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Will C-SECTION cause SACROILIITIS postpartum?

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This is a question for an OBGYN &/or a traumatologist. I am a 35 year old mother of a nine year old girl and currently pregnant, in the 36th week of my second pregnancy. My daughter was delivered by an emergency c-section after I dilated to between 8 and 9 cm (because her heart stopped beating in response to too much pitossin and the epidural - not because of position or size). Before this current pregnancy I was 5´2" and 165 pounds. I lost so much weight the first trimester that I have only gained back the weight plus 2 pounds up until now. The baby is estimated at 3 kilos. I live abroad and it is difficult to communicate with the doctors here - so I seriously need another opinion about my condition so that I can make a decision about my upcoming labor and delivery.

About a year ago I had a bad fall in my kitchen and injured my tailbone & sacrum. I already had a pre-existing condition of scoliosis (5% S curve) and an uneven gait (one of my legs is 1/2 an inch or so shorter than the other). I have had back problems all of my life since I was 15. But I thought I had healed from the fall and so I wasn't worried about it affecting the pregnancy. However it turns out that the relaxin hormone of pregnancy had loosened my SI joint and about a month ago I had a horrific incident that landed me in the emergency room:

I had been having some major constipation problems and also the baby was changing positions alot - and so over a period of days I noticed that my sacrum area was swollen and that I could almost feel the bones in the back of my pelvis - like they were rubbing together or something - it was painful but bearable. But suddenly one day when I tried to get out of bed it was like a lightening bolt to my brain - I couldn't move and barely breathe. My husband had to practically carry me back and forth to the bathroom and whenever I tried to put ANY weight on my right leg I felt an excruciating pain inside the back right of my pelvis, more or less the right side of my sacrum where it meets my hip/pelvis bone. I nearly passed out a few times from the pain. I rested in bed all day but it got so bad at one point that I was stuck on my hands and knees almost an hours, crying and screaming in pain at the end - unable to move.

When we got to the emergency room I was unable to leave the wheelchair or lay down on the examination bed. They tried but I was screaming and in so much pain that after I had my IV in they let me stay in the wheelchair until I was checked out. They gave me a drip of tylenol and cortisone. After a few hours they said there wasn't much they could do because I was pregnant and so they couldn't do any diagnostics. They guessed that I seemed to have sacriolitis, since I was so swollen and I guess based on the location and demonstration of the pain I was in. They told me that if there was an injury or other condition causing the inflammation, we would have to wait until after the baby was born to run tests. So they sent me home with a prescription for painkillers and six straight days of cortisone shots at home. After the week of shots and applying ice, I did start to feel better. Plus I bought a mattress topper and a sacrum support belt - both of which seemed to help a little. I can almost walk normally now, especially with the belt.

After this terrible experience I began to have serious doubts about my VBAC. I know that when the baby comes it will press on my sacrum and if that happens I knew that would not be able to tolerate the pain of labor plus what I experienced with the SI inflammation or sacroilitis or whatever it was. My plan at that point was to have the baby on my hands and knees, to let gravity do the work and to keep the baby from pressing as much on my sacrum/tailbone & lower back.

However I knew that if the pain was too bad I would need an epidural... and as they don't do low dose epidurals here, I would wind up on my back. That would increase the possibility of my sacrum being more injured by the baby's descent. Also my OBGYN here told me I need continuous fetal monitoring with the doppler belt, and he isn't sure that they will be able to accurately pick up the baby's heart rate if I am on my hands and knees... so it looks like I will most likely be on my back - like it or not. He doesn't seem enthusiastic about my VBAC but he is leaving the choice to try up to us.

I was concerned about how this might affect my delivery & postpartum recovery so I did some research and I discovered that there are alot of women who suffer sometimes months or even years old patientof similiar sacriolitis or SI joint problems after giving birth ... and they don't even have a previous history or problems with the sacrum or SI joint. I learned that when the baby comes through the pelvis bones, the ligaments that hold the SI joint together can stretch and move to allow the baby to pass through... but that this can result in hypermobility afterwards. Sometimes this reverses after the relaxin leaves the body, but sometimes not. I found many women with this experience who needed to have surgery and meanwhile they couldn't care for their children or live normal lives. I cannot afford to risk this as I am all on my own here and have no friends or family for support to help me care for my children.

I have been to two traumatolgists here and they all say the same thing... that I wont feel anything with the epidural anyway so what does it matter. Also they are not at all concerned about why I had the inflammation and pain before (since they can't diagnose it anyway - therefore it must not exist I guess lol) and so they are not worried about it happening again or affecting my birth or my postpartum recovery. They are acting like nothing happened and that I should just not worry about it at all. I feel extremely frustrated because I have started having similiar pain as I did before the last flare up, and I am now absolutely terrified to go into labor.

Despite wanting a VBAC so bad, now I am seriously considering a c-section. I would do this in the hopes that avoiding the baby passing through my pelvis I might prevent trauma to my sacrum as well as the stretching on the SI joint/ligaments and so minimize the postpartum hypermobility that so many women has complained has disabled them (either in the short or long term). But I can't seem to get a comprehensive opinion from anyone about this, either pro or con.

So my question is this: In your opinion, based on what I have described so far, is there a real risk of developing a SI or sacrum problem postpartum (or during delivery) - and is avoiding this a legitimate reason for a c-section? I understand there are no guarantees either way, I just want to make the most informed and responsible decision I possibly can, for myself, my baby and my family. Thank you.Will


Category: OBGYN

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Category: Infertility Specialist
Dr. Aarti Vazirani is online now

Expert:  Dr. Aarti Vazirani replied 4 Days.

Hello
Thanks for posting your query at DoctorSpring.com
Firstly, I would like to comment that your query clearly shows that you are a very perceptive, intelligent and logical person.
The question has been so lucidly put and worded.
In all probability, what you have is sacro ilitis, and the acute bout was an acute flare up of it , which is quite common in pregnancy.
Also, proper diagnosis by imaging , joint aspirate etc is possible only after you delivery.
Yes, this is a disease with protean ( varied ) manifestations.
It goes into remission after childbirth and in some instances ( upto 20 - 30 % ) if you want statistics, it may flare up post delivery.
Having experienced what you have, I would not recommend going through the risk of VBAC.
Particularly since your doctors are not very vigilant about the sacro iliitis part and also because of their inexperience with low dose epidurals.
There is no point in risking major back injury and probable morbidity all your life, primarily since you are a caretaker and provider for your family.
Yes, an elective C section is a most legitimate, safe and sensible solution to possibly circumvent to the best extent ( I say this since even after childbirth you might have a flare up irrespective of the mode of delivery ) major back injury.
Childbirth and labour would most definitely put tremendous stress and pressure on the back and the sacro iliac joints, irrespective of the pain.
IN short , to answer your question -
There is a real risk of developing SI related problem during delivery ( more ) and post birth ( remote ). The risks of both can be more than halved by an elective C section.
Even if you are lucky and nothing happens during labour or childbirth, do not ignore the incident, and make sure you have extensive workup to diagnose what really happened that day.
All the best
Please feel free to discuss further.


Dr. Aarti Vazirani
Category: Infertility Specialist
Experience: 
Residency: Obstetrics & Gynecolog, BJMC,Civil hospital, Ahmedabad, 2008
Post Graduate: MS (Obstetrics & Gynecology), B.J. Medical College, Ahmedabad, 2008
Medical School: MBBS, B.J. Medical College, Ahmedabad, 2004
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