstetrician is.
You might be pregnant andpreparing for birth.

(00:22):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, the OBSpod is for you.
Episode 176 Pelvic girdle paina chat with Sarah.

(00:58):
Sarah, Welcome.
I am absolutely delighted todayto have a guest, Sarah Fishburn
, and she is the chair of thePelvic Partnership that she has

(01:27):
really pioneered through thePelvic Partnership in trying to
educate and support women andalso help educate professionals.
Sarah, welcome to the OBS pod.

Sarah (01:35):
It's lovely to have you here and perhaps you could just
briefly tell us a little bitabout yourself before we get
stuck in briefly tell us alittle bit about yourself before
we get stuck in, okay, well,thank you so much for inviting
me to be part of this.
I'm really delighted to be here.
Yes, I chaired the PelvicPartnership, as you said, and
that came about as a result ofhaving three pregnancies, each

(01:59):
with PGP, and really strugglingto find information, being told,
told you know, the goalpostsbasically kept moving.
When I was pregnant, I was toldit was normal aches and pains,
it was my hormones, nothingcould be done.
And then, when I'd had my baby,I was told it would take two
weeks, six weeks, three months,six months a year to get better.

(02:22):
And when I was a year postnatal,I remember having a
conversation with my GP who toldme, when I'd had the baby and
couldn't walk and was in a lotof pain, that I was going to get
better in two weeks.
She said, oh, maybe you're justone of those women who doesn't
get better.
And that was a real light bulbmoment for me because I thought,

(02:44):
hang on a minute, you're thesame person and this is a GP
who'd known me for a number ofyears You're the same person who
told me a year ago that it wasgoing to be better in two weeks,
and now you're saying I'm nevergoing to be able to walk
normally again and that that'sokay.
And so I'd sort of met quite alot of women along the way who

(03:06):
were in a similar position.
You know, we were allstruggling to walk and we were
all just being told it wasnormal.
We were all trying to live anormal life, and it's really
difficult when you go to atoddler group and you can't sit
on the floor and you can't chaseyour baby around, and so I
didn't go to toddler groupsbecause it was just too painful.
So it was.

(03:27):
It was through meeting otherwomen and and having that kind
of joint experience although allour conditions were slightly
different that the pelvicpartnership started.

Florence (03:38):
Wow, that's, I can imagine, really shocking as a
young woman having a baby,suddenly your mobility changing
so radically and then not beingexpected to recover.
I definitely think when we wereemailing in the run up to this

(04:00):
episode, I was thinking, yeah,there have definitely been times
in my career when I've toldpeople, yeah, it's going to get
better once you have the babyand it's hormonal and I
definitely see women that reallystruggle.
So I'm hoping this episode isgoing to be really useful for
people.
Tell us a little bit what ispelvic girdle pain?

Sarah (04:25):
So it's a fairly straightforward condition.
It affects the joints of yourpelvis.
So you've got the symphysispubis at the front and then two
sacroiliac joints at the back ofthe pelvis which attach onto
your sacrum and normally theyall move just a little bit to
allow you to walk, climb stairs,turn over, turn over a bed, do
all those normal day to daythings.

(04:46):
And what happens with PGP isthat one of the joints often one
of the sacroiliac joints at theback gets a bit stuck, stops
moving normally, and that has aknock on effect on the other two
joints because they're havingto compensate.
So they move a little bit moreand they get irritated and
painful.
Often it's the symphysis pubisat the front that hurts first

(05:06):
because it's a smaller, lessstable joint and whereas the
sacroiliac joints at the backare big, solid joints with lots
and lots of ligaments acrossthem.
So the consequence of that isit hurts and it gets more and
more irritated the more you walkon it and then all your muscles
start to join in becausethey're trying to keep you up
against gravity, because you'retrying to function.

(05:28):
You're trying to do all thethings that the lovely pregnancy
magazines say you should do.
You should be blooming inpregnancy, you should be
exercising, you should be doingthis, that and the other and you
can't but but you're tryingreally hard to do it.
So it just kind of carries onand on.
And at any stage in that cycleif somebody refers you to get

(05:50):
somebody to have a proper lookat your pelvis, work out which
of the joints isn't workingproperly and treat it, you can
break into that cycle and startto improve.
So one of the pelvicpartnerships key messages is
don't just put up with it, goand ask for treatment as soon as
you start to get symptoms,really because it's really

(06:12):
treatable.
It's really treatable at anystage in pregnancy and we talked
about random numbers earlier on.
You know the two weeks, sixweeks thing.
Often people will say oh well,you can't get it in the first
trimester, or you can't get itin the first trimester, or you
can't get it in the secondtrimester, or you can't get it
in the third trimester.
It's too early, too late.

Florence (06:30):
If anybody ever says to somebody that it's too
something or other to treat, Ialways suggest we'll go and get
a second opinion then, becausethey probably just don't feel
confident in treating it and soit's definitely worth asking,
asking for some help elsewhereyeah, I was looking at your

(06:51):
website, the pelvic partnershipwebsite, and it really struck me
that one of the resources youhave on the website is a little
leaflet on how to go and talk toyour doctor or midwife, and
it's so practical and sensible.

(07:12):
But it also kind of gave me areal heart sink feeling that
women have got to use certainlanguage or really advocate so
strongly to be heard, and Ifound that quite difficult as a

(07:34):
health professional.
But I can see it's necessarybecause, yes, when a woman comes
, perhaps in the first or secondtrimester, I think as health
professionals we can sometimesfeel a little bit helpless in
knowing, yeah, how, how can weget this treated?
How can we best support thewoman for the remainder of that

(07:58):
pregnancy and and beyond?
So did you produce that leafletas a response, because people
were really struggling to beheard?

Sarah (08:11):
absolutely yes, and one of the things I do for the
public partnership is answer thetelephone helpline.
So I talk with a number ofwomen.
It's actually reduced at themoment because we've got now got
facebook and instagram and lotsof other things and other
members of the team do that.
So I tend to do the phone callsbecause I'm comfortable with

(08:32):
that and so many women will talkabout their experience and
they'll say you know, and I'vetold my gp and they don't
understand, my midwife doesn'tunderstand, and so we talk
through.
I really what I've just talkedabout now and then a bit about
treatment, which we can come onto.
But they say that one of themost useful things is actually

(08:53):
having it validated, that itdoes exist, it's not just in
their head, and that it's okayto go and ask for another
opinion and it's okay to go andsay, actually I really can't
walk, I really have got aproblem, this is pain, this is
not just something that that I'mimagining and I need your help
to get treatment.
And please listen, and and Ithink one of the things that

(09:16):
they find helpful from talkingon the helpline is is that kind
of validation and list, talkingto somebody who's actually had
an experience of PGP and we'renot all the same, you know, we
all have slightly differentsymptoms, but we do understand
what it's like not being heardand being in pain for a long

(09:37):
time and just not being notbeing understood.

Florence (09:42):
Um so yeah, yeah, I can definitely see it fitting
with that slight pattern ofwomen's problems that don't get
listened to.
You know, I, as you're talkingthen I was thinking a little bit
about the episode I've done onhyperemesis and that kind of

(10:04):
slightly old-fashioned thing ofwell, if you just made a bit
more effort, pulled yourselftogether or whatever, you'd deal
with this.
This is a normal pregnancysymptom and yet I see women come
to clinic, on crutches maybe,and really struggling, and
there'd be no other point inlife.

Sarah (10:27):
or when someone came to see you and they were, they'd
lost their mobility so radicallythat you'd be ignoring it no,
absolutely yeah, or just tellingthem that you know, I remember
in my second pregnancy I wasabout 20 weeks and I needed
crutches and the midwife said,oh, it can't be PGP because that

(10:51):
doesn't happen till the thirdtrimester.
And well, yeah, but I can'twalk, so I don't care what you
call it, but actually, yeah, itis PGP.
Yes, and another one was I waspart of the pelvic partnership.
I was part of the MaternityService Liaison Committee so
what's now?
Maternity Voices Partnershipfor a long time and met a

(11:15):
retired GP and I was on crutchesand pregnant and he said, oh,
what have you done to yourself?
And I said, oh, I've got pelvicgirdle pain.
He said, well, if you girlswill get pregnant and I was I
was so angry I just had to walkaway.
I just didn't have the words toto with that, so it.

(11:35):
And when you're already, youknow, pregnant, in pain,
vulnerable, it's really hard tosay what a ridiculous thing to
have said, which is what Iwanted to say.
I just couldn't, I couldn't sayit and I, you know I'm well,
I've changed a lot.
My personality has changedthrough having PGP.
I used to be quite quiet andretiring and I'm still not

(11:59):
terribly extrovert, I think.

Florence (12:02):
but it has made me a lot more confident to speak up
for other people and say,actually that's not an
acceptable thing to say yeahyeah yes, so one of the things
that we say to women in clinic alot is we talk to them about

(12:22):
hormonal changes and the factthat their joints are just
softening and loosening a littlebit and that's partly kind of
preparation for for giving birth.
But the way we've justdiscussed things, the hormones
are not the issue.
Do you want to say anythingabout hormones and what is and

(12:45):
isn't true about hormones?

Sarah (12:47):
yes, I mean, as you say, women.
I would say 99.9% of women aretold oh, it's all your hormones
and that that's why they're toldit'll get better as soon as
you've had the baby, becauseyour hormones will change then.
But actually, if it was yourhormones, no hands on treatment
would work, because you knowhands on treatment doesn't treat

(13:10):
a hormonal problem, does itHormonal imbalance?
And?
But there is, there is a subtlehormonal change and, as you say
, you know your joints do changeduring pregnancy.
But what?
The theory is that?
What that does is it shows up anunderlying imbalance in your
joints.
So you know, if you've had anold injury that you've

(13:31):
functioned really well with, youknow you might have injured
your back at some point and youfunctioned fine when you weren't
pregnant, and then you've gotthat slight hormonal change and
it just shows up and irritatesthat underlying problem.
So the thing you have to sortout is the underlying joint
problem, not the hormones.

(13:51):
But it also comes backpostnatally.
So often, when women's periodsrestart, they'll say oh, you
know, I'll have a terrible week.
My PGB is so much worse.
Now my periods have come backand again it's that subtle
hormonal change and it's just areally clear sign to go and get
somebody to have a look at themechanics of your pelvis and

(14:13):
that will.

Florence (14:14):
That will generally sort it out that's really clear,
that it's kind of unmaskingthat slightly existing issue
yeah that's true of some otherthings in pregnancy, like you
know.
If I think about, I know it'sdifferent, but if you think
about gestational diabetes, orhypertension.

(14:34):
It's that little window thatthe pregnancy changes are just
giving that glimpse into.
This is a potential future orthis is a potential issue that
pregnancy is just unbalancing.

Sarah (14:51):
So that makes sense thinking about it like that yeah
, that, yeah, it does.
and and the same withbreastfeeding.
You know, often women are toldoh well, you know, as soon as
you stop breastfeeding it'll goaway.
And it it doesn't, it doesn'tmake any difference.
And again, there was aScandinavian study where they
looked at a lot of women I can'tremember 46,000 springs to mind

(15:15):
, but I might be making that upbut a lot of women who'd
breastfed or formula fed, andthey found that women who
breastfed got better, fasterthan those who formula fed.
Again, I suspect there's amechanical reason for that.
I suspect it's because ifyou're formula feeding, you're
having to go to the fridge,you're having to make up formula

(15:35):
, all those kind of things.
That's quite difficult ifyou're on crutches or struggling
with a baby, whereas if you'rebreastfeeding, you tend to be
with your baby and and sofeeding is easier is not the
right word, is it?
But once you've got intobreastfeeding, um, it's, the
baby is is more accessible thanthan formula in the fridge in

(15:58):
the middle of the night.
Um, so, yeah, position is themain, the main thing.
Um, for for feeding.
And yeah, don't let anybodytell you that it's because
you're breastfeeding that you're, that you're still having pain,
but it is a really common myththat's really important to to

(16:20):
bust, bust that myth, then yes,definitely yeah, it's

Florence (16:25):
yeah so if I think about my medical training, it's
probably wayfully inadequate inthis area.
We would probably say, get asupport belt and refer to physio
.
But physio may be, may behelpful.

(16:49):
They may or may not be equippedto deal with it.
So I think there's been ashortage of of women's health
physios and maybe some of thewomen I would send would be sent
to a class.
Maybe they'd be given somebasic exercises.
So if you take that as maybethe standard kind of response

(17:13):
people are getting at the moment, what would you be hoping they
would get?

Sarah (17:22):
I think that is absolutely a standard response
if you did a kind of straw pollacross the country and it's sort
of gone back to where it waswhen I had my babies, which is,
you know, my eldest is now 25.
So I've been doing this a longtime and we went through a phase
where people started to listena bit more.

(17:43):
There was lots of hands-ontreatment starting to to take
place and I, along with a coupleof physio colleagues, I ran
some courses around the countryso we trained about 400 physios
over 10 year period in inhands-on manual treatment and

(18:03):
that's impressive.
It was really good, it wasreally powerful to be able to do
that because you could actuallyhave an impact.
And you know that they're still.
You know I still hear from someof them.
You know they're still out theretreating people and getting
them better and the basictreatment is to have a really
good look at at the pelvis,pelvic joints.
So get somebody to undress downto their underwear so they can

(18:26):
actually see and feel the pelvicjoints and then feel what
happens when they stand on oneleg, stand on the other leg,
feel the sacroiliac joints atthe back of the pelvis, whether
one side's a bit stuck orwhether they're moving equally.
Get them to lean forward and dothe same.
You know, feel whether thejoints are moving equally.
Sit on the edge of the bed withyour thumbs on the back of the

(18:48):
pelvis and again feel whetherit's moving equally.
And then check, lying on theirback, check on the, the levels
of the symphysis pubis.
So you're not looking for painbecause the symphysis pubis is
likely to be tender, but you'relooking to see whether one
side's slightly forward or backor up or down.
Okay, and from that you get thekind of 3d idea of what the
pelvis is actually doing andthen they'll work out what

(19:11):
joints not functioning properlyand treat it.
So it's not a long or complexthing to do.
It's really a kind of lookingat the, at the pelvis as a whole
, as a, a mechanical structure,and treating that.
And often you know if peoplehave had it for a while, they've
got tight muscles and so on aswell.

(19:31):
Those will need releasing aswell.
If they've had pain for areally long time, they're likely
to have, you know, somepsychological impact from that,
from being in pain for a longtime.
So that may need treatment aswell.
But the, the kind offundamental hands-on treatment
is kind of key to getting youback on your feet.
And what I say to women on thehelpline is you know, once

(19:55):
you've had the physio should dothe assessment, explain to you
what's wrong, what, what theyfound on the assessment, explain
what they're going to do, do itand you should walk out feeling
different.
So maybe you've got less pain,maybe you can walk better
hopefully both.
But you should feel a changewithin each session and so

(20:15):
that's what a kind of manualtherapy you know, if you're, if
you're getting a really goodmanual therapy treatment should
look like and that is providablein an NHS setting.
What's happened in the last fewyears with COVID is that there's
been a lot less face-to-facephysio treatment in the NHS.

(20:38):
The private practitionersreturned to treatment a lot
faster, so they were able to seepeople face to face, and a lot
of the NHS physio is stillsheets of exercises, telephone
advice, that kind of thing.
So it's really variable whatpeople are getting.
That's had a huge impact onwomen, because if you can pay

(21:01):
for it, you can therefore gettreatment in, because if you can
pay for it, you can thereforeget treatment, and if you can't,
you're in a really sticky placebecause you can't you know you
can't access the, the manualtherapy.
And just just going back to whatsomething you said about
women's health physio, itdoesn't have to be women's
health physio.
So the physio who treated mewas a private physio in the end

(21:22):
because they had tried NHSphysios and not improved because
I was just getting exercisesand advice.
Like I say, this is 25 yearsago, but the physio I saw was a
rugby physio so she was used totreating mashed up pelvises and
biomechanical problems.
So often a sports injury physiois a really good person to go

(21:45):
and see because they've got thatkind of hands-on, mechanical
mindset really to treating itthat's really interesting.

Florence (21:56):
I I think one of the things I've learned already
today, kind of preparing forthis chat, was the idea that
after every session you shouldfeel some difference, some
change, I mean that's.
That's feels almost like magicto me when I when.

(22:19):
So something so simple and yetseemingly so unobtainable,
because I think of the women Isee in pain for weeks and months
or, like you've described,years, and yet even from a
single session with the rightperson, with the knowledge, it

(22:44):
could make a difference.
That's astounding, really.
I'm also interested in what yousaid about sports physio,
actually, because I thinkthere's a lot within the NHS
that almost we don't understandour own bodies or we don't have
the capacity to do that.

(23:04):
I had a bad back quite a fewyears ago now and because I am a
doctor, I looked up the NICEguidance and I saw that the only
thing there was any evidencefor really was Pilates, and so I
took myself off to Pilates andI've had to pay for it, but I

(23:27):
don't have a bad back anymoreyou know, because I do Pilates
regularly and I've got themuscle strength and the
realignment and everything.
So I can really see how doingthe right thing could make a big
difference.
Make a big difference.
So you mentioned it's kind of abit patchy, so you should be

(23:47):
able to get this on the NHS butyou might not be able to.
What when you kind of look atyour people using your helpline
or website and so on?
You you did a little surveywhat sort of proportion of
people are able to access propermanual treatment on the nhs?

Sarah (24:12):
yes, you mentioned our survey, so this this was done
last year, so it's a sort ofit's a post-COVID survey, and
86% of respondents weren'toffered manual therapy on the
NHS.
The previous year it was 80%.

Florence (24:33):
Sorry, 80% 86% didn't get it, didn't get it no.
But, only 14% are actuallygetting it on the NHS.

Sarah (24:43):
Yeah, wow.

Florence (24:47):
That's really depressing.

Sarah (24:49):
It is, and it's really difficult when I'm talking to
women on the helpline saying youknow you can get better, can
you pay?
So you know, I always say goback to your NHS physio, go back
to your GP, start there,because if they don't know that
there's a need, if it's notregistered, then the NHS is

(25:10):
never going to improve yes somepeople are just so desperate,
you know they've already beenaround the houses for months and
they say actually I justhaven't got the energy to do
that, I'm going to go straightto to a private physio and if
you are going to go private, howdo you decide who's a kind of

(25:39):
reputable OK or someone that'sgoing to have the right skills?
Yeah, I mean there are variousways of finding somebody.
So there is a website calledPhysio First where all private
physios have to be registeredand you can look up there
somebody who does sportsinjuries and manual therapy, and

(26:01):
you know, you can enter yourpostcode and and find somebody.
We do have a list ofrecommended practitioners so on
our website.
So that's people who've beenrecommended by at least two
other women and they've got themfrom.
You know, crutches, crutches tosignificantly better.
So not just, oh yes, they werereally nice to me.

(26:22):
It's quite hard to weed thatout because you know we've got
lots of people who would like tobe on our recommended
practitioners list, but actuallywe're quite fussy about who we
let on but we don't check themdirectly.
So it's not not a list ofpeople we validated, it's just
that's that.
Other women have have said thatthis person was really good and

(26:46):
really, I think, having quitehigh expectations.
So you know, if you seesomebody and they say, oh yes,
it's going to be at least sixmonths before you see any
improvement, then that's, that'sa no-no for me.
That would be a complete redflag.
And if you've seen somebody fortwo or three sessions and you
don't really feel that you'remaking much improvement, having

(27:09):
that really grown-upconversation, say, look, we
don't seem to be gettinganywhere very fast.
Do you know why that is?
Or would it be helpful to lookat this with a colleague so that
we can and anybody who's goodwill be confident enough to
bring their colleague in and say, look, I'm really stuck with
this and I mean I'm sure you'ddo that as a doctor.

(27:31):
You would discuss it with acolleague and say, what do you
think?
And it's a sign of really goodpractice.
It's not a sign of lack ofcompetence, it's a sign of
really good practice.
It's not a sign of lack ofcompetence.
So it's having having highexpectations really of the
clinician, whether you're payingfor them or not.
Actually, you know, even if,even if you're getting free

(27:54):
treatment on the NHS, if you'renot getting any better and
you've been seeing them for sixmonths, this is your life that's
passing by.
Yes, yes, I think, havinghaving those conversations and
and asking so.
So why are we not improvingwhat?
What's the problem?

Florence (28:07):
yes, I think that's a very good point.
I think certainly you'reabsolutely right.
As a doctor, I get otheropinions and you know my
colleagues do as well.
We're kind of oh I've got thistricky situation, what would you
do?
Or I don't know about this.
Can you help me?
So definitely that's a strength.
I I would agree with you.
And if women can't afford it,can they?

(28:32):
Can they get funding fromanywhere?

Sarah (28:35):
there is a, an organization, it's a charity
called Frederick AndrewCharitable Trust, fact, and they
do fund some treatments forpeople who can't afford it.
But you know, it's a small,it's a small organisation, so
they don't have unlimited funds.
But if people are in direstraits we do know of a few

(28:56):
people who have managed toaccess funding through that.
But often people ask family andfriends and and you know, ask
for for support to to gettreatment.
And particularly if you'reseeing somebody really good, it
may not be that expensive.
You may only need sort of threeor four treatments to get

(29:17):
significantly better.
So it shouldn't be that you'regoing to have to spend your life
savings on this.
And also, if you know, ifyou're in in the situation I was
in, you know, 14 monthspostnatally I couldn't have gone
back to work.
But if I'd been able to getback to work and and then earn
money, you know it kind of paysitself back.

(29:38):
It's that kind of sometimesthat sort of investment.
But you know, everybody's invery individual positions,
aren't they?
And some people just can'tafford it and therefore I think
going back to the NHS and sayingthis isn't working you know,
I've not had treatment, I'm notany better.

(29:59):
This isn't working.
You know, I've not hadtreatment.
I'm not any better.
Please don't just fog me offwith a pain clinic, or what's
happening at the moment is a lotof women are being told, as I
was 25 years ago oh, this is all, it's all in your head.
You know, it's because you'redepressed and overweight and not
exercising enough.
Well, I was depressed because Iwas in pain.
I was overweight because Icouldn't exercise and I wasn't

(30:20):
depressed because I was in pain.
I was overweight because Icouldn't exercise and I wasn't
exercising because I was in painand depressed.
You know, it was very much akind of three or a multi
multifaceted problem and oncethe pain was reduced, because I
and then I could walk, my lifewas transformed.
You know, it really istransformative getting getting
treatment that that reduces yourpain yes, I can.

Florence (30:45):
I can hear that and that sort of brings me to the
next thing we were planning totalk about, which is stories of
of people and the the impact.
I think really trying to getpeople to understand the impact
that PGP has on people's lives.

(31:06):
So we've talked quite a bitabout the physical symptoms in
terms of pain and limitedmobility, but and you've just
touched slightly there onpsychological aspects, but also
looking after other kids, work,et cetera.

(31:27):
So I don't know if you wantedto share any particular thoughts
about what people are tellingyou about the impact it's having
on them and their lives oftelling you about the impact
it's having on on them and theirlives.

Sarah (31:45):
Yeah, I think it's something that, during a
discussion on on the helpline,often people go through sort of
their symptoms and and then wetalk about treatment and and so
on, and then they can often getquite tearful and say, you know,
this just has taken over mylife, because anything I do
hurts, whether I'm standing,sitting, lying, because your
pelvis is at the center of yourbody, isn't it?

(32:09):
So you know, if you're sittingdown, your trunk is sitting on
your pelvis and if you try tomove a leg or even an arm, you
know everything is linked intoyour pelvis.
If it hurts, it thereforeaffects everything you do, and
you know that does have aneffect on looking after your own
children.
Or, you know, going out to work.

(32:31):
People will say they've managedto negotiate a parking space
near the office door so thatthey can get into work and you
just think, gosh, that justshouldn't be that hard to do it.
You know, if you've got anemployee who's on crutches, you
would think it.
It should be, as an employer,an obvious thing to do to to

(32:54):
work out how you're going to getthem to work uncomfortable but
but just just thinking aboutsome of the stories that that
people tell me about treatmentand and recovery, that one of
the ones that really sticks inmy mind, which I mentioned to
you, is a woman in her 70s who'dhad pain in her pelvis since

(33:17):
she had her, her baby in her 30sand she'd split up from her
partner.
She'd only ever had the one babyand she just had quite a tricky
life managing around this andit just gradually got worse and
worse to the point where she waspretty much housebound, taking

(33:38):
morphine and just vomiting withthe pain because it was so
severe, and the GP was saying oh, you know, there's nothing more
we could do, you just have tolive with this.
And I think we'd done an articleon in a magazine or something
and she that she'd read and shethought that sounds just like me
, even though I had my baby 40years ago, and so we talked

(34:01):
through exactly the same thingsabout how the pelvis works and
what treatment involves.
And so she went off and foundan osteopath who treated her and
she wrote to us a few weekslater and said she'd had, I
think, three or four sessions ofosteopathy and it had just been
transformative.
She didn't need morphine, she'dcome off all the pain relief

(34:24):
and she'd gone horse riding.
And you know, just to just toknow that it made that much
difference is enormous.
And that's just from a fewsessions of treatment and she
could have had such a differentlife.

Florence (34:38):
That's such a powerful story and I agree I was just
thinking, oh, all those wastedyears of pain.
I mean that's just devastating,but so incredible that getting
the effective, right treatmentcould make such a difference.
I mean I've just been flickingthrough some of the.
So you sent me a copy of thesurvey and some of the comments

(35:03):
people are making about, youknow, just being told to kind of
put up with it or being unableto walk even five steps impact

(35:23):
on their well-being, theirability to exercise and their
mental health.
I mean it's just everything,isn't it?
it's so debilitating and and soso sad that we're not managing
to effectively treat and respondto this and particularly when
it's so treatable.

Sarah (35:39):
Yes, and and that's why the pelvic partnership exists,
because we're, you know, we'vegot a fantastic committee of
volunteers and trustees who'veall had pgp and all feel
absolutely passionately thatthis should not be happening to
anybody else, that this, this istreatable.
It's treatable early inpregnancy.

(36:01):
Why are we just letting womenexperience this when they and
and the impact it's having onthe rest of their lives and
society as a whole of havingwomen disabled in this way, and
it doesn't make any sense and itdoesn't make any sense.

Florence (36:25):
Something I was thinking about was a little bit
about labor care, becausesometimes when we see a woman
with pgp, we get kind ofinstructions about trying to
avoid lithotomy position, forexample, or something about the

(36:52):
angle at which she can or can'tmove her hips and legs and not
going beyond that you know.
However, many degrees and I wantto, you know, work with that
and do the right thing.
And obviously sometimes inlabor that can be easy.
You can maybe use water or youcan be on your side if you're

(37:13):
having epidural.
But there are some situationsin which I find it really
difficult because actually I doneed to think about lithotomy
position.
Maybe there's been a bad tearthat I need to repair or there's
a need for an assistive vaginalbirth, and I find that really

(37:34):
quite challenging to know how tokind of fit what I might need
to do to help one aspect of thatwoman's care alongside the need
to try and support and notexacerbate her, her PGP symptoms

(37:56):
and problems.
So I don't know if there's anykind of wisdom you could share
about that yeah, I don't knowabout wisdom, but I can give you
some ideas.

Sarah (38:06):
So, like you say, water can be fantastic with PGP,
because it just means you canmove.
So I had my second baby at ahospital water birth and my
third at a home water birth,which was just fantastic were

(38:28):
being able to move.
You know, I could changeposition just by pulling on my
arms, I could roll over andthings like that, rather than on
land.
I was, yeah, beached whale,didn't describe it and and I do
very long pregnancies as well.
So I did 42 weeks for each ofmy pregnancies, so I was quite
big by the time my babiesdecided they were going to turn
up.
But things like lithotomy it's.
It is really important and Ithink you know you're halfway

(38:50):
there, actually thinking aboutwhat am I going to do here,
because you can be reallycareful with the pelvis, can't
you?
You can.
I mean, the key things arekeeping the legs symmetrical, so
you know if you're lifting bothlegs up at the same time so
that they're in a symmetricalposition, having them up for as
short a time as possible andjust really thinking about.

(39:25):
Do you know, thinking beforebefore the woman goes into labor
, actually what?
What are the options going tobe if you do need assisted
delivery and have thoseconversations in advance, not
when you get to a difficult umdecision.
But you know, I remember onewoman fairly early on in pelvic
partnership days and she had atwo inch pain-free gap but she

(39:49):
managed to give birth.
She said it was fantastic lyingon her side with somebody
supporting her top leg and andshe managed to give birth like
that without aggravating it, andshe said it was transformative
because it just didn't give herall that aggravation and
exacerbation that she had had inher previous births.

(40:10):
For this birth it made adifference.
And then the the other thing toconsider that you know I've
heard some obstetricians sayingit is possible is if you're
doing the forceps or volunteersdoing it inside lying so that
you're not actually going intolithotomy um to do that.

(40:32):
I remember going into into thehospital.
One of the reasons I decidednot to have a hospital birth for
my third.
I went in and with my secondand you know I was on crutches
and struggling a bit and I hadplanned water birth and my birth
options were water birth or, ifthat, if anything was going,

(40:55):
slightly pear shaped cesarean.
I wasn't going to do anythingbetween, because I had an awful
forceps first time round wherenobody looked after my legs, and
it really made my pelvis muchworse.
Nobody looked after my legs andit really made my pelvis much
worse.
So the midwife wanted me to lieon my back on the bed and I

(41:19):
said well, I can't, because assoon as I lie on my back on the
bed I know my sacroiliac jointswill shift and I don't lie on my
back anywhere else.
So no, I can't.
And so she was quite cross aboutit and I said you know, if you
want to examine me, you can doit lying on my side.
So sort of huffed and puffedand did.
And then she said now we needto do a CTG for 20 minutes.
And I said well, I don't, Idon't want a CTG.

(41:41):
You know, I've written that inmy birth plan.
I'd like intermittentauscultation.
All is well, as far as we know.
So I don't think I need it.
And she said oh well, I'll haveto do intermittent auscultation
for 20 minutes.
And you can't do that.
And I said I don't think you do, do you?
So she huffed and puffed again,went off to see my consultant
who was upstairs.

(42:01):
I don't know what theconsultant said, but five
minutes later the pool wasrunning.
I had a different midwife.
He was quite happy to do it.
You know, it's just thatlistening, supportive, not
saying.
This is what our protocol is.
So you've got to follow it,even though we've had these
discussions ad nauseum duringyour pregnancy.
Yeah, so sorry, that wasanother ramble, but I think it's

(42:26):
the the thing about listeningand which you know clearly
you're doing, if you're eventhinking what are we going to do
with the lithotomy position.
It's, it's listening andthinking and thinking about how
can we do it and how can we makesure that mechanics work here
yes yeah yeah, no, I don't thinkyou're rambling at all.

Florence (42:46):
I think it's really valuable.
I think that sort of.
Also, I do get women coming andsaying this is so un much
choice and women have a cesareanfor so many different reasons.

(43:14):
But I do worry that I'm kind ofadding insult to injury so I, I
will never, I'll never not givesomeone a cesarean if they feel
that's the right thing for them, obviously, but I do worry.
Oh, I'm adding a surgicalintervention and a surgical

(43:34):
operative recovery to a womanwho's already got a debilitating
problem.

Sarah (43:41):
Am I just multiplying the difficulty in the postnatal
period for her yeah so I do findthat quite difficult to kind of
help her think through andbalance up yeah, and I don't
think there's a right or wronganswer, because I think, yeah,
the women I talk to, the, theones who, who do better, the

(44:05):
ones who've actually made achoice and been supported in
that choice.
So, whether they want a vaginalbirth, and that's supported, or
they want a cesarean birth, andthat's supported, they, they do
okay.
It's the ones who want avaginal birth but are told no,
you have to have a cesarean.
And they then have symptomsafterwards and they say, well, I
told you so if I'd had a vagina, you know if I'd, or whichever

(44:28):
way around.
It is, and there was a studydone in in Scandinavia, probably
about 10 years ago now, wherethey looked at recovery
post-cesarean and found that yourecovered slightly more slowly
after cesarean.
But it was a cohort study, soit was just following people

(44:49):
through, it wasn't randomizing.
So I suspect it was probablypeople with more severe symptoms
who were having cesareans.
Therefore, you might expectthem to recover more slowly.
But that's the only, that's theonly research I've seen on it
and I think.
I think choice is reallyimportant, I know.
For again, for my second, I wasabsolutely panicked.

(45:10):
I'd planned the pregnancy, butI was really panicked about how
I was going to get this baby outwhen I was eight weeks pregnant
because the first, my firstbirth had been so awful.
So I changed hospital, changedconsultant, and the consultant
said, yeah, absolutely fine, youknow, I think probably along

(45:30):
your lines.
Florence said, you know, we'llsupport whatever you'd like to
do.
And so I was booked in for mycesarean when I was eight weeks
pregnant, and that just allowedmy headspace to free up and
think, ok, that's, that's great,that's what I'm going to do.
And then I carried on havingphysio all the way through and I
gradually, you know, stayed onmy feet and even though I needed

(45:53):
crutches and I wasn't supermobile, I, you know, I wasn't in
pain all the time.
It was, it was manageable.
And when I got to about 20-25weeks, I started thinking, oh
well, maybe I could have thatwater birth that I really wanted
, and so started and said youknow, do you to her, do you
think that's magic?

(46:13):
No, no, you do what you like,but you know, if you change your
mind either way.
And so that was how I ended uphaving that water birth.
And then, third time around,she was really supportive of the
home birth and just said youknow, absolutely, obviously, by
this stage I knew that.
I knew in my head that I couldgive birth and so I didn't.

(46:35):
And the hospital experiencehadn't you know there'd been a
lot of saying, no, I don't wantthis, no, I don't want that.
Could you leave me alone,please, um?
Whereas at home I could have amidwife on you and, um, she was
quite happy to, to support whatI needed.
So the the second birth wasempowering, but the the third
birth was really kind of almosta healing type of experience.

(46:58):
That that actually I feltreally listened to and supported
and it was.
It was complete, completelydifferent, and I didn't feel the
need by then.
I didn't feel the need to haveany more babies to prove I could
do it.

Florence (47:14):
I'd achieved that, yeah yeah, I think that's the
key, isn't it?
It's the being alongsidesomeone, listening to,
supporting and understanding,isn't it?
And?

Sarah (47:27):
I mean, it's like like everything really we.

Florence (47:31):
If we get that right, then actually some of the kind
of nuts and bolts and medicalstuff isn't the important stuff.
It's it's the listening to andacknowledging and all the soft
stuff.
Isn't it that's that's socrucial to how people come
through it or, yeah, and comeout of it, so obviously after

(47:57):
you've given birth?
We're encouraging women toperhaps think about a pelvic
floor and doing pelvic floorexercises in the postnatal
period particularly, but alsoduring pregnancy.
Does the pelvic floor musclesand perhaps birth injuries to
the pelvic floor, does that playinto pelvic girdle pain and

(48:21):
have have an impact?

Sarah (48:22):
do you find yes, it can have quite an impact because the
pelvic floor attaches onto thesacrum at the back and the
symphysis pubis at the front, soit's kind of another part of
the muscles surrounding thepelvis.
So, particularly if you've hadan episiotomy or a tear, you can
end up with some tight scartissue in that area which can

(48:54):
then lead to a tight area inthat side of your pelvic floor
and that then often women aretold you know, do lots of
tightening exercises, lift upyour pelvic floor, lift and let
go, and all that, and that canjust exacerbate it, so they end
up with a really, really tightbit on one side and the other
side just sort of think, oh well, that side's doing all the hard

(49:14):
work, so I'll just stop, and sothey've still got the
continence problems or the painor whatever, despite doing all
those exercises.
And also because it's holding onto the, the symphysis and the
sacrum, it also, even if you'vehad your pelvis aligned,
realigned it can sometimes thenpull it back out of alignment

(49:36):
and aggravate your your pelvicgirdle pain problems as well.
So, finding a physio and theseare much more available on the
nhs a pelvic floor physio whowill treat an overactive pelvic
floor and they'll do someinternal work to release tight
areas and show you how to how todo that and often give you some

(49:57):
releasing type exercises andthat then allows that area to to
kind of release and become morebalanced with the the other
side and then your pelvis worksand your pelvic floor works as a
whole again together that makesa lot of sense.

Florence (50:17):
But again, you're educating me because I have had
women come and tell me oh no, myphysio told me I've, I've got
to relax bits of my pelvic floor.
Yeah, and I must admit I was alittle bit confused because
that's completely the oppositeto everything I've been taught
historically in my training.
Yeah, so, but now you'veexplained it like that

(50:40):
beautifully, I can see.
Yes, it's that misalignment andtight bits yeah that need
releasing to balance everythingyeah, yes, that makes sense.

Sarah (50:51):
It's like any bits of the body, though.
It all has to worksymmetrically to work properly,
doesn't it?
And and if you've only got onehalf of it working, the other
side either becomes floppy orvery tight.
But it, you know, they have toboth be, have normal tone and
normal activity to be able towork as a whole yes, yeah, and

(51:12):
you're right that is becomingmore available.

Florence (51:15):
On the NHS, definitely because there's been quite a
lot of focus in the maternitytransformation program and then
the long-term NHS plan on pelvicfloor health for women after
childbirth.

Sarah (51:32):
So definitely something people can go away and and
access some help with yeah, andthe the long-term plan does also
include PGP, but only in a verysmall way.
So we're trying to just raiseawareness that actually it is in
there and it should be part ofany pelvic health service.

(51:53):
But but in a way pelvic floortreatment is much easier to to
kind of administer, it's muchclearer and you've got a cohort
of women's health physios whohave the skills to do it already
.
So it's much easier to focus onthat than expand out and treat
pgp, and that's why we try andencourage people to not just

(52:16):
think about it as a women'shealth problem but think about
it as a musculoskeletal problem.
So if you've got a goodmusculoskeletal physio and they
should be able to help, but notwith your pelvic floor yes just
to be clear, you might need.

Florence (52:31):
You might need two physios yes, you may well do
yeah, yes yeah, two physios andsome talking therapy.

Sarah (52:38):
You may need all of those , if you know, if you've had
pain for a long time, you mayneed all of that.
Yeah, and I think that'sprobably what we're trying to do
with the pelvic partnership istrying to move people into that
space where they feel actually Ican ask for the thing that I
want or the thing that I need.
And it's okay to ask, and also,I'm not the only one in this

(52:59):
position.
There are lots of other womenout there like me, and so it's
having that tribe almost of ofpeople who understand and and
who will support.
And I always say the end of mycalls you know, do come back if
you, if you want to discuss itanymore.
And I have some repeat callers,particularly people who've had

(53:20):
it for a while, who call aboutevery six months saying you know
, I've hit a bit of a roadblockand we kind of reset and discuss
what their options are and andmove on.
But generally people don't needto come back that often that
once they've got that kind of,actually I could do this and the
information's all there.

(53:42):
Yeah, we touched on.
We touched on the kind ofpsychological impact as well and
there is a kind of grievingprocess and we talked about the
woman in her 70s who hadtreatment but had had the impact
of PGP throughout her life, andI think it also has a massive

(54:04):
impact, you know, if you'reduring a pregnancy and you're
not able to be like the othermums and you're not able to be
like the glossy magazines sayyou should be, and you know, I
often get women talking to meabout sort of three, four months
postnatally and they say youknow, I can't do any of these
things and I can't push the pramand I, you know, I can't take

(54:26):
my baby out and show him off,and and I think there is a sense
of grief and and loss from notbeing able to do all the all
those things.
Yeah, I think I think it spreadsacross a huge number of areas
of their lives.
But I think it's reallyimportant firstly to to get
treatment, but also to getpsychological support to help

(54:48):
with that, because it's reallyimportant to acknowledge the
loss that they're experiencingas well into potentially whether
or not they're going to havemore children in the future or

(55:10):
how?
they approach another pregnancybecause they're still carrying
all that with them yes, yeah,yeah, and I have a lot of those
conversations as well, withwomen saying I really want
another baby but I can't bearthe thought of it.
And we talk about treatment alot and also about some people

(55:33):
are told oh well, you know, itmight not happen this time.
I think that's really unfair tosay to somebody, because it's
much more likely to happen thannot, particularly if you've not
had good treatment, whereas ifyou say, well, if you get
treatment now and you go into apregnancy with minimal pain,
you're starting from a goodpoint.

(55:54):
You've got a good clinicianwho's going to look after you
all the way through thepregnancy.
Negotiate that with them.
You know I negotiated with myphysio.
I'm thinking about gettingpregnant.
You're not going anywhere, areyou?
Because I need you know I needyou around for the next nine
months and do that planning.
And have you got somebody whocan help with sort of hands-on

(56:18):
stuff with the toddlers and andthat kind of thing?
But yeah, there's quite a fewof us in the pelvic partnership
who've had two or three babiesand and just that planning is
really important and not notbeing told oh well, it might, it
might be okay this time wishfulthinking isn't it.

(56:38):
Well it's?
It's sort of fobbing off, isn'tit?
it's it's sort of saying oh well, it's not that important anyway
, it's only aches and pains ofpregnancy yes yeah, we wrote an
essay for the heather trickyprize a couple of years ago and
we were joint winners withanother woman from pelvic
partnership, so there were twopelvic partnership essays in it

(56:59):
and that was the kind of whatone of the key things really was
around the women being fobbedoff and gaslit and told it
wasn't really happening and itwas all in their head and yeah,
it just isn't.
It's treatable and it'smechanical.
Yeah.

Florence (57:22):
I normally end my episode with a zesty bit, a kind
of this is the really key thingthat we want people to remember
from our conversation.
I don't know if you have anythoughts on that.

Sarah (57:41):
PGP is treatable.
It's never too early, too late,too severe, severe, too mild to
you're not, never too old, toofat, too thin to anything.
If anybody's saying any ofthose things to you, you're
being fobbed off and do, do askagain and and just keep trying.

(58:02):
And if all else fails, get incontact with the pelvic
partnership.
We're happy to talk you throughit.
But, yeah, really happy to tosupport anybody who needs help.

Florence (58:13):
That is definitely my takeaway that this is really
treatable.
I don't think I'd appreciatedhow I'd appreciated it was
treatable, but not how I'dappreciated it was treatable,
but not how I hesitate to saythe word easily treatable
because it's not easy if youcan't access the right NHS care,

(58:33):
but if you have the rightperson, easily treatable yeah
yeah, I think.

Sarah (58:41):
I think the only caveat to that is people who are hyper
mobile.
Where that it may be, may takelonger, more complex, but still
the same principles apply, thatyou should never be fobbed off
and told nothing can be done.
Just thinking about, mybackground is as a neurophysio

(59:03):
originally, and I wasn't able togo back to that because of my
pelvis, because of the treatmentI didn't get.
But there you were oftendealing with people with really
long-term problems and there wasalways something that you could
do to improve them.
And I suppose I just kind ofapply that principle in life,
that and particularly to PGP,that that even if you've had it

(59:25):
a really long time or or you'vegot really difficult, complex
issues just a bit like the theeating an elephant analogy you
just do it bit by bit and keepmoving it forward and you will
get there and some you know,sometimes it takes a while, but
it's really worth perseveringand getting your life back.

Florence (59:48):
I think that's really good advice, and I think one of
the things that makes me sopassionate about maternity care
and the work that I do is theidea that we're looking after a
cohort of people who are givingbirth to the next generation.
So we're setting the health ofthe next generation, but also

(01:00:14):
looking after people who are, bydefinition, usually young and
therefore the potential you canhave, not only in the pregnancy
but in forming good healthhabits for the rest of their
lives and, um, you know, interms of healthy eating and
exercise and smoking and allthese other things, and and

(01:00:37):
pelvic and and physical healthis the same, the impact you can
have is much greater becausethey've got, hopefully, years
and years of longevity in frontof them if you can get it right.
But then that means if you getit wrong, you're you're kind of
dooming them to a reallydifficult time for a prolonged

(01:00:58):
period.
So I think you're right.
There's that thing of keepchipping away.
There is hope, even if it seemsintractable and very difficult.
So you're doing phenomenal work.

Sarah (01:01:14):
Thank you.
Thank you.
I'm really proud of what we doand we do have some really good
resources on the website.
So we've got a video of whattreatment looks like which goes
through in a bit more detail.

Florence (01:01:28):
So you know, sometimes being armed with that kind of
information and, like you said,the toolkit about how to explain
it to you, to a midwife ordoctor, who you know just isn't
familiar with it and doesn'treally understand what, what's
needed, can be really helpfulyes, I will put a link to the
website and some of thoseresources in the in the show

(01:01:51):
notes of the episode so peoplecan go off and explore it,
because I my hope from today'sconversation is that we educate
a few more midwives, studentmidwives, obstetricians and also
, obviously, pregnant womenthemselves or postnatal women
who are still struggling well.

(01:02:11):
Thank you so so much, sarah,for giving up your time.
That has been such a greatconversation.
There's so much richinformation and knowledge and
experience there.
So, yeah, I'm very grateful toyou.
Thank, yeah, I'm very gratefulto you.

Sarah (01:02:27):
Thank you.
Well, I'm really grateful toyou for doing it, because I'm
hoping that it'll be anopportunity to get the message
out there yeah, absolutely, andfor lots more women to get
really good treatment.

Florence (01:02:40):
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interesting.
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, rate and review, on whateverplatform you find, your podcasts
, as well as recommending theOBS pod to anyone you think
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(01:03:00):
There's also tons of episodesto explore in my back catalogue,
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and life in the NHS moregenerally.
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very seriously and take greatcare not to use any patient

(01:03:25):
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permission of the personinvolved on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at

(01:03:48):
the programme notes, where I'veattached some links.
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(01:04:09):
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Episode 176 Pelvic Girdle Pain (PGP) - a chat with Sarah

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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Episode 176 Pelvic Girdle Pain (PGP) - a chat with Sarah