Hello dear reader and fellow colleagues! I'm extremely excited about this post and especially about the new MED-HIVE community 😁. I have a feeling that great things will come from this community 😊. The idea of creating an international database of health related information and being able to interact and discuss different subjects with fellow colleagues around the world is just amazing. And most important, a decentralised one!

For the readers that already know me and follow along my posts, you probably know one of my goals for my Hive journey. As stated on my own intro post back in December of 2021, that goal is:

Empowering women on Hive who experience motherhood with information and tools to help on their journey.

However, sadly, I must confess I haven't done any concrete steps towards this goal just yet. To be honest I'm just afraid of getting out of my comfort zone, to be able to affirm my opinion and expose myself out there, professionally speaking.

My mind is always telling me that I don't have enough knowledge about it yet, therefore I shouldn't even speak about it. This deep and wrong belief is keeping me from progressing. I'm paralysed by fear. But then... Aren't we all afraid?

For that reason, and after a great amount of encouragement given by fellow hivers, (to whom I will properly give my gratitude in the end) now is the time to push forward and just go for it!

Lastly, before I begin, to all the non-medical readers, today's post will be a bit more technical. But don't give up on me just yet dear reader, because I will do my best to try and leave several practical, easy understandable tips throughout, while trying to explaining the best I can all the difficult and technical language 🤗 (note to self - oh boy! It's gonna be a long post 😅...).

With that being said, this week's prompt is about Obstetrics, more specifically the health of the mother and child. In fact, all the content I hope to develop here on this community is within this topic, therefore the minute I saw this I was a bit overwhelmed! There's just so much to talk about it that, at the time, it seemed impossible to know how to start.

Luckly, thanks to the kindness of @jaydr who clarified things for me, I was able to choose one topic within obstetrics to talk about. Therefore, I'm going to explore the biomechanics of pregnancy and how it can affect quality of life. That is, the main changes that occur in the joints, motion and function of the body while gestating and how they influence the quality of life in that time-frame.

As the theme I want to start to explore here is so complex, I'm going to have to divide it into a series of three posts, as kindly and cleverly suggested by my dear friend @samsmith1971. That way I think it will be easier to explain some important things for all the non-medical readers in the easiest way I can, which I believe is the major goal of this community. To share information accessible to all hivers. By doing so I also hope not to bore or overwhelm my dear readers with too much information at once.

I'll be supporting my statements from this systematic review from 2019, which was the most recent I found. So, throughout my post you will see quotes retrieved from this article. In the next section of this post, I'll review the information I find most relevant about this paper while adding some notes for the non-medical readers and how I relate all of this information with my clinical practice.

Dear reader, are you as excited as I am to discover all the wonders the pregnant body is capable of?

During pregnancy, a number of biomechanical and hormonal changes occur that can alter spinal curvature, balance, and gait patterns by affecting key areas of the human body.

This means that certain hormones and some expected changes of the human body during pregnancy have the ability to change our posture, our balance and the way we walk. All those changes happen for a reason and on this post we'll dive into the changes in our posture during pregnancy.

Biomechanics is just a fancy way for us to study and understand how and why those changes happen in the first place, as well as their consequence on the capability to move (function) and pain relationship.

Let's find out how and why, shall we, dear reader?

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Posture

Studies have shown that pregnancy significantly increases the lordotic angle of the spine [21], as well as the kyphotic angle in the developing pregnancy between trimesters two and three [4,22].

Ok ok! Don't go anywhere just yet, let's try to make it simple 😁. So the lordotic angle is the reference for the curvature of our lower back. Three good quality studies say that the curvature increases during pregnancy, more accentuated between the 2nd and 3rd trimesters. The kyphotic angle refers to the top of our back, from the lower back until the neck and also is shown to increase during pregnancy.

Too hard? Here's a GIF to demonstrate in a few seconds the amazing and deep change that can occur during pregnancy. It may seem weird in my non-pregnant body and I made a marked move to show you what I mean, so don't panic 😊. It's just a demonstration of the increased curvature of the spine overall.

This assumption is also widely spread in my country and in several of my fellow physio colleagues.

Would you say this happens to every pregnant person? Let's see!

Other studies report findings of increased lordosis in the third trimester of pregnancy (preceded by a small reduction between trimesters one and two), but no changes in kyphotic angles throughout pregnancy
However, Betsch et al. [25] found that there was no change in lordotic angle during pregnancy but an increase in kyphosis was observed both in the developing pregnancy and when comparing pregnancy results to postpartum results. Another study observed no changes in either kyphosis or lordosis angles throughout pregnancy [26]

So, what this means is that other good quality studies have found that lower back curvature increased only on the 3rd trimester and was a bit reduced in the 1st and 2nd, while there was no changes at all in the top back. Others found no changes in the lower back but an increase on the top curvature. And even other study that reported no changes at all in those spine curvatures.

Confused? I was too at the time I read this. But with this information, we can say that:

it is likely that spinal curvature of the participants varies depending on the individual. This difference could be due to factors including body weight and tendency to exercise.

It seems about right. So it's safer to presume that the changes in our spine can vary from person to person during pregnancy, and therefore we cannot say that every pregnant person has an increase of both spine curvatures.

The degree of pelvic tilt has also been shown to change in pregnant women, while the results vary among studies. Pelvic tilt has been shown to be significantly more anterior in pregnant women in their third trimester, in comparison to non-pregnant control women [28], which can cause instability.

So now we are going further down, over to the pelvis. This bone structure is the home to our pelvic organs: the cervix, uterus, bladder, urethra, rectum and vagina. For understanding the movement of the pelvis let's do an exercise.

Please stand up. Imagine your pelvis as a bucket full of water, to the top.

_Source

Now, try and tilt your bucket forwards as if you wanna pour a few drops ahead of you. Got it? Great! Now tilt backwards, pouring a few more drops behind you. If you're moving like this I'll be the happiest physio in the world as it is a sign I was able to explained it right (note to self - it's much harder finding relatable metaphors in English 😆).

So, the evidence suggests that during pregnancy our pelvis becomes progressively more tilted forward and this is a significant change in the 3rd trimester. It's like our bucket is always in a position that pours the water in our front - called anterior tilt. You can see the first movement I do in the GIF above is the anterior tilt of the pelvis.

Do you see the position my lower back gets with that tilt forward?

The available literature discusses the idea that the tilt of the pelvis may be associated with alterations in the spine. Weakened abdominal muscles during pregnancy due to increased levels of relaxin and progesterone (which relax the muscles), or as a result of the overstretching of the muscles due to increased abdominal size, are thought to be responsible for an increase in anterior pelvic tilt. An anteriorly-tilted pelvis shortens the hip flexors and increases lordosis of the spine.

Simply put, it's all very much connected! Our body is one, no muscle works alone and every joint is deeply influenced by the others. So it's easy to understand that our belly stretches (A LOT!) in order to make room for the developing baby and growth of the uterus. So, our abdominal muscles stay in a stretched position for a long time. This deeply affects their ability to contract because they are in a whole new position. In addition, the hormone changes during pregnancy causes them to become more relaxed and floppy otherwise they would tear with that much stretching.

You see how amazing the female body is dear reader?

These changes in our muscles are thought to be responsible for making our pelvis go into that forward position. If you look again at the GIF you'll see that when I move my pelvis forward, the curvature of my lower back increases.

Several studies also assess the association of spinal curvature with pain levels in pregnancy [21,22,24–26,34], reporting that levels of low back pain increase with the developing pregnancy [4]. It is estimated that around 56% of pregnant women experience lower back pain (LBP) at some point during their pregnancy [2].

Lower back pain is very common during pregnancy and most common in the last trimester. An important thing to retain here is that low back pain in pregnancy is common - NOT NORMAL. In my country at least, a lot of my patients come to me saying their back hurts but they're told that it is normal to have pain during pregnancy. This is a myth dear reader. Pain is never normal.

Considering it normal only increases the probability of that person dismissing their symptoms and most likely will not seek out help... It saddens me to think in my country we still widely view pain as normal as well as urinary incontinence and other things. I hope this post will be a contribution to start to change that 🙏.

Studies suggest that the inclination of the trunk during pregnancy increases with the developing pregnancy [29]. Nicholls et al. [36] reported that this was not consistent in two participants, as they displayed no trunk inclination changes. This is concordant with data from other studies, which has shown no changes to trunk inclination with pregnancy [27]. This suggests that despite general trends, posture in this aspect again depends on the participants’ characteristics.

About the trunk movement the findings are again controversial. Some studies say bending the trunk to the side increases during pregnancy, others say it doesn't change at all. And once again, the most likely is that the changes that occur in this part of the body throughout pregnancy vary from person to person.

A study assessing sitting posture established that the angle of the trunk was on average larger in pregnant women as the upper trunk was more curved, thus supporting reports of increased degrees of kyphosis in pregnancy [38]

While studying the seated posture, researchers findings are in agreement with the reports of the top of the back being more curved in pregnancy.

Reduced inclination of the trunk has been shown to be associated with increased levels of pain [25]. Therefore, it is possible that women increase their trunk lean backwards in an effort to reduce discomfort.

This is very interesting. If you ever saw a pregnant person in their late trimester you probably noticed that the upper trunk was leaned backwards right? This is thought to be an unconscious compensation of the body to maintain function and reduce discomfort. You can imagine how the organs like intestines, stomach and bladder are really tight together when close to the due date right?

So this leaning backwards is a way for the body to also create more space in that area for the baby to develop and the uterus to grow in the most comfortable way possible (note to self - Well, at this time will probably be a bit harder to breathe 🤷‍♀).

This change of the trunk has also an important relation to our balance and stability but I'll leave that for another day. Just keep in mind that the same changes can affect a wide number of different things.

Now that we review the most recent evidence I would like to give my personal view about the topic considering my, yet short, 5 years of clinical experience.

Although we have seen that the spine curvatures vary from person to person, it is more common that I find an anterior tilt of the pelvis as well as a bigger lordotic angle of the spine in my clinical evaluations. However, I will never assume that this is what I'll find before I do a detailed examination of the patient. I have had cases where this was not verified which completely altered my diagnosis, so my advice for fellow colleagues is just to assess and then jump to conclusions based on those.

It's also important we remind ourselves that the person we have in front of us is unique and an individual. I believe we need to personalise our treatments better. More and more recent evidence is coming together and showing us how our life habits and style can influence the changes we see in the body.

If I have a pregnant patient coming to me, I'll not only do a physical exam but also need to know their entire clinical history. Like exercise habits, job, mental state, symptoms, obstetric history, coping strategies already adopted and most important - the patient's goals (note to self - I feel like I'm forgetting something here, but it's almost 1 am 😅).

Only then we will have the information to adequately treat the person in front of us, so we can have a more efficient medicine and healthier mother and therefore - healthier child.

Lastly I have to say:

The more I learn about the changes during pregnancy the more fascinated I get about the amazing capability of the female body 😍.

I wanna thank the #med-hive community for this opportunity. I will give 30% of this post payout to the @med-hive account in order to help the community start and grow. I know it's most likely to have few upvotes since it's a brand new community, but I hope to be around to see it grow into an essential one! Feel free to drop any questions or doubts you may have! I will be more than happy to discuss it with you and try my best to explain it better 😁.

I'm a bit nervous again to see how this post will be received, if I explained myself well enough and in an easy way but I'll take this as a good sign for getting out of my comfort zone and actually taking action towards one of my goals here 😊. Good or bad I'm here to give my best every single post I do and I'll always search around for my margin for improvement.

Lastly I wanna thank @jaydr for taking the time to answer all my doubts before I did this post and making me feel part of this community from the start. Thank you @samsmith1971 for the chat today and for helping me to see a simpler solution to my problem as you always do so well ❣️

Finally, thank you @taskmaster4450le (I hope you don't mind me tagging you 🙏) for the chat we had a few weeks ago in this post. Your encouragement and advice to not let my fear stand in the way was really important to me. That day something clicked in my head, and a few days later I saw this community being formed which felt almost like a sign I couldn't just ignore.

Well, a 15 minute post... Since it's only 1/3 of the topic I wanted to talk about aren't you glad I decided to divide it into 3 parts, dear reader? 😆

Thank you so much for your time 🙏 That's it from me today 😊

Take care! 👋