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Pregnancy & Postpartum Musculoskeletal Health

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About Pregnancy & Postpartum Musculoskeletal Health

Pregnancy and the postpartum period are associated with substantial and predictable changes in biomechanics, load tolerance, connective tissue properties, sleep, and activity patterns. These changes contribute to a range of musculoskeletal (MSK) presentations that can affect pain, mobility, function, and participation in daily life, including caregiving, employment, and physical activity.

MSK concerns during pregnancy and postpartum are common and may involve the spine, pelvis, hips, and upper extremity. Presentations often fluctuate over time, may be influenced by physical and psychosocial factors, and can persist beyond the early postpartum period if not appropriately addressed. While some discomfort can be expected with pregnancy-related physiological change, persistent or function-limiting MSK symptoms are not “benign by default” and warrant assessment, education, and evidence-informed conservative management.

This care pathway focuses on conservative, rehabilitation-led management of MSK symptoms in pregnancy and postpartum, emphasizing patient-centred care, safety, and shared decision-making. It supports clinicians in:

  • identifying common MSK presentations,
  • screening for red flags requiring medical attention,
  • guiding physical examination and clinical reasoning,
  • selecting safe conservative management options,
  • recognizing risk factors for persistent symptoms and delayed recovery.

This pathway does not address obstetric complications management, labour and delivery planning, or detailed pharmacologic prescribing. Instead, it emphasizes functional recovery, participation, and safe progression of activity across pregnancy and postpartum, including referral to appropriate providers when indicated.

About CCG Care Pathways

Purpose

CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.

Development

Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.

Principles of Conservative Care

Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.

Disclaimer

CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.

Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.

Pregnancy & Postpartum Musculoskeletal Health Care Pathway

1. Record Keeping

Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.

Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.

Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.

Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.

Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.

Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.

Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.

2. Informed Consent
  • Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
  • Key Aspects:
    • Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
    • Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time. 
    • Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
      • Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
      • Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
    • Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.
3. Health History
  • Apply cultural awareness and trauma-informed care principles. Acknowledge prior healthcare experiences, reproductive history, and potential impacts of pregnancy, birth, and postpartum recovery on physical and mental health.
  • Sociodemographic information: Age, race/ethnicity.
  • Pregnancy or postpartum context:
    Current pregnancy status (gestational age) or postpartum stage (weeks/months since birth), mode of delivery (vaginal, assisted, cesarean), pregnancy or birth complications, breastfeeding/chestfeeding status, sleep disruption, and caregiving demands.
  • Primary MSK concerns (question-based prompts):
    • Where is the pain or functional difficulty located? (e.g., low back, pelvic girdle, hips, thoracic spine, wrists/hands, shoulders)
    • When did symptoms begin? (during pregnancy vs postpartum; gradual vs acute)
    • How have symptoms changed over time?
    • What activities aggravate or relieve symptoms? (e.g., walking, standing, turning in bed, lifting/carrying the baby, feeding positions)
    • Are there associated symptoms such as instability, clicking, weakness, numbness, or radiating pain?
    • How do symptoms affect sleep, caregiving, work, and daily activities?
  • Body systems review: Neurologic, cardiovascular, genitourinary (including urinary or pelvic symptoms), gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
  • Health, lifestyle, and history: 
  • Pre-pregnancy MSK issues, prior pelvic or spinal pain, hypermobility, osteoporosis risk factors.
  • Current and recent medications (including analgesics), supplements, and relevant medical conditions.
  • Physical activity before and during pregnancy, return-to-activity postpartum.
  • Sleep habits, fatigue, nutrition, smoking, alcohol or substance use.Functional and participation context:
  • Impact on caregiving tasks, household activities, work duties, and physical activity; use of supports or adaptive strategies.
  • Social determinants of health:  Employment status, maternity/parental leave, childcare support, housing, financial stressors, access to rehabilitation services, and ability to modify daily demands.
  • Previous treatments and responses: Prior advice or treatment received (e.g., exercise, supports, manual therapy), perceived effectiveness, and any adverse effects.
  • Beliefs and expectations: Understanding of MSK symptoms in pregnancy/postpartum, expectations for recovery, concerns about safety of movement or exercise.
  • Flag considerations: Identify red, orange, and yellow flags for potential referrals.

​​Outcomes Assessments:  Prioritize approaches aligned with the individual’s goals, stage of pregnancy or postpartum recovery, and participation needs.

  • Pain: Use pain scales (e.g., NRS) and diagrams.
  • Function and Participation: Evaluate impact on daily activities (PSFS, WHODAS).
  • Recovery: Use Self-rated recovery scales.
  • Quality of Life: Assess using tools such as SF-12.
  • Work/school Status: Monitor return to activities, participation.
  • Sleep quality: Assess using tools such as PSQI.
  • Individual Goals: Set SMART goal setting (Specific, Measurable, Achievable, Relevant, Timely).
  • Patient Feedback: Gatherand integrate patient experience and satisfaction.
4. Red Flags : Differential Diagnosis Requiring Medical Attention

ACTION: Refer immediately to emergency care:

  • Neurologic compromise:
    Progressive or severe neurologic deficits, saddle anesthesia, new bowel or bladder dysfunction, or rapidly worsening weakness.
  • Suspected infection:
    Fever, chills, unexplained malaise, focal spinal or joint pain with systemic symptoms, wound redness or drainage (post-cesarean or perineal), or signs of mastitis with systemic illness.
  • Thromboembolic events:
    Sudden onset calf or thigh pain, swelling, redness; acute shortness of breath, chest pain, hemoptysis, or unexplained tachycardia.
  • Severe trauma or suspected fracture:
    Significant falls, high-impact trauma, or sudden inability to bear weight.
  • Obstetric or gynecologic emergencies (refer immediately to obstetric care):
    Vaginal bleeding outside expected postpartum lochia, severe abdominal or pelvic pain, signs of preeclampsia/eclampsia (e.g., severe headache, visual changes, hypertension), or retained products of conception (suspected).

ACTION: Refer to appropriate medical provider:

  • Progressive or severe pain that is disproportionate, worsening, or not responsive to conservative measures.
  • Suspected pelvic instability or significant pelvic girdle dysfunction with inability to mobilize or perform basic caregiving tasks.
  • Persistent or worsening neurologic symptoms (e.g., radicular pain, numbness, weakness).
  • Suspected inflammatory or rheumatologic condition (e.g., inflammatory back pain pattern, morning stiffness >30 minutes, night pain not relieved by rest).
  • Signs of postpartum complications impacting MSK recovery (e.g., delayed wound healing, severe anemia contributing to fatigue and functional decline).

ACTION: Consider referral or co-management when any of the following are present

  • Persistent MSK pain or functional limitation beyond expected recovery timelines postpartum.
  • Significant psychosocial distress (e.g., depression, anxiety, trauma-related symptoms) that limits engagement in care.
  • Complex or multi-region MSK presentations requiring interdisciplinary input (e.g., pelvic health, rheumatology, pain management).
  • Barriers to recovery related to social determinants of health (e.g., lack of caregiving support, inability to modify physical demands).

Notes:

  • Pregnancy and postpartum status do not exclude serious pathology.
  • MSK symptoms should be assessed in the context of physiological changes, but persistent or disabling pain is not expected by default.
  • Early recognition of red flags and timely referral are essential to support maternal safety, recovery, and participation.
5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

  • Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   
  • Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
  • Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

  • Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

  • Triage: Ensure primary management by medical/psychiatric providers.
  • Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)
6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

  • Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
  • Social: Lack of family/social support, limited connections.
  • Socioeconomic: Employment status, financial stress, litigation/compensation.
  • Environmental/cultural: Social inequality, unsafe/unsupportive environments.
  • Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
  • Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers: 

  • Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).  
  • Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)

7. Physical Examination

The physical examination should prioritize safety, comfort, and functional relevance, and be adapted to the individual’s stage of pregnancy or postpartum recovery. Findings should be interpreted in the context of physiological changes associated with pregnancy and early postpartum, without assuming symptoms are benign.

  • General observation:
    Posture, alignment, movement behaviour, use of supports or braces, and overall comfort with movement. Observe for guarded movements, asymmetry, or avoidance behaviours.
  • Vital considerations and safety:
    Modify positions to avoid prolonged supine lying in later pregnancy; allow frequent rest breaks; monitor symptom response and tolerance throughout the examination.
  • Spine and pelvic girdle assessment:
    • Active range of motion of the lumbar, thoracic, and cervical spine as tolerated
    • Observe movement quality, symptom reproduction, and variability rather than absolute range
    • Assess pelvic girdle movement and load transfer during functional tasks (e.g., rolling, sit-to-stand)
  • Hip examination:
    Screen hip range of motion and strength, particularly movements relevant to walking, transfers, and caregiving tasks. Avoid end-range provocative testing when unnecessary.
  • Upper extremity assessment (as indicated):
    Assess wrist, hand, shoulder, and thoracic region for pain, strength, and functional use, particularly in postpartum individuals with caregiving-related overuse symptoms.
  • Strength and motor control:
    • Assess trunk, hip, and lower limb strength using functional or low-load testing appropriate to recovery stage
    • Observe motor control during transitional movements and lifting tasks
  • Neurologic screening:
    Brief neurologic screen (strength, sensation, reflexes) when indicated to exclude neurologic compromise.
  • Functional assessment:
    Evaluate tolerance and quality of:
    • Walking and standing
    • Sit-to-stand and bed mobility
    • Lifting, carrying, and feeding positions
    • Single-leg loading or balance tasks as appropriate
  • Symptom response to movement:
    Note whether symptoms improve with gentle movement or worsen with specific positions or loads.

The physical examination should be repeated and adapted over time to monitor recovery, guide progression of conservative care, and identify when further assessment or referral is required.

8. Clinical Presentations for Pregnancy & Postpartum MSK Health

Clinical presentations during pregnancy and postpartum are common, variable, and stage-dependent, reflecting physiological changes, activity demands, and recovery trajectories. Symptoms should be interpreted in the context of gestational stage or time since birth, functional impact, and response to movement and load, without assuming persistence is “normal.”

Common Pregnancy-Related Presentations

  • Low back pain and pelvic girdle pain (PGP):
    Pain localized to the lumbar spine, sacroiliac joints, pubic symphysis, or buttocks; often aggravated by walking, stairs, turning in bed, prolonged standing, or single-leg tasks.
  • Hip and groin pain:
    May be activity-related and influenced by load tolerance, gait changes, and sleep positioning.
  • Thoracic and rib pain:
    Associated with postural changes, breast growth, and altered breathing mechanics.
  • Functional limitations:
    Difficulty with walking tolerance, transfers, sleep, and prolonged static postures.

Common Postpartum Presentations

  • Persistent low back or pelvic girdle pain:
    Symptoms that continue beyond early postpartum recovery, often affecting caregiving tasks and return to activity.
  • Upper limb overuse conditions:
    Wrist, hand, shoulder, and thoracic pain related to infant lifting, feeding positions, and repetitive caregiving tasks.
  • Deconditioning and movement avoidance:
    Reduced strength, endurance, and confidence with movement following pregnancy and birth.
  • Sleep-related symptom amplification:
    Pain and fatigue influenced by disrupted sleep and caregiving demands.

Typical Symptom Behaviour

  • Fluctuating pain and stiffness influenced by load, posture, fatigue, and sleep
  • Symptoms may improve with gentle movement and graded activity, and worsen with sustained positions or repetitive tasks
  • Variable day-to-day presentation, particularly in early postpartum

Atypical or Concerning Presentations

  • Severe or worsening pain disproportionate to activity
  • Progressive neurologic symptoms
  • Marked functional decline or inability to perform basic caregiving tasks
  • Symptoms suggestive of inflammatory, neurologic, or systemic conditions (see Red Flags)

Clinical presentations in pregnancy and postpartum MSK health are heterogeneous and dynamic. Ongoing reassessment is essential to guide conservative management, support participation, and determine when referral or escalation is warranted.

9. Conservative Management Considerations for Pregnancy & Postpartum MSK Health

Conservative management is the first-line approach for pregnancy- and postpartum-related MSK conditions. Care should be individualized, stage-specific, and function-oriented, with a strong emphasis on safety, education, and progressive return to activity. Recommendations below reflect established standards of care from clinical practice guidelines and high-quality systematic reviews.

Core Principles

  • Management should support function, participation, and caregiving capacity, not just symptom reduction.
  • Symptoms should not be dismissed as “normal” if they are persistent, worsening, or function-limiting.
  • Care plans should evolve across pregnancy and postpartum recovery stages.

Education and Self-Management

Education is foundational and should emphasize:

  • The biomechanical and load-related contributors to most pregnancy/postpartum MSK pain
  • Expected recovery trajectories and reassurance regarding safe movement
  • Strategies for activity modification, pacing, and load management (e.g., turning in bed, lifting mechanics, feeding positions)
  • Promotion of continued movement and avoidance of prolonged rest
  • Support for self-management behaviours (physical activity, sleep strategies, stress management)

Exercise Therapy

Exercise therapy is recommended throughout pregnancy and postpartum, with appropriate modification.

Programs should be:

  • Individually tailored and progressive
  • Focused on improving strength, endurance, movement control, and load tolerance
  • Adapted to gestational stage, postpartum recovery, and symptom response

Common components include:

  • Trunk, hip, and pelvic girdle strengthening
  • Functional training for transfers, lifting, and caregiving tasks
  • Aerobic activity as tolerated

No single exercise type is superior; adherence, safety, and functional relevance are key.

Manual Therapy

Manual therapy may be used as an adjunct to support:

  • Short-term pain modulation
  • Movement confidence
  • Engagement in active rehabilitation

Manual therapy should:

  • Be integrated with education and exercise
  • Not be used as a stand-alone intervention

Supports and Ergonomic Strategies

  • Pelvic belts or supports may be considered for pelvic girdle pain in selected cases
  • Ergonomic advice for sleeping, feeding, lifting, and carrying should be routinely provided

Multidisciplinary and Psychosocial Considerations

  • Screen for psychosocial contributors (fear, distress, fatigue, role strain)
  • Consider referral or co-management with pelvic health, mental health, or medical providers

Interventions Generally Not Recommended for Routine Use

  • Passive physical modalities as stand-alone care
  • Prolonged activity restriction or bed rest

These may be used selectively as adjuncts but should not replace active care.

(ACOG 2023; Davenport 2019)

10. Risk and Prognostic Factors for Pregnancy & Postpartum MSK Health

Risk and Prognostic Factors

Recovery trajectories are influenced by a combination of biological, functional, and contextual factors. 

Factors commonly associated with persistent pain or delayed recovery include:

  • History of MSK pain before or during pregnancy (especially prior low back or pelvic girdle pain)
  • Higher pain intensity and functional limitation during pregnancy
  • Pelvic girdle pain involving multiple regions (e.g., posterior + anterior pelvis)
  • Reduced physical activity or prolonged movement avoidance
  • Sleep disruption and fatigue, particularly postpartum
  • Psychosocial factors (e.g., distress, fear of movement, low recovery expectations)
  • High caregiving demands with limited support
  • Barriers to accessing rehabilitation or modifying daily loads

Protective factors associated with better outcomes include:

  • Early, appropriate education and reassurance
  • Continued physical activity and graded exercise during and after pregnancy
  • Timely access to conservative, rehabilitation-led care
  • Adequate social and caregiving support

Prognosis

  • Prognosis is generally favourable when care emphasizes function, load management, and participation, with escalation guided by response to care rather than time alone.
  • Many pregnancy-related MSK symptoms improve within weeks to months postpartum, particularly with appropriate conservative management.
  • A substantial minority experience persistent pain and functional limitation beyond the early postpartum period if risk factors are present.
  • Persistent MSK symptoms should be reassessed and actively managed, rather than normalized or dismissed as expected postpartum recovery.
11. Ongoing Follow-up
  • Monitor progress: Reassess symptoms, functional status, and patient-reported outcomes at appropriate intervals. Confirm that care remains aligned with the patient’s goals, values, and expectations.
  • Adjust treatment plan: Continuously realign the management plan based on evolving goals, treatment response, clinical findings, and professional judgment. Modify interventions, dosage, frequency, or focus as needed to support meaningful improvement.
  • Support self-management: Reinforce the patient’s understanding of home strategies, activity recommendations, and behavioural approaches. Encourage adherence and address barriers that may affect progress.
  • Recognize plateaus or change in status: Identify when the patient is improving, stable, or worsening. Reassess for contributing factors such as comorbidities, psychosocial influences, or new functional limitations.
  • Referral and co-management: Consider referral or co-management with an appropriate provider when there is limited or no significant improvement within an expected timeframe (for example 6 to 8 weeks), when new or concerning findings emerge, or when additional expertise is required to support optimal care.
  • Documentation: Record follow-up assessments, changes to the plan, patient feedback, reassessment of goals, and any referral or co-management decisions.
12. Criteria for Discharge
  • Discharge criteria: Establish clear criteria for concluding active care. These may include achieving the patient’s initial goals, demonstrating meaningful improvement in symptoms or function, reaching a plateau in progress, or transitioning to self-management as the primary approach. Consider patient preferences, functional demands, and clinical judgment when determining readiness for discharge.
  • Clinical reassessment: Prior to discharge, complete a focused reassessment to confirm stability of symptoms, functional status, and the patient’s confidence in managing their condition. Address any remaining concerns and ensure no new issues require further evaluation.
  • Post-discharge planning: Discuss ongoing self-management strategies, including activity recommendations, home exercises, behavioural or lifestyle modifications, and symptom monitoring. Provide guidance on when to return for follow-up, when to seek additional care, and what indicators should prompt medical evaluation.
  • Future care needs: Clarify options for episodic care, preventive visits, or re-engagement with the provider if symptoms recur or functional demands change. Encourage ongoing communication if new concerns arise.
  • Documentation: Record the rationale for discharge, the patient’s status at the time of discharge, self-management recommendations provided, and the agreed-upon follow-up plan

References