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Santé musculo-squelettique pendant la grossesse et le post-partum

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À propos de la santé musculo-squelettique pendant la grossesse et après l'accouchement

Pregnancy and the first year after birth involve changes in load, movement, sleep, recovery, caregiving and participation. Low back pain and pelvic girdle pain are common, and upper-limb, thoracic, abdominal-wall and pelvic-floor concerns can also affect daily life. Symptoms are not dismissed as an inevitable part of pregnancy or postpartum recovery (Salari et al., 2023).

Population and language: This pathway is for pregnant and postpartum adults with musculoskeletal concerns, including women, trans men and non-binary people. Use the patient’s terms for their body, pregnancy, birth, infant feeding and family. Postpartum refers to the first year after a pregnancy ends when using postpartum physical-activity guidance; relevant birth-related symptoms may continue beyond that period.

Portée: This pathway supports conservative musculoskeletal assessment, rehabilitation, self-management and shared care during pregnancy and after birth or pregnancy loss. It does not replace prenatal, obstetric, postpartum or primary care; manage labour or birth; prescribe medication; or manage obstetric, gynaecologic, cardiopulmonary, neurological, infectious or psychiatric emergencies.

À propos des parcours de soins du CCG

Objectif

Le CCG est une ressource de transfert des connaissances de l'Association chiropratique canadienne. Ses parcours de soins aident les chiropraticiens et autres cliniciens à organiser les soins conservateurs pour les affections musculosquelettiques. Chaque parcours décrit les principales étapes de la consultation et appuie les décisions concernant l'évaluation, les soins, le suivi, l'orientation vers un autre professionnel, la prise en charge conjointe et la sortie. Ces parcours offrent une approche structurée des soins, et non une ordonnance fixe.

Développement

Les parcours de soins s'appuient sur les recommandations de pratique clinique pertinentes, les revues systématiques, la littérature scientifique évaluée par les pairs et les sources professionnelles ou de sécurité. Ces sources éclairent le contenu des parcours, sans toutefois le déterminer. Leurs conclusions reflètent les questions, les populations, les résultats, les méthodes et les jugements utilisés et pourraient ne pas s'appliquer à tous. Les sources spécifiques à chaque pathologie sont identifiées par auteur ou organisme et année de publication, et leurs références complètes figurent dans une bibliographie unique à la fin du parcours.

Principes de soins

Les affections musculo-squelettiques sont influencées par des facteurs physiques, psychologiques, sociaux, culturels et environnementaux ; il n’existe donc pas de solution unique. Des soins de qualité sont éthiques, fondés sur des données probantes, centrés sur la personne, adaptés à sa culture et conçus en fonction de ses objectifs, préférences, situation et réactions.

La prise de décision partagée et le consentement éclairé orientent les soins. L'éducation, la réadaptation active et l'autogestion favorisent le rétablissement, l'autonomie, la participation et la santé à long terme. La fréquence, la durée et le volume global des soins sont déterminés par les données probantes disponibles, les besoins et la réponse du patient, ainsi que par une réévaluation régulière, plutôt que par un protocole prédéfini. Cette réévaluation régulière permet de déterminer l'efficacité du plan et d'identifier les moments opportuns pour le poursuivre, l'adapter, l'interrompre, l'orienter vers un autre professionnel, le cogérer ou décider de la sortie.

Aperçu du déroulement du parcours

Le parcours suit un cycle clinique récurrent : comprendre la personne et ses objectifs ; évaluer les besoins en matière de sécurité et d’orientation ; élaborer un profil clinique de travail ; convenir d’un plan et des résultats pertinents ; fournir des soins ; réévaluer la réponse et la sûreté ; et poursuivre, adapter, arrêter, orienter, cogérer ou congédier selon le cas.

Avis de non-responsabilité

Les parcours de soins des CCG appuient le jugement clinique professionnel ; ils ne le remplacent pas, ni l’avis d’un professionnel de la santé qualifié. Ils ne sont ni prescriptifs, ni contraignants, ni réglementaires, et ne servent pas au diagnostic ni à la facturation. Les cliniciens demeurent responsables de l’exercice de leur profession dans les limites de leurs compétences et de leur champ de pratique, du respect des exigences légales et réglementaires applicables, de l’obtention du consentement éclairé, de la reconnaissance des urgences et de l’organisation d’une orientation ou d’une prise en charge conjointe au besoin.

Parcours de soins de santé musculo-squelettiques pendant la grossesse et le post-partum

1. Tenue des registres

Une documentation précise, opportune et suffisamment détaillée est essentielle à la sécurité et à la qualité des soins. Le dossier doit refléter les interactions pertinentes avec le patient, le raisonnement clinique, les décisions prises, les soins prodigués et l'évolution de son état. La documentation doit respecter les exigences légales, réglementaires, de confidentialité, de conservation et organisationnelles applicables au lieu d'exercice du clinicien. Un format structuré, tel que le SOAP, peut favoriser la cohérence, la clarté et la continuité des informations et peut être adapté à la consultation et au contexte de pratique.

Subjectif : Consignez les préoccupations, les symptômes, le fonctionnement et la participation du patient, ses objectifs, ses préférences, ses antécédents et le contexte pertinents, ainsi que sa réponse ou les effets indésirables des soins antérieurs.

Objectif: Enregistrez les résultats pertinents de l'examen, les mesures des résultats, les résultats des tests diagnostiques lorsqu'ils sont disponibles et les changements cliniquement importants.

Évaluation: Enregistrez l'interprétation clinique des résultats, le diagnostic provisoire ou le profil clinique, les considérations différentielles et de sécurité, les facteurs de risque ou modificateurs pertinents, ainsi que l'évolution ou la réponse du patient.

Planifier: Consigner les soins prodigués ou proposés, l'éducation et l'autogestion, le consentement et les décisions du patient, les modifications apportées au plan, les résultats convenus et le point de réévaluation, les orientations ou la cogestion, le suivi et la planification de la sortie.

Documentez la consultation au moment même ou dès que possible. Les corrections et les ajouts doivent préserver l'intégrité du dossier. Des dossiers clairs favorisent la sécurité des patients, la prise de décision partagée, la communication, la continuité des soins et la responsabilisation.

2. Consentement éclairé
  • Définition: Un processus continu dans lequel un patient capable, ou un mandataire autorisé lorsque cela est nécessaire, consent volontairement à un examen ou à une intervention proposée après avoir reçu et compris les renseignements nécessaires pour faire un choix éclairé.
  • Aspects clés :
    • Avant l'interaction : Obtenez le consentement éclairé avant tout examen, intervention ou traitement, sauf disposition contraire de la loi. Expliquez la procédure proposée et ses raisons. Reprenez le processus de consentement en cas de modification du plan ou des informations importantes.
    • Volontairement et spécifiquement : Le consentement doit être libre et adapté aux soins proposés. Il faut évaluer la capacité du patient à prendre cette décision au moment où elle est requise et respecter les exigences applicables en matière de prise de décision par un tiers lorsque le patient est incapable de le faire. Le patient peut poser des questions, refuser, limiter son consentement ou le retirer.
    • Processus transparent : Utilisez une communication honnête, claire et accessible. Offrez des services d'interprétation ou d'autres formes de soutien à la communication au besoin et tenez compte de la langue, de la culture, du niveau de littératie en santé, du handicap et des traumatismes antérieurs. L'information écrite ou numérique peut soutenir la discussion, mais ne la remplace pas.
    • Compréhension et entente du patient :
      • Diagnostic/pronostic : Expliquez dans un langage compréhensible les résultats pertinents, l'impression clinique ou le diagnostic provisoire, les incertitudes importantes et l'évolution attendue.
      • Plan de traitement : Discuter de la nature et de l'objectif des soins offerts, des avantages attendus, des risques et effets secondaires importants, des contraintes, des alternatives raisonnables, de l'option de ne pas intervenir et des conséquences probables de l'acceptation ou du refus.
      • Questions : Invitez les gens à poser des questions, explorez leurs objectifs et leurs préférences, laissez-leur le temps nécessaire pour prendre une décision et vérifiez leur compréhension, par exemple en utilisant la méthode de la reformulation.
    • Documentation : Consignez la discussion relative au consentement et la décision prise, y compris les renseignements importants fournis, les questions posées, la capacité ou le mandataire désigné le cas échéant, le consentement, le refus, les limites ou le retrait du consentement, ainsi que toute nécessité de réexaminer le consentement. Respectez les exigences de documentation applicables à la juridiction et au contexte de pratique.
3. Historique médical
  • Use culturally safe, trauma- and violence-informed care. Explain why sensitive questions matter, ask permission, provide choices and account for previous healthcare, reproductive, pregnancy, birth, loss or interpersonal trauma (Agence de la santé publique du Canada, 2018).
  • Informations sur le patient et le contexte : age; sex and gender when clinically relevant; pronouns and preferred terms; language and communication needs; occupation or school; caregiving; activities and roles important to the patient; cultural practices; and community connections.
  • Contexte de grossesse ou de post-partum : gestational age and estimated due date; date and outcome of the pregnancy; time since birth or pregnancy loss; gravidity and parity; multiple pregnancy; prenatal and postpartum care providers; and whether routine maternity follow-up is in place.
  • Pregnancy, birth and recovery history: previous pregnancy-related musculoskeletal symptoms; current or previous pregnancy complications; mode of birth; labour duration and positioning; assisted birth; caesarean, perineal or abdominal wound; perineal tear or episiotomy; postpartum haemorrhage; infection; anaemia; infant feeding; and any activity or medical restrictions with their reason and review plan.
  • Primary musculoskeletal concerns: onset, location, quality, intensity, irritability and pattern of pain, stiffness, swelling, weakness, numbness or tingling; trauma or sudden load; relationship to pregnancy or birth; and whether symptoms are improving, stable, fluctuating or worsening.
  • Fonctionnement et participation aux activités : effects on walking, transfers, turning in bed, stairs, self-care, household tasks, work or school, sleep, exercise, sexual activity, infant feeding, lifting, carrying, floor care, stroller use, caregiving and community participation.
  • Pelvic and abdominal symptoms: pelvic pressure or heaviness; urinary or faecal leakage, urgency or retention; constipation; prolapse symptoms; pelvic or perineal pain; pain with sexual activity; abdominal-wall concern; wound pain; and the patient’s goals for pelvic health or abdominal recovery.
  • Revue des systèmes corporels : constitutional symptoms; neurological; cardiovascular and peripheral vascular; respiratory; genitourinary and gastrointestinal; reproductive and obstetric; breast or chest; musculoskeletal and bone health; immune, infectious or inflammatory; endocrine or metabolic; skin and wound; haematologic or bleeding; sleep; cognition; and mood symptoms that may change safety, the differential diagnosis, exercise participation, medication decisions or referral.
  • Health and safety context: hypertension or pre-eclampsia; diabetes; cardiac, respiratory or thromboembolic disease; bleeding disorder; inflammatory or autoimmune disease; cancer; osteoporosis or fracture risk; hypermobility; migraine; anaemia; infection; recent surgery, immobilization or trauma; and current medicines and supplements, including anticoagulants and medicines that affect alertness, balance or exercise response.
  • Physical activity and recovery context: activity before and during pregnancy; current walking, aerobic, resistance and pelvic-floor activity; changes in load tolerance; fear or uncertainty about movement; access to rest and recovery; nutrition and hydration; sleep and fatigue; smoking; alcohol or substance use; and goals for return to work, exercise, running, sport or other valued activity.
  • Psychological and social context: mood, anxiety, intrusive thoughts, birth or loss experience, body-image concerns, confidence, social support, caregiving load, partner or family support, safety at home, employment or leave, income, housing, food security, transportation, discrimination and access to maternity, rehabilitation, pelvic health, mental-health or lactation care.
  • Soins et interventions antérieurs : education, activity change, exercise, pelvic health care, hands-on care, medication, braces or supports, mental-health care, obstetric or other medical care, and culturally grounded approaches tried; benefits, adverse effects, burden and reasons care was difficult to use or continue.
  • Point de vue du patient : understanding of the symptoms; concerns about pregnancy, birth, healing, damage, infant safety, feeding or exercise; priorities, preferences, cultural context, expectations, strengths and what a meaningful improvement would look like.
  • Signaler un avis : check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant. Reassess when pain, bleeding, fluid loss, neurological status, breathing, blood pressure, fetal movement, mood or general health changes.

Mesures des résultats

  • Choose a small set that reflects the patient’s goals and can be repeated. Add a region- or symptom-specific measure only when it helps answer a clinical question.
  • Fonctionnement propre au patient : Échelle fonctionnelle propre au patient (PSFS).
  • Handicap et participation : Échelle d'évaluation du handicap de l'OMS 2.0 (WHODAS 2.0).
  • Qualité de vie : WHOQOL-BREF or another suitable validated quality-of-life measure.
  • Pelvic girdle symptoms and activity: Pelvic Girdle Questionnaire (PGQ) when pelvic girdle pain is the working presentation (Stuge et al., 2011).
  • Pelvic-floor symptoms: a validated measure matched to the concern can be added when it will guide pelvic health care. Check current access and licensing requirements before distributing a questionnaire.
  • Physical performance: a repeatable task such as walking, sit-to-stand, stairs, carrying, balance or a patient-prioritized caregiving task can be added. Record the conditions and symptom response.
  • Individual goals and recovery: agree on patient-defined goals and how progress will be recognized. A global rating of change or recovery can support review when useful.
4. Red Flags: Possible Serious Conditions During Pregnancy and Postpartum

Red flags are prompts for clinical reasoning, not diagnoses on their own. Interpret timing in pregnancy or postpartum, onset, severity, progression, bleeding, fluid loss, fever, blood pressure, vascular risk, neurological findings and the combination of features. Recent pregnancy remains relevant to emergency assessment for up to 12 months after the pregnancy ends (Provincial Council for Maternal and Child Health, n.d.).

ACTION : Organiser immédiatement une évaluation d'urgence :

  • Major obstetric or gynaecologic emergency: heavy or rapidly increasing vaginal bleeding, passing large clots with weakness or faintness, severe abdominal or pelvic pain, shoulder-tip pain, collapse, shock, or severe pain with bleeding in pregnancy or after a pregnancy ends.
  • Pulmonary embolism, cardiac emergency or stroke: sudden shortness of breath, chest pain, coughing blood, fainting, a rapid or irregular heartbeat with marked illness, FAST stroke signs, seizure, or sudden focal neurological change (Public Health Agency of Canada, 2024).
  • Severe hypertensive disorder or eclampsia: seizure; severe or persistent headache with visual change, upper abdominal or epigastric pain, shortness of breath, confusion or severe hypertension; or rapid deterioration during pregnancy or postpartum.
  • Sepsis or severe infection: fever or chills with confusion, faintness, breathing difficulty, rapid deterioration, severe abdominal or pelvic pain, foul-smelling discharge, or an infected caesarean or perineal wound with systemic illness.
  • Cauda equina syndrome or rapid neurological decline: new bladder, bowel or sexual disturbance; saddle or perineal numbness; severe or progressive bilateral leg symptoms; or rapidly worsening weakness (National Institute for Health and Care Excellence, 2023).
  • Major trauma or fracture with immediate safety concerns: substantial trauma, deformity, inability to bear weight or use the limb, head injury, severe spinal pain with neurological findings, or a fall with maternal or fetal concern.
  • Acute psychiatric crisis: immediate risk of suicide or serious harm, thoughts or plans to harm the baby, inability to maintain immediate safety, severe agitation, psychosis, mania, confusion or rapidly deteriorating mental status.

ACTION : Organiser une évaluation médicale rapide :

  • Pregnancy bleeding, fluid loss, contractions or fetal concern: vaginal bleeding or spotting; possible amniotic fluid leakage; regular or increasing contractions, pelvic pressure or new low backache suggesting preterm labour; or decreased fetal movement needs prompt contact with the obstetric or maternity team. Escalate to emergency care for heavy bleeding, severe pain, faintness or systemic illness (Public Health Agency of Canada, 2020).
  • Thrombose veineuse profonde : new one-sided leg swelling, pain or tenderness, warmth, redness or discolouration, particularly during pregnancy or postpartum or with previous clot, thrombophilia, caesarean birth, immobility or other risk factors.
  • Postpartum bleeding, infection or wound concern without current instability: persistent or increasing bleeding, offensive discharge, fever, shivering, abdominal, pelvic or perineal pain, worsening breast redness or swelling, wound redness, separation or drainage, or symptoms that do not respond to initial care (National Institute for Health and Care Excellence, 2021).
  • Persistent or severe headache, visual symptoms or concerning blood pressure: a new, worsening or persistent headache, visual change, facial or hand swelling, upper abdominal pain, dizziness or elevated blood pressure during pregnancy or postpartum needs timely medical assessment; use emergency care when severe features or rapid deterioration are present.
  • Progressive neurological, inflammatory or systemic presentation: persistent or worsening weakness, numbness or radicular symptoms; a hot swollen joint; prolonged morning stiffness with swollen joints; unexplained fever, weight loss or night pain; or symptoms that do not fit a musculoskeletal pattern.
  • Severe pelvic girdle, hip or spinal presentation: inability to walk or complete basic self-care, sudden severe pubic or hip pain, suspected fracture, rapidly progressive pain, or pain disproportionate to the examination needs medical assessment.

ACTION : Prévoir une orientation planifiée ou des soins partagés lorsque :

  • Pelvic health symptoms affect daily life: urinary or faecal incontinence, urinary retention, pelvic organ prolapse symptoms, pelvic or perineal pain, pain with sexual activity, bowel concerns or difficulty coordinating pelvic-floor activity can prompt pelvic health and medical shared care.
  • Pregnancy or postpartum medical factors change exercise safety: an obstetric or medical complication, current restriction, wound or perineal healing concern, symptomatic anaemia, uncontrolled condition, medication issue or uncertainty about moderate-to-vigorous activity needs review by the appropriate maternity or primary care provider (Davenport et al., 2025; Mottola et al., 2018).
  • Perinatal mood, anxiety or trauma symptoms are present without immediate danger: symptoms that affect sleep, self-care, bonding, caregiving, participation or engagement in care need appropriate perinatal mental-health assessment and support. Follow the fixed Orange Flags module.
  • The musculoskeletal presentation persists or is unclear: progressive, multisite or high-impact symptoms, limited progress with suitable care, diagnostic uncertainty or findings outside the clinician’s scope need appropriate regional, medical, obstetric, pelvic health, rheumatology, neurology or other specialist assessment.
  • Infant feeding or caregiving difficulties contribute to symptoms: feeding pain, positioning difficulty, breast or chest concerns, infant-handling barriers or marked sleep and support needs can prompt lactation, primary care, occupational therapy, social or other interdisciplinary support.
  • Conseils sur les filets de sécurité : Tell the patient to seek emergency care for heavy bleeding with faintness, sudden breathing difficulty, chest pain, coughing blood, seizure, severe neurological change, collapse, severe infection, a severe hypertensive presentation or immediate risk of harm. Arrange earlier reassessment for bleeding, possible fluid leakage, contractions, reduced fetal movement, one-sided limb swelling, fever, wound change, persistent headache, progressive neurological symptoms or another substantial change. Document the findings, action, advice and follow-through.
5. Signaux d'alerte (drapeaux orange) : Symptômes de troubles psychiatriques nécessitant une orientation vers un spécialiste

Les signaux d'alerte orange indiquent qu'un problème de santé mentale ou de toxicomanie peut nécessiter une évaluation d'urgence ou rapide, voire une prise en charge partagée, et peut influencer la prise en charge musculo-squelettique. Ce n'est pas un diagnostic. En cas d'inquiétude, posez des questions directes et respectueuses en tenant compte de la sécurité immédiate, de la gravité du problème, de tout changement par rapport au fonctionnement quotidien habituel et du contexte. Les facteurs psychosociaux susceptibles d’affecter le rétablissement, mais ne nécessitant pas d’évaluation médicale ou psychiatrique distincte, sont abordés sous la rubrique « Signaux d’alerte jaune ».

ACTION : Organisez immédiatement une évaluation d'urgence en cas de danger immédiat ou de besoin médical urgent :

  • Suicide, automutilation ou violence envers autrui : intention ou plan actuel, tentative récente, incapacité à rester en sécurité ou comportement suggérant un risque immédiat de préjudice grave.
  • Changement grave de l'état mental : agitation extrême, confusion, désorganisation, psychose ou manie possible avec altération du jugement ou comportement dangereux, ou incapacité à satisfaire les besoins fondamentaux lorsque cela crée un danger immédiat.
  • Urgence médicale ou liée à la consommation de substances : Suspicion de surdosage, intoxication grave, sevrage dangereux, délire ou autre changement soudain nécessitant des soins médicaux urgents.

En cas de danger immédiat, ne laissez pas la personne seule pendant que les secours sont organisés. Suivez les procédures d'urgence locales et composez le 911 en cas de danger immédiat ou d'urgence médicale. Si la personne a des pensées suicidaires, téléphonez ou envoyez un SMS. 9-8-8 : Ligne d’assistance en cas de crise suicidaire avec eux ou les aider à le faire.

En cas de violence, d'abus ou d'exploitation avérés ou soupçonnés, assurez immédiatement la sécurité des personnes concernées et respectez les procédures de sécurité et de signalement applicables.

ACTION : Organisez rapidement une évaluation médicale ou psychiatrique si :

  • Pensées suicidaires ou d'automutilation : Des pensées sans danger immédiat.
  • Symptômes ou effets importants : symptômes graves, persistants ou s'aggravant de dépression, d'anxiété, de traumatisme, de psychose ou de manie possible, de troubles alimentaires ou de consommation de substances qui affectent considérablement la vie quotidienne, la prise de décision ou la participation en toute sécurité aux soins.
  • Autres motifs d’évaluation : un changement marqué par rapport au comportement ou au fonctionnement habituel ; une inquiétude concernant les effets des médicaments ou des substances ; une présentation qui dépasse les compétences du clinicien ; ou une demande d'aide.

Informer le patient des personnes à contacter, du délai de contact et de la marche à suivre en cas d'aggravation de son état. S'assurer que le patient a bien pris contact avec le service lorsque cela est cliniquement nécessaire.

ACTION : Adapter et coordonner les soins musculosquelettiques :

  • Soins en toute sécurité : Les soins peuvent se poursuivre lorsqu'ils sont sécuritaires et acceptables et ne retardent pas l'évaluation nécessaire. Adaptez la communication, l'examen et les soins ; obtenir un consentement continu ; et coordonnez-vous avec les autres professionnels de la santé avec la permission du patient.
  • Poursuivre l'évaluation musculosquelettique : Ne présumez pas qu'un problème de santé mentale ou de toxicomanie explique les symptômes musculo-squelettiques. Continuez à considérer les causes physiques et à tenir compte du récit du patient.
  • Questionnaires: Ils peuvent soutenir la discussion et le suivi, mais ne permettent pas d’établir un diagnostic et ne remplacent ni les questions directes, ni le jugement clinique, ni les mesures à prendre.
  • Soutien acceptable : Demandez à la personne quel type d’aide lui convient et si le soutien linguistique, culturel, familial, communautaire ou autre est important pour elle.

ACTION : Documentation et suivi :

Consignez la préoccupation, les questions pertinentes et les réponses de la personne, la décision relative à la sécurité et les raisons qui la justifient, les mesures prises, les conseils donnés et les références effectuées, les communications et le consentement, le suivi prévu ainsi que toute préoccupation non résolue. Respectez les exigences applicables en matière de confidentialité, de sécurité et de signalement.

Pour obtenir des renseignements sur les services provinciaux, territoriaux et nationaux, consultez : Soutien en santé mentale : obtenir de l’aide (Agence de la santé publique du Canada, 2026).

6. Signaux d’alerte psychosociaux (drapeaux jaunes) : Facteurs pouvant influencer le rétablissement ou la participation

Les signaux d’alerte psychosociaux (drapeaux jaunes) sont des facteurs personnels, sociaux, professionnels, scolaires, liés aux soins de santé, environnementaux ou structurels qui peuvent influencer les symptômes, le fonctionnement, la participation aux activités ou la réponse aux soins. Ils sont liés au contexte et ne constituent ni des diagnostics ni des prédictions certaines. Ils ne signifient pas que les symptômes sont d’origine psychologique. Ils permettent d’adapter la prise en charge et ne nécessitent pas, à eux seuls, une orientation urgente vers un autre professionnel de la santé. Explorez ces facteurs par la discussion et le suivi continu des résultats, en tenant compte des priorités, des forces et de la situation de la personne. Il n’est pas nécessaire d’utiliser un score distinct pour les signaux d’alerte psychosociaux (drapeaux jaunes). Les nouveaux signes ou l’aggravation de signes d’une maladie physique grave doivent être traités selon la procédure relative aux signes d’alerte (drapeaux rouges). Les préoccupations liées à la santé mentale ou à la consommation de substances qui nécessitent une évaluation distincte, ainsi que toute préoccupation immédiate concernant la sécurité, doivent être traitées selon la procédure relative aux signaux d’alerte psychosociaux urgents (drapeaux orange) et aux protocoles d’urgence ou de protection applicables.

Explorez les facteurs pertinents :

  • Compréhension, attentes et expériences en matière de soins de santé : Préoccupations liées aux blessures ou aux dommages, incertitude, attentes quant au rétablissement, confiance en ses capacités, conseils contradictoires, expériences antérieures de banalisation des symptômes ou de préjudices subis, et confiance envers les soins reçus.
  • Réactions aux symptômes et à l’activité : Inquiétude, peur, évitement, alternance entre périodes d’activité excessive et périodes de repos prolongées, difficulté à gérer le rythme des activités, stratégies d’adaptation, sommeil, confiance en sa capacité à gérer ses symptômes et reprise des activités significatives.
  • Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
  • Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
  • Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
  • Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

  • Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
  • Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
  • Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
  • Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
  • Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.
7. Examen physique

Select examination elements that answer a clinical question or may change safety, the working presentation, care or referral. Adapt pace, positioning, exposure and loading to gestational or postpartum stage, symptoms, healing, fatigue, feeding needs, trauma history, mobility and patient preference.

  • Ongoing consent, dignity and comfort: explain each step, offer choices, ask permission before touch or exposure, provide draping, offer a chaperone according to policy and preference, and stop or modify the examination when requested. Internal pelvic examination is not routine and is completed only by a clinician with appropriate competence, consent and scope.
  • Immediate safety and general observation: observe general appearance, breathing, posture, gait, transfers and spontaneous movement. Record blood pressure and other vital signs when obstetric, cardiovascular, respiratory, infectious or systemic concern is present, and act on abnormal findings within local protocols.
  • Positioning: use comfortable alternatives and frequent position changes. Avoid prolonged supine positioning when it causes light-headedness, nausea, pallor or other symptoms of aortocaval compression, particularly later in pregnancy.
  • Regional musculoskeletal examination: examine the symptomatic spine, pelvic girdle, hip, thorax or upper limb with active and passive movement, resisted testing, palpation and focused tests only when results may change care. Use the least provocative approach needed and record symptom response, strength, movement quality and capacity.
  • Pelvic girdle examination: assess walking, rolling, transfers, stairs, single-leg loading and other relevant tasks. A small cluster of pain-provocation and functional tests can support a pelvic girdle pain presentation after lumbar, hip and serious causes are considered; no single test establishes the diagnosis.
  • Neurological and vascular examination: assess strength, sensation, reflexes, coordination, neural tension or upper motor neuron findings when indicated. Assess limb swelling, tenderness, perfusion and pulses when vascular concern is plausible without using a musculoskeletal test to rule out thrombosis.
  • Abdominal wall and wound context: inspect and assess the abdominal wall, linea alba behaviour, breathing, pressure management and function when relevant. Inter-recti distance can be recorded consistently when it will change care, but width alone does not define disability or treatment need. Inspect caesarean or perineal healing only within scope and with explicit consent (Gluppe et al., 2024).
  • Pelvic-floor context: ask permission to screen bladder, bowel, prolapse, pain and sexual symptoms. When within competence and scope, assess the ability to contract, relax and coordinate the pelvic floor with breathing and functional tasks; otherwise arrange pelvic health assessment.
  • Physical performance and caregiving tasks: select meaningful measures of walking, sit-to-stand, stairs, balance, lifting, carrying, feeding position, floor transfer or return-to-activity capacity. Record symptoms, confidence, quality, assistance and test conditions.
  • Investigations and imaging: tests are not routine solely because a patient is pregnant or postpartum. Imaging and medical investigation follow Red Flags, the working differential and whether the result is likely to change care. Pregnancy status and radiation or medication exposure are communicated to the imaging or medical team.
  • Reassessment: repeat the findings and tasks needed to review progress, revisit the working presentation, identify adverse effects and decide whether further assessment or shared care is appropriate.
8. Présentations cliniques 

Working clinical presentations

Use these as working clinical descriptions rather than fixed stages. Presentations can overlap or change, and a serious obstetric, medical or psychiatric condition can coexist.

  • Pregnancy-related low back or pelvic girdle pain: pain is located between the posterior iliac crest and gluteal fold, at the pubic symphysis, or in the lumbar region and is influenced by walking, stairs, rolling, standing, single-leg loading or other activities. Examination supports a mechanical lumbopelvic presentation after serious, hip, neurological and obstetric causes are considered.
  • Postpartum low back or pelvic girdle pain: symptoms continue or begin after the pregnancy and affect mobility, sleep, caregiving, work or return to activity. Birth recovery, previous pain, symptom severity, mood, sleep and access to support can influence the course (Wiezer et al., 2020).
  • Pelvic-floor presentation: urinary or faecal leakage, urgency, prolapse symptoms, pelvic pressure, pelvic or perineal pain, sexual pain, poor pelvic-floor coordination or reduced confidence affects activity and participation.
  • Abdominal-wall or diastasis-related presentation: concern about abdominal separation, pressure control, trunk function, appearance or task capacity is present. Inter-recti distance is one finding and does not by itself establish impairment severity or the need for treatment (Gluppe et al., 2024).
  • Upper-limb or cervicothoracic presentation: wrist, thumb, hand, shoulder, neck or thoracic symptoms relate to local loading, fluid-related nerve symptoms, feeding, lifting, carrying, sleep position, equipment or work. Use the relevant regional pathway when appropriate.
  • Hip, coccyx or other regional presentation: symptoms fit a local musculoskeletal condition after obstetric, fracture, inflammatory, neurological and referred causes are considered. Use the relevant regional pathway and retain pregnancy or postpartum factors that change positioning, loading or shared care.
  • Deconditioning or return-to-activity presentation: reduced strength, endurance, balance, confidence or load tolerance affects daily activity, work, running, sport or recreation, with or without regional pain or pelvic-floor symptoms.
  • Alternative or systemic presentation: the pattern fits an obstetric, vascular, hypertensive, infectious, inflammatory, neurological, traumatic, gynaecologic, cardiopulmonary or psychiatric condition better than a musculoskeletal presentation. Revisit Red Flags and arrange appropriate assessment.
9. Considérations relatives au traitement

Develop care with the patient and coordinate with maternity, primary care and other providers when needed. Choices reflect gestational or postpartum stage, the working presentation, safety, healing, goals, preferences, culture, access, infant feeding, caregiving, other health conditions, previous responses and treatment burden. Respect the patient’s right to accept, decline, limit or stop any part of care.

Éducation, autogestion et participation aux activités

  • Understanding symptoms: validate the patient’s experience and explain the working presentation without describing symptoms as inevitable, harmless or caused by a single structural change. Discuss reasons for reassessment and shared care.
  • Daily activity and caregiving: pacing, task variation, brief recovery periods, comfortable sleep and feeding positions, changes to lifting or carrying, help with caregiving, and gradual return to valued activity can reduce avoidable disruption without making rest the main strategy.
  • Protection and optimal loading: temporary support, an aid, task modification or reduced loading can help after injury, during a marked flare or while tissue healing or a serious condition is clarified. Progress toward tolerable, meaningful loading as safety, healing and symptoms allow; routine immobilization is not needed for uncomplicated musculoskeletal symptoms.

Activité physique et exercices

  • Pregnancy physical activity: in an uncomplicated pregnancy, options can work toward at least 150 minutes of moderate-intensity activity each week over at least three days, using aerobic and resistance activity and daily pelvic-floor muscle training. Type, dose and progression reflect previous activity, symptoms, gestational stage, medical guidance and patient preference (Mottola et al., 2018).
  • Postpartum physical activity: early light-intensity activity can begin as tolerated, followed by an individualized, gradual and symptom-based progression. Options can work toward at least 120 minutes of moderate-to-vigorous activity over four or more days each week, combining aerobic and resistance activity. Progression to moderate-to-vigorous activity follows sufficient healing of incisions and perineal tears and no increase in vaginal bleeding (Davenport et al., 2025).
  • Exercise screening and modification: les Get Active Questionnaire for Pregnancy ou Get Active Questionnaire for Postpartum can support identification of medical guidance needs. Exercise is paused and the appropriate maternity or medical team contacted for vaginal bleeding, possible amniotic fluid leakage, regular painful contractions, dizziness, headache, chest pain, unusual shortness of breath, calf pain or swelling, or muscle weakness affecting balance (American College of Obstetricians and Gynecologists, 2020).
  • Lumbopelvic rehabilitation: individualized aerobic, resistance, mobility, trunk and hip exercise can be graded around symptoms and goals. Movement and task strategies, walking or other preferred activity, and a trial of a pelvic support belt can be combined when they improve a specific activity; response determines continuation.
  • Pelvic-floor rehabilitation: training can include awareness, coordination, strengthening, endurance, relaxation and integration with breathing and functional tasks according to the examination. Daily pelvic-floor muscle training is part of the Canadian postpartum guideline, while pain or an overactive presentation can require relaxation and down-training rather than repeated strengthening alone (Davenport et al., 2025; Woodley et al., 2020).
  • Abdominal-wall rehabilitation: progressive abdominal and whole-body exercise can target trunk capacity and meaningful tasks. There is no established single best program for diastasis recti, and changes in inter-recti distance are interpreted alongside symptoms, confidence and functioning (Gluppe et al., 2024).
  • Return to running, impact, heavy lifting or sport: progression is based on healing, symptoms, pelvic-floor and abdominal response, strength, balance, impact tolerance, sleep and recovery, previous activity and the demands of the goal. A single universal postpartum date or test does not establish readiness.

Hands-on, supportive and comfort strategies

  • Hands-on care: regional mobilization, spinal manipulation, soft-tissue techniques or massage can accompany active care when a short-term goal is to improve comfortable movement or participation. The evidence does not establish one individual hands-on intervention as consistently effective for pregnancy- or postpartum-related lumbopelvic pain. Positioning, pressure, consent and response are reviewed at each visit; hands-on care is not used as the sole approach (Weis et al., 2020a; Weis et al., 2020b; Weis et al., 2022).
  • Safety and informed consent: published adverse-event evidence for spinal manipulation during pregnancy and postpartum is limited and does not allow incidence or relative risk to be estimated. Technique and positioning reflect gestational or postpartum stage, comfort, hypermobility, symptoms and contraindications, with discussion of expected benefits, uncertainty, alternatives and the option to decline or stop care (Weis et al., 2021; Weis et al., 2022).
  • Supports and equipment: a short trial of a pelvic belt, wrist or thumb support, pillow, feeding support, mobility aid or task-specific equipment can be used when it improves a defined activity. Fit, skin, circulation, dependence and continued need are reviewed.
  • Comfort strategies: heat, cold, breathing, relaxation, water-based activity or another acceptable strategy can support movement, rest or participation when safe. Avoid overheating in pregnancy, protect skin and circulation, and review whether the strategy helps the agreed goal.

Soutien psychologique, social et interdisciplinaire

  • Sleep, mood and coping: practical sleep support, pain-coping skills, relaxation, psychological care and perinatal mental-health services can be integrated when sleep, anxiety, depression, trauma, intrusive thoughts or distress affects functioning and these options match the patient’s priorities.
  • Caregiving, work and access: partner or family support, workplace changes, community services, lactation support, occupational therapy, social care and culturally grounded supports can be combined according to identified barriers and patient preference.
  • Pelvic, obstetric and medical shared care: coordinate with pelvic health, midwifery, obstetric, primary care, lactation, mental-health or other services when the presentation crosses scopes or an exercise precaution, wound, bleeding, pelvic health, feeding or medical issue needs follow-through.

Medication and supplement shared care

  • Médicament : decisions about pain medicines or other drugs during pregnancy or lactation sit with an authorized prescriber or pharmacist. Review indication, benefits, adverse effects, interactions, pregnancy or infant-feeding context and effects on alertness, balance or exercise.
  • Supplements and natural health products: questions are reviewed with an authorized prescriber or pharmacist. Discuss evidence, product authorization, dose, interactions, duplication, adverse effects and cost rather than assuming that a product labelled natural is safe in pregnancy or lactation.

Not part of routine care

  • Prolonged bed rest or broad activity restriction for uncomplicated musculoskeletal symptoms.
  • Passive physical modalities, hands-on care, taping, bracing or support garments used as stand-alone care in place of active care and self-management.
  • A one-size-fits-all six-week clearance, a fixed return-to-running date or pressure to return to pre-pregnancy appearance or performance on a preset timeline.
  • Using pain, posture, joint sounds, pelvic alignment or inter-recti distance alone to claim damage, instability or treatment need.
  • Internal pelvic examination, perineal or breast or chest examination, or exposure without explicit informed consent, appropriate competence and clinical need.

Suivi et réévaluation

  • Agree on a reassessment point based on gestational or postpartum stage, symptom course, safety, healing, goals, the options being tried, patient needs and access rather than a fixed visit schedule.
  • Repeat the small outcome set recorded at baseline and review pain, bleeding or wound change, activity tolerance, strength, pelvic-floor and abdominal symptoms, task performance, functioning, participation, confidence, benefits, adverse effects, treatment burden and progress toward patient-defined goals.
  • Continue what is useful and acceptable; adapt or stop what is not; and revisit Red Flags, the working presentation, differential diagnosis, investigation, referral or shared care when progress differs from expectations or new safety concerns emerge.
10. Facteurs de risque et de pronostic 
  • Évolution attendue : many pregnancy-related musculoskeletal symptoms improve after birth, but recovery varies by presentation, symptom severity, pregnancy or birth events, sleep, caregiving and access to care. Pelvic girdle, low back, pelvic-floor or abdominal symptoms can persist, and there is no single postpartum recovery timeline (Wiezer et al., 2020).
  • Facteurs associés à une évolution moins favorable : previous low back or pelvic girdle pain, more severe or multisite pelvic pain in pregnancy, greater limitation in functioning, other pain conditions, depressive symptoms, higher physical workload and relevant comorbidity have been associated with persistent postpartum lumbopelvic symptoms. These are group-level associations, not certain causes or individual predictions (Wiezer et al., 2020).
  • Facteurs pouvant favoriser le rétablissement : validating information, feasible activity and exercise, gradual loading, pelvic-floor and abdominal rehabilitation when indicated, sleep and mental-health support, help with caregiving and work demands, timely medical or pelvic health shared care, and access to preferred services may support functioning and participation.
  • Discussion du pronostic : describe uncertainty in plain language, ask what the patient wants to know, and update the outlook using goals, repeated outcomes and the observed response over time. Do not use mode of birth, postpartum week, pain intensity, inter-recti distance or one examination finding as a fixed prediction.
11. Suivi continu

Ongoing follow-up is a shared review of whether the plan remains safe, useful, acceptable and aligned with the patient’s goals. The timing of review should reflect symptoms, risk, the care being tried, goals and access rather than a fixed visit schedule.

  • Review symptoms and safety: ask what has changed in symptoms, functioning and daily activities; review adverse effects; and check for new or worsening Red Flags and relevant Orange or Yellow Flag concerns. Arrange earlier or urgent assessment when the findings require it.
  • Review outcomes: repeat the small set chosen at baseline and use the same measures when possible. These may include the Patient-Specific Functional Scale, WHODAS 2.0, quality of life using the patient’s own rating or a measure such as WHOQOL-BREF, symptom impact, participation and the patient’s own assessment of change. Interpret measures with the patient and alongside what has changed in daily life rather than relying on a score alone.
  • Review goals, preferences and consent: ask whether care remains acceptable, feasible and worthwhile; revisit goals and priorities; and confirm consent when the plan or circumstances change.
  • Adapt care: continue what is useful and acceptable, and change, pause or stop what is not. If progress is not sufficient from the patient’s perspective, review the clinical impression, the fit and amount of care, barriers to participation, other health or social factors and whether other expertise is needed.
  • Support self-management and participation: review the strategies the patient is using, including physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Ask what is helping and which barriers can be addressed.
  • Orientation et cogestion : arrange emergency assessment for Red Flags requiring urgent care. Consider referral or co-management when findings or needs are beyond the clinician’s role, the patient’s condition is worsening, progress remains insufficient after the plan has been reviewed, or the patient requests another opinion.
  • Plan the next step: agree whether to continue, change the interval between visits, move toward more self-directed care, or apply the Criteria for Discharge section.
12. Critères de sortie

Discharge is a shared decision about ending or transferring a course of care. It does not require complete symptom resolution, a normal outcome score or a fixed number of visits.

  • When discharge may be appropriate: consider discharge when the patient’s goals have been met to a degree they consider satisfactory; the patient feels able to manage with less or no clinician involvement; the patient chooses to end care; continued care is not providing enough benefit to justify its burden, cost or time; or care is being transferred to another provider.
  • Reassess before discharge: review symptoms, functioning, participation, selected outcomes, goals, adverse effects, confidence and preferences. Check for new or worsening Red Flags and any Orange or Yellow Flag concerns that still require action. If the condition is worsening or a safety concern remains, arrange the required assessment or referral rather than routine discharge.
  • When progress has slowed: review the clinical impression, response to care, goals, barriers and access, other health or social factors, and other reasonable options before deciding with the patient whether to continue, change or end care.
  • Plan after discharge: agree on self-management, physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Explain which changes should prompt earlier or urgent assessment and when and where to seek care.
  • Future access to care: explain how the patient can return if symptoms recur, functioning declines, or goals or demands change. Any planned future review or supportive care should have an agreed purpose, expected benefit and review point.
  • Referral or transfer: explain the reason, share a relevant summary with the patient’s consent, and clarify who will address outstanding concerns when possible. Avoid an unintended gap in care when safety or ongoing needs remain.
  • If the patient ends care or does not return: respect the patient’s right to stop. Record what is known and unknown about the outcome, advice or referral offered, attempts to communicate when clinically warranted, and any unresolved safety concern. Follow applicable record keeping and communication requirements.
  • Documentation : record the reason care ended, the patient’s status and selected outcomes, goals and preferences, unresolved concerns, advice and self-management plan, referral or transfer details, and how to seek care again if needed.

Références

Divulgation :

  • Generative artificial intelligence tools assisted with drafting, editing, and reference organization. They did not approve the pathway or replace clinical judgment. CCG reviewers verified all content.