Pregnancy & Postpartum Musculoskeletal Health

• Apply cultural awareness and trauma-informed care principles. Acknowledge prior healthcare experiences, obstetric history, birth experience, and the impact of pregnancy, birth, and postpartum recovery on physical and mental health.
• Sociodemographic information: Age, race/ethnicity, gender identity, language, occupation, caregiving responsibilities.
• Pregnancy or postpartum context:
  • Gestational age by trimester or postpartum stage (early, less than 6 weeks; late, 6 weeks to 12 months; beyond one year).
  • Mode of birth (vaginal, cesarean, instrumental, episiotomy, or perineal tear).
  • Pregnancy or birth complications (preeclampsia, gestational diabetes, prolonged labour, postpartum hemorrhage).
  • Breastfeeding/chestfeeding status and positioning.
  • Sleep disruption and caregiving demands.
  • Multiparity and time since previous pregnancies.
• Primary MSK concerns (question-based prompts):
  • Location (low back, pelvic girdle, hips, thoracic spine, wrists/hands, shoulders, coccyx)
  • Localized or migratory
  • Onset (during pregnancy vs postpartum, gradual vs acute) and course
  • Aggravating and relieving activities (walking, standing, turning in bed, sit-to-stand, lifting or carrying the baby, feeding positions, stairs)
  • Associated symptoms (instability, clicking, weakness, numbness, radiating pain)
  • Impact on sleep, caregiving, work, and daily activities.
• Body systems review: Neurologic; cardiovascular; genitourinary (urinary symptoms, pelvic floor concerns, pelvic organ prolapse); gastrointestinal; musculoskeletal; bone density; eyes/ears/nose/throat; respiratory; skin; mental health (mood, anxiety, perinatal depression, birth trauma); reproductive; breast health (including breastfeeding pain, mastitis).
• Health, lifestyle, and history: 
  • Pre-pregnancy MSK issues, prior pelvic or spinal pain, hypermobility, prior pregnancy-related MSK pain, osteoporosis risk factors.
  • Current and recent medications, supplements, and relevant medical conditions.
  • Physical activity before, during, and after pregnancy; return-to-activity postpartum.
  • Nutrition (protein, iron, calcium, vitamin D), sleep habits, fatigue, smoking, alcohol or substance use.
• Social determinants of health:  Employment status, maternity/parental leave, childcare support, housing, food security, financial stressors, access to rehabilitation, ability to modify daily demands.
• Previous treatments and responses: Prior advice or treatment (exercise, manual therapy, pelvic healthcare, pharmacological options), perceived effectiveness, adverse effects.
• Beliefs and expectations: Understanding of pregnancy and postpartum MSK symptoms, expectations for recovery, concerns about safety of movement or exercise, previous experiences of being dismissed.
• Flag considerations: Identify red, orange, and yellow flags for potential referrals.

​​Outcomes Assessments:  Prioritize approaches aligned with the individual’s goals, life stage, and participation needs. Examples include:

• Pain: Use pain scales (NRS) and body diagrams; pain interference (PROMIS Pain Interference).
• Functioning and Participation: Daily activities (PSFS, WHODAS).
• Region-specific outcome measures: Oswestry/RMDQ for low back; pelvic girdle pain questionnaire (PGQ) for PGP; QuickDASH for upper limb.
• Pelvic floor symptoms: ICIQ-UI-SF (urinary incontinence), PFDI-20 (Pelvic Floor Disability Index).
• Recovery: Use Self-rated recovery scales.
• Quality of Life: SF-12 or EQ-5D.
• Work/school Status: Monitor return to activities, participation.
• Mental health: EPDS (Edinburgh Postnatal Depression Scale), PHQ-9, GAD-7.
• Sleep quality: PSQI or Insomnia Severity Index.
• Individual Goals: Set SMART goals aligned with what matters most to the patient.
• Patient Feedback: Gather and integrate patient experience and satisfaction.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• 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.

Prioritize safety, comfort, dignity, and relevance to functioning. Adapt the examination to gestational or postpartum stage, symptom presentation, and trauma history.

• Trauma-informed approach (Healthcare Excellence Canada, 2026):
  • Many pregnant and postpartum patients carry histories of obstetric, sexual, medical, or interpersonal trauma; birth itself can be traumatic.
  • Offer choice at each step (positioning, draping, location of contact, presence of a support person, pace). Explain each step before performing it and invite ongoing consent.
  • Confirm consent before any examination involving the trunk, pelvis, hips, or breast region. Avoid unnecessary undressing or palpation of intimate regions; refer to a pelvic health provider for internal pelvic examination when indicated.
• Safety: In pregnancy, avoid prolonged supine positioning after the mid-second trimester (inferior vena cava compression); allow frequent position changes. Take blood pressure when clinically indicated; refer promptly if elevated in pregnancy (preeclampsia risk). Postpartum, interpret findings and set pace by recovery stage.
• Observation:
  Posture, gait, movement behaviour, guarded movements, asymmetry, avoidance, use of supports or braces.
• Spine and pelvic girdle:
  • Active range of motion of the lumbar, thoracic, and cervical spine as tolerated.
  • Movement quality and symptom reproduction.
  • Pelvic girdle load transfer during functional tasks (rolling, Sit-to-Stand, single-leg loading, active straight leg raise).
• Hip:
  Range of motion, strength, and load tolerance. Avoid unnecessary end-range provocative testing.
• Upper extremity:
  Screen wrist (De Quervain’s tenosynovitis is common postpartum from repetitive infant lifting and feeding positions), thumb (carpometacarpal region), shoulder, thoracic region, and cervical spine for pain and functional use.
• Abdominal wall: Assess for diastasis recti abdominis (DRA), including inter-recti distance and load transfer at the linea alba. DRA is common in late pregnancy and early postpartum; functioning matters more than absolute width.
• Strength and motor control:
  • Trunk, hip, and lower limb strength using functional or low-load testing appropriate to stage.
  • Motor control during transitional movements, lifting, and caregiving tasks.
• Neurologic screening:
  Screen (strength, sensation, reflexes) when indicated.
• Functional assessment:
  • Walking and standing tolerance
  • Sit-to-Stand quality
  • Lifting, carrying, and infant handling
  • Single-leg loading, balance, and stairs
• Symptom response to movement:
  Note whether symptoms improve with gentle movement or worsen with specific positions or loads.
• Repeat and adapt the examination over time to track recovery, progress conservative care, and identify when further assessment or referral is required.

Common Pregnancy-Related Presentations

• Low back pain and pelvic girdle pain (PGP): Pain in the lumbar spine, sacroiliac joints, pubic symphysis, or buttocks; aggravated by walking, stairs, turning in bed, prolonged standing, or single-leg tasks.
• Hip and groin pain: Activity-related; influenced by load tolerance, gait changes, and sleep positioning.
• Thoracic and rib pain: Associated with postural changes, breast growth, and altered breathing mechanics.
• Symphysis pubis dysfunction (SPD) / pubic symphysis pain: Anterior pelvic pain with weight-bearing, walking, stairs, and separation of legs; part of the PGP spectrum.
• Round ligament pain: Sharp lower abdominal or groin pain, typically second trimester, aggravated by sudden movement.
• Carpal tunnel syndrome: Wrist and hand paresthesia related to fluid retention; often resolves postpartum.
• Meralgia paresthetica: Lateral thigh paresthesia from lateral femoral cutaneous nerve compression.

Common Postpartum Presentations

• Persistent low back or pelvic girdle pain: Continued beyond early postpartum, often affecting caregiving.
• Diastasis recti abdominis (DRA): Common in late pregnancy and early postpartum.
• Coccydynia: Coccygeal pain, particularly with sitting and sit-to-stand transitions; associated with vaginal delivery, prolonged second stage, or instrumental birth.
• De Quervain’s tenosynovitis: Radial-sided wrist pain from repetitive infant lifting and feeding positions.
• Cervicothoracic and shoulder pain: From feeding positions, infant carrying, and postural loading.
• Pelvic floor dysfunction: Urinary incontinence (stress, urge, mixed), fecal incontinence, pelvic organ prolapse, dyspareunia, and pelvic pain. Approximately one third of women experience urinary incontinence after childbirth (Woodley et al., 2020).
• Deconditioning and movement avoidance: Reduced strength, endurance, and confidence with movement.

Whole-Person Considerations

• Perinatal depression, anxiety, and birth-related trauma affect pain experience, functioning, and engagement in self-management.
• Caregiving load (feeding, lifting, carrying, sleep disruption) interacts with MSK symptoms; pressure to “bounce back” can drive premature progression.
• Symptoms fluctuate with load, position, sleep, and fatigue, and often improve with graded, sustained physical activity. Multi-region symptoms are common and do not necessarily indicate serious pathology but warrant whole-person assessment.

Care is individualized, stage-specific, biopsychosocial, and delivered alongside obstetric and primary care, with functioning, participation, caregiving capacity, and patient-defined goals as the targets.

Education and Self-Management

• Explain expected physiological changes across pregnancy and postpartum and their relationship to MSK symptoms; validate the patient’s experience.
• Reassure that continued movement and graded exercise are safe and beneficial in the absence of contraindications.
• Provide strategies for activity modification, pacing, load management, progressive return to valued activities, and practical approaches to common caregiving loads (turning in bed, sit-to-stand, lifting mechanics, infant carrying, feeding positions).

Exercise Therapy

• Pregnancy: Accumulate at least 150 minutes per week of moderate-intensity aerobic activity, spread across at least three days, plus resistance training, throughout pregnancy in the absence of contraindications (Mottola et al., 2018).
• Postpartum: Accumulate at least 120 minutes per week of moderate-to-vigorous physical activity (MVPA), including aerobic and muscle-strengthening exercise. Initiate light-intensity activity shortly after childbirth; progression toward MVPA should be individualized, gradual, and symptom-based. Beginning or returning to MVPA within the first 12 weeks postpartum is associated with improved mental health outcomes, including reduced risk of postpartum depression (Davenport et al., 2025).
• Pelvic floor muscle training (PFMT): PFMT during and after pregnancy reduces the risk of urinary incontinence in the antenatal and postnatal periods and treats postnatal urinary incontinence (Woodley et al., 2020).
• Region-specific rehabilitation: Graded loading for pregnancy-related low back and pelvic girdle pain (Davenport et al., 2019); progressive loading for postpartum abdominal wall and pelvic floor recovery; return to running and higher-impact activity when foundational capacity is restored, guided by individual assessment.

Contraindications and precautions:

• Pregnancy: Absolute contraindications to exercise include ruptured membranes, premature labour, unexplained persistent vaginal bleeding, placenta previa after 28 weeks’ gestation, preeclampsia, incompetent cervix, intrauterine growth restriction, high-order multiple pregnancy, uncontrolled type I diabetes, uncontrolled hypertension, and uncontrolled thyroid disease (Mottola et al., 2018).
• Postpartum: Return to running and resistance training is generally safe once surgical incisions or perineal tears have sufficiently healed and vaginal bleeding does not increase with MVPA. Activities of daily living are recommended for all postpartum individuals given the known harms of activity restriction and bed rest. Use the Get Active Questionnaire for Postpartum to screen for relative contraindications (Davenport et al., 2025).

Manual Therapy

• Manual therapies (joint mobilization, spinal manipulation, soft-tissue techniques) may be offered as an adjunct to active care in pregnancy-related low back, pelvic girdle, or combination pain; effectiveness has not been established for individual manual therapy interventions (Weis et al., 2020a).
• When used, integrate manual therapy with education, exercise, and self-management rather than delivering it as stand-alone care; obtain clear consent at each step with attention to positioning, dignity, and comfort; and match it to patient preference, stage, and any contraindications (Weis et al., 2022).
• The evidence base on adverse events from spinal manipulation in pregnancy and postpartum is dominated by case reports; incidence cannot be estimated from the available literature (Weis et al., 2021). Absence of high-quality safety data is not evidence of safety.
• Modify technique to gestational or postpartum stage, use positioning modifications, and consider lower-force techniques, for example with hypermobility or symptomatic pelvic girdle pain (Weis et al., 2022).

Supports and Ergonomic Strategies

• Pelvic support belts may be considered for pelvic girdle pain in selected cases (Weis et al., 2022).
• Provide ergonomic advice for sleeping, feeding, lifting, carrying, and workstation setup as relevant.

Psychosocial and Multidisciplinary Considerations

• Screen for psychosocial contributors (distress, fear of movement, birth-related trauma, low expectations, caregiver burden, isolation) and for perinatal mood and anxiety symptoms.
• Co-manage with obstetric care, primary care, pelvic health, mental health, and lactation support providers as needed.

Not Recommended

• Passive physical modalities as stand-alone care.
• Prolonged activity restriction or bed rest.
• Compounded or unregulated supplements marketed for pregnancy or postpartum; encourage critical appraisal and primary care discussion.

 Factors associated with persistent symptoms or delayed recovery:

• Low back pain before pregnancy and pelvic girdle pain during pregnancy; higher pain intensity and functional limitation during pregnancy; pelvic girdle pain involving multiple pelvic regions (Davenport et al., 2019; Wiezer et al., 2020).
• Depression during pregnancy (Wiezer et al., 2020).
• History of heavy physical workload during pregnancy (Wiezer et al., 2020).
• Pre-pregnancy body mass index above 25 (Wiezer et al., 2020).
• Persistent pelvic floor dysfunction or unaddressed incontinence (Woodley et al., 2020).

Protective factors:

• Sustained physical activity, including PFMT during and after pregnancy (Woodley et al., 2020); meeting the 2025 postpartum activity targets and initiating activity within the first 12 weeks postpartum (Davenport et al., 2025).

Prognosis

• Many pregnancy-related MSK symptoms improve within weeks to months postpartum with appropriate conservative management (Davenport et al., 2019).
• A substantial minority experience persistent pain and limitation in functioning beyond the early postpartum period, particularly when risk factors are present (Weis et al., 2020b).