Aches and Pains… When should I worry?

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About 100% of pregnant moms will experience some sort of abdominal or pelvic pain during their pregnancy and most wonder at some point, “is this normal, or should I be worried?”

Leigh Ann Joel, CNM with Midwifery at Women’s Health Alliance, serving Durham, Chapel Hill and Raleigh, has some incredible feedback for pregnant women who may need some soothing and/or answers to their concerns.

Many of the amazing physiological changes of pregnancy are responsible for a variety of aches and pains, and most of them are not worrisome. The “art” and challenge is figuring out which is normal, and which may signal a potential problem. We will address all manner of contractions and uterine activity, and also the sharp pains and twinges so common and distressing during pregnancy.

Fortunately, most of the time, all these very common complaints fall into the category of “won’t kill you, but might make you crazy.” The important difference is often the presence of a WARNING SIGN. By WARNING SIGN, we mean the following:

  • Vaginal bleeding
  • Constant pain, particularly if it is increasing in intensity
  • More than 6 contractions/hour prior to 37 weeks of pregnancy
  • Leaking of fluid from the vagina
  • Decrease in fetal movement
  • Nausea and vomiting different from usual during pregnancy
  • Pain with urination
  • Sudden change in your vaginal discharge
  • Pain or swelling in one leg
  • Headache that is not typical for you, and is not relived by Tylenol
  • Epigastric pain, which is pain in your stomach and up under your ribs that is not from the uterus.
  • Other instructions your doctor or midwife has given to you based on YOUR particular risk factors.

Through the course of this article, reference to WARNING SIGNS includes the above list.

Contractions that are not true labor contractions:

The uterus starts contracting from very early in pregnancy, as soon as it starts to grow. Many women experience typical “Braxton Hicks” (named after Dr. Braxton-Hicks) or “practice contractions” in the second or third trimester. Some women don’t feel a contraction until true labor begins. Either is normal, and doesn’t “mean” anything about the timing and course of labor and birth. With subsequent pregnancies, you may feel your Braxton Hicks much earlier and in a more pronounced way. This is perfectly normal.

These practice contractions are usually “tight” and felt “all over” your belly. You may feel low pelvic pressure or back discomfort as well. They may be uncomfortable and take your breath away, but they do not hurt in the way real labor does. They may occur with physical activity, sexual activity, or before or after you urinate. Many women notice that contractions start up at night, as soon as you kick your feet up to relax after a long day. As long as these warm-up contractions do not become consistently regular (more than 6 per hour), or continue to increase in strength and duration, or you do not have any other WARNING SIGNS, they are probably normal.

What to do:

Usually practice contractions will slow down with rest and hydration. Make sure to drink plenty of water. A warm bath also helps both you and your muscles relax, and will often slow or stop a run of Braxton Hicks contractions. If rest doesn’t work, sometimes changing position of a walking may help.

Cramping and Pressure:

Most women will experience periods of cramping that will feel like mild menstrual cramps at some point during their pregnancy. After 37 weeks, this is a little uncomfortable, but not dangerous. Prior to 37 weeks, it demands a bit more attention. Most of the time, the sensation is a result of uterine growth and stretching, along with stretching and pulling of the ligaments that support the uterus. In subsequent pregnancies, you may feel more pressure and the baby likely feels “lower.” This complaint is almost universal. Remember that your intestines are squished aside by the growing uterus, so the cramping may be the result of constipation or gas. Intestinal cramping and uterine cramping can feel very similar.

“I’m feeling so much pressure!” is also a very common complaint during pregnancy. Most of the time, the pressure you feel is actually NOT the baby’s head or your uterus about to fall out. The increased blood and lymph flow to the entire pelvis, vagina, vulva, and rectum is to blame. Of course, the weight of the growing baby is also a factor. You may feel like you want to walk around while holding up your vagina with your hands. This sensation will be stronger after periods of prolonged standing, walking, or after sexual activity. Sexual activity increases blood and lymph flow to the pelvis even more.

Some women develop varicose veins in the vulva. These can cause strong pressure and discomfort. Vulvar varicosities often occur in the same women who develop varicosities in their legs. Varicose veins often run in families. Vulvar varicosities can make the vulva look lumpy, and you may see the bluish-purple outline of the soft, but swollen vein if you look. They are harmless and go away soon after birth.

What to do:

If these sensations go away when you lie down, or rest, it’s probably OK. Make sure to maintain regular bowel movements so you are not confused as to which body part hurts. Pregnancy belts and binders can help a lot. If you are in the market for a belt or binder, it is wise to try it on in the store or make sure you can return one that you have ordered. Some women love their binders, but others find them aggravating. Special vulvar support belts are available for women with vulvar varicosities. Enjoy submerging yourself in water, a tub or pool, whenever you can. This provides terrific relief from pressure and cramping. Sitting on a birth ball (others call them exercise or physical therapy balls) can give some comforting upwards pressure. Placing two good old-fashioned, thick sanitary pads in your panties can also give upwards pressure. Witch Hazel pads or soaks can reduce swelling.
Fortunately, education, reassurance, and comfort measures are all most women need to manage these common discomforts. You should call if you’ve tried the comfort measures and they don’t work. Call if you are concerned, or the sensation is increasing. Call if you are experiencing a WARNING SIGN. If you are at risk for a preterm birth or have a higher-risk pregnancy, you should call. If your provider has given you certain parameters or other instructions, you should follow those.

“False Labor”:

“False Labor” is the unfair term that describes the woman who is experiencing regular, painful contractions after 37 weeks of pregnancy that will not soon produce a baby into her arms! Some women experience what seems for sure to be the “real thing” only to find out that the cervix has not dilated and she is returning home from the office or the hospital. The experience is generally quite frustrating and exhausting. Your still packed suitcase taunting you from the back-seat of the car, and the baby still happily kicking in your belly only make matters worse. Of course we’re all happy about happily kicking babies….
For some reason, that we as medical professionals cannot fathom, many women experience embarrassment and shame from coming to the hospital “too early” or for a “false alarm.” Please remember that your midwives, doctors, and nurses do not cast judgment upon the poor soul who experiences an episode of False Labor. Certainly, calling your labor-support team together, and activating your child-care or work contingency plan for a false alarm is inconvenient. We much prefer to properly evaluate you, rather than risk an unintended car, highway, or home birth. Out of respect for the mom-to-be, we will refer to the experience of “False Labor” as “Practice Labor.”

Practice Labor occurs when the uterus becomes active and contracts regularly and enthusiastically, but the muscle layers are not contracting in a coordinated way. Think “Olympic Trials” and you’re preparing for a Gold Medal Event. The uterus is a thick-walled muscle and contains three different layers: a horizontal layer, a vertical layer, and a figure 8 layer. When true labor begins, all three layers contract together. The contractions become more intense and more regular and the cervix dilates. Ultimately, the cervix fully dilates, mom pushes, and baby is born. The medical definition of labor is regular, painful contractions accompanied by cervical dilation. The hormone Oxytocin, or the synthetic version, Pitocin, plays a very important role in the coordination of uterine contractions.

Most women come to discover that the contractions of true labor ultimately feel quite different than what they experienced during a episode of Practice Labor. The contractions of real labor often start in the back and wrap around to the front and are very low and deep. They hurt. They may hurt in the same way strong menstrual cramps, or diarrhea cramps hurt, or they may hurt only in your back. Practice contractions tend to be more in the front and sometimes across the middle or top of the belly. Real labor almost always produces “bloody show” which is a pink, red, or brown tinged discharge from the vagina. The blood is often mixed with mucous. If your water breaks, it’s a no-brainer. Rest assured, it’s always real labor if your water breaks.

What to do:

False labor is unproductive. Usually reassurance, rest, oral hydration, and a warm tub or shower is all that’s needed to halt this harmless, but frustrating process. If you have come to the hospital for evaluation, treatments may include IV hydration, or medication to slow or stop the contractions. Medications for pain, sleep, and sedation, used alone or in combination, are often necessary to calm things down. Many of these drugs are the same ones used during active labor for moms requesting pain relief. We have a few “special cocktails” just for Practice Labor. Sometimes the mom receives medication and can go home to sleep in her own bed. Other times, she may stay in the hospital until the medicine wears off.

Sharp Pains and Twinges:

Sharp, stabbing, or knife-like pains during pregnancy are very common, and sometimes scary. Ironically, they are almost never worrisome. Particularly towards the end of pregnancy when the uterus is quite large, women experience these severe but short- lived sensations.

Stabbing or aching pain down low on the sides of your abdomen- These pains are usually the round ligaments pulling or stretching. This pain can make you want to bend over and clutch your belly. They often happen when you are changing position, rolling over in bed, emptying your bladder, or going from sit to stand. The round ligaments start off like short thick rubber bands and anchor the small, non-pregnant uterus to the pubic bone. At term, they have stretched to the top of your uterus. Most women will feel those ligaments protest at some point during their pregnancy!

Pain at the very top of their uterus, or at the top on the sides- Women may frequently experience this discomfort from the insertion of the round ligaments at the top of the uterus. These aches are common in the third trimester.

Skin pain – You may also feel areas of more superficial pain that is more “on your skin.” Many women say it feels sore “like a sunburn.” This discomfort is caused by harmless nerve irritation as the skin stretches. It may be relieved by using a hydrating body lotion, or cocoa butter. Loose, comfortable clothes also help.
Belly-button pain and sensitivity – This sensation is likely caused by the natural separation in the abdominal muscles as the uterus and belly grow. The medical term is “diastasis recti” You may notice a bulge down the center of your belly when you lift your head off the bed, or tighten your abs. Occasionally, women have an umbilical hernia at their navel, but this is not common. Your baby will have the same bulge on their belly that you will notice when he or she cries. As baby grows and learns to sit, this goes away.

“Crotch Lightening” (we are forever grateful to the patient that accurately coined the term) – refers to the stabbing pains women experience down low in their cervix or into their vagina. These pains can also shoot into the inner, upper thighs, vulva, and rectum. They typically happen later in pregnancy, and are usually caused by the baby using your cervix or bladder as a trampoline. They are strong, but brief, and are not harmful to mom or baby. Stretching ligaments, descent of the baby’s head lower into the pelvis, and pelvic bone relaxation also contribute to Crotch Lightening. A heating pad or hot-water bottle is safe to use, as is a warm tub. A growing baby, stretching ligaments, and a relaxing pelvis are all good signs that the body is getting ready for labor and birth.

What to do:

A reasonable guideline to follow is that if you feel something once, or just occasionally, and it goes away, it’s probably fine. If you experience a discomfort combined with a Warning Sign, then call.

In the above article you may notice frequent use of the word “often,” and no reference to the words “always and never.” Women are all different, and the range of normal is very broad. If you are unsure or worried, then it’s best to call your midwife or Obstetrics physician so we can address YOUR specific needs and concerns. Pregnancy is a new and exciting time, but the many sensations and discomfort can sometimes be a cause of stress and worry. We all share the common goal of healthy moms and babies. We also want you to comfortable with your care and to feel that your concerns are addressed.