Many women develop problems associated with pelvic floor dysfunction, which often stem from the peripartum period. Those at most risk include: women of an older maternal age, those with a high body mass index (BMI), women who have heavier babies, women have had four or more normal births, and women who have had a forceps birth (Glazener et al, 2009). It has also been shown that birth by caesarean section is not protective for incontinence in the longer term (Press et al, 2007).
Pelvic floor dysfunction can cause urinary incontinence, anal incontinence, and pelvic organ prolapse; all of which can have a significant impact on a woman's quality of life. In 2013–2014, a parenting website on behalf of the Chartered Society of Physiotherapy (CSP, unpublished), carried out a survey of 1900 mothers and found that over 80% had experienced urinary leakage at some point with 49% continuing to leak at 6 months.
The incidence of anal incontinence (i.e. ‘leakage from the back passage of wind, liquid or solid stool’: Norton et al, 2005: 1591), is difficult to determine because it is often not reported. However, in a population-based study, more than one in four women reported experiencing faecal incontinence within 6 months of childbirth, with almost half reporting onset of symptoms after birth of their first child, and four in 10 women reporting loss of flatus or stool during intercourse (Guise et al, 2007).
The third common pelvic floor dysfunction is pelvic organ prolapse. A degree of prolapse is common after any vaginal birth, with 40% of women older than 50 years having some degree of prolapse on examination, and 11% requiring at least one surgical intervention (Smith et al, 2010).
With the increasing birth rate (over the last decade the birth rate has risen from 11.34 (2002) to 12.27 (2012) births per 1000 persons in the UK (Indexmundi, 2014)) and an ageing population forecasted, it is important that measures are put in place to help prevent or treat pelvic floor dysfunction. The human, social care and financial consequences to the NHS of pelvic floor dysfunction are costly. There is robust evidence that PFM exercises are effective in the prevention and cure of pelvic floor dysfunction (National Institute for Health and Care Excellence (NICE), 2013); however, adherence is central to ensuring long- and short-term effects.
The teaching of PFM exercises traditionally fell within the physiotherapist's remit, but is now the responsibility of all health care providers involved in the perinatal period. With less than 700 physiotherapists in the UK with a specialist interest in obstetrics, and a reduction in time for contact pre- and postnatally, many women are not getting taught these important exercises.
Health promotion is a key role that midwives play in caring for pregnant women (Nursing and Midwifery Council, 2012). They have a unique window of opportunity to prevent illness and injury and to promote health and wellbeing during pregnancy, birth and in the postnatal period. Incontinence following childbirth is a serious but avoidable public health concern. Midwives play a key role in preventing PFM weakness; however, due to staff shortages, detailed and busy antenatal booking appointments, the provision of antenatal screening information as well as other public health advice during pregnancy, PFM exercises have often been less of a priority for midwifery teams.
The evidence is clear, early intervention by a health professional to teach correct PFM contractions will prevent problems with incontinence and pelvic organ prolapse (Hagen et al, 2014). Boyle et al (2012) advises that PFM exercises are discussed at 10 weeks (booking appointment). Furthermore, Boyle et al's (2012) Cochrane review states that:
Joint initiative
The Royal College of Midwives (RCM) recognised that many midwives felt uncertain of how to teach PFM exercises and were unsure when it was appropriate to refer onward for more specialist input. Discussions with the CSP and the RCM were instigated and it was decided to launch a joint initiative to prevent and reduce incontinence among women during pregnancy and following birth, in order to prevent the development of incontinence and pelvic organ prolapse in later life by:
Through joint working, the CSP, RCM and Pelvic, Obstetric and Gynaecological Physiotherapy (POGP) have developed a number of resources to support the aims of the project (Box 1).
Key messages
The key message is that midwives should take a few minutes at each review appointment to discuss PFM exercises and their importance in reducing bladder, bowel and pelvic floor dysfunction (Table 1). Within the i-learning platform, simple scripts on how to do PFM exercises have been devised and are presented clearly (Figure 1), with supporting background and evidence.
| 1. | Explain why the woman needs to do pelvic floor muscle (PFM) exercises |
| 2. | Explain where the PFM are |
| 3. | Sitting or lying are good positions for learning PFM exercises. Ask the woman to squeeze inside her back passage, as if holding in wind. Ask her to then add in a squeeze at the ‘front’, as if holding in urine. Then relax. Practise this a few times. This is a short squeeze |
| 4. | Relaxation is more explicitly taught when doing long squeezes i.e. hold for 10 seconds and relax for 5 seconds, whereas with the quick contractions it is not |
| Learning point—be careful to pause briefly between short squeezes, to avoid tiring the muscles too quickly | |
Information regarding when to refer for more specialist intervention (Table 2) and where to seek further information and advice are also provided on the platform.
| Antenatal | Woman who have had urinary or anal incontinence or symptoms of prolapse that are becoming more severe despite midwifery instruction in pelvic floor muscle exercises and advice |
| Postnatal | Women who experienced antenatal urinary or anal incontinence or have symptoms of prolapse |
| Women who have had Obstetric Anal Sphincter Injuries (OASIS)—ideally for advice with first few days postnatally, followed up at 6 weeks for pelvic floor assessment | |
| New urinary, anal incontinence or symptoms of prolapse that are not improving with midwifery instruction in pelvic floor muscle exercises and advice |
The joint project was officially launched in the UK at the Primary Care and Public Health Conference in Birmingham in May 2014 and the i-learning platform was presented at the International Confederation of Midwives, in Prague in June 2014.
In the short-term, the project will be judged to have been successful if there is:
In the longer-term, a reduction in the number of women reporting pelvic floor dysfunction, e.g. urinary or faecal leakage, and/or pelvic organ prolapse will indicate that this project has been successful.
Patient information leaflet
Five thousand printed copies were produced and distributed at two conferences, Primary Care and Public Health (May 2014) and Royal College of GPs (October 2014), and 10 000 have been downloaded from the website.
i-learning information for midwives
To date, 120 members have accessed it with over 50 certificates being issued for the module.
Profile raising
The CSP Press and PR have used the launch of the project to target a number of key media outlets to raise the profile of continence and physiotherapy.
Discussion
The UK is not the only country developing initiatives around the teaching of PFM exercises. A recently published abstract (Frawley et al, 2014) reported on a translational research study undertaken in Australia, which focused on the barriers and facilitators that could increase the uptake of continence screening and PFM instruction with midwives. Lack of awareness of guidelines, time required and lack of knowledge and experience with PFM instruction were cited as barriers. However, once adapted to contextually fit within routine clinic priorities, midwives felt empowered by the positive feedback from women and the model gained cultural acceptance. Only one country—France—prescribes 10 to 20 sessions of la rééducation périnéale for all postnatal women and has done since 1985. While such a regimen may be the ideal, it is unlikely that it will be adopted by the present day NHS.
As well as the initiatives described above, this joint venture has resulted in a raising of awareness professionally and publicly of the importance of PFM exercises during the peripartum period, and the largely unrecognised impact pelvic floor dysfunction has on thousands of women. Incontinence is an exceptionally difficult topic to get in the public domain, patients are reluctant to discuss it and the media do not see it as a topical area. The launch of this venture has raised the profile with several radio interviews, magazines and peer reviewed articles. In addition, it has started a debate nationally between midwives and physiotherapists around their roles and the most appropriate mode of service delivery in these times of social changes and financial constraints.
Heads of midwifery services have been extremely supportive of this collaborative project—to include the teaching of PFM exercise as part of their service remit—yet recognise the difficulties faced by midwives in their everyday clinical practice. The RCM Pressure Points campaign (RCM, 2014) highlighted how stretched maternity services are, for example when women were asked did they discuss a postnatal care plan with a member of the maternity team after the birth, 64% said no.
When midwives were asked what is the average number of postnatal visits a woman receives, it was evident that visits had significantly decreased to an average of three visits (54% of women) from selective postnatal home visiting while 14% only received one visit. Pressure Points clearly demonstrated that there is little time or resources to convey the importance of pelvic health. This initiative provides clear and concise scripts so the information can be imparted in a timely fashion. In addition, if a similar initiative to help other professionals, e.g. health visitors, become more competent with asking women about continence and pelvic floor problems, the message to women would be sustained.
It is well recognised that while women's health physiotherapists have specialist knowledge and skills in the area of PFM exercises, their services are also under pressure with decreased resources for maternity services; therefore, different ways of reaching women have to be explored. This is an area in which patients require maximum exposure to enable them to develop and adhere to a highly effective self-help preventative technique. There is evidence of effect both in prevention and treatment following this initiative, albeit not wholly defined around the most appropriate methods in various populations, and it is now up to professionals to raise awareness and support implementation as widely as possible.
Following on from this project several further ventures are proposed:
This project will also bring significant benefit to physiotherapy practice and service delivery. By increasing midwives’ confidence with teaching and talking about PFM with women, problems can be identified at an earlier stage, and women referred to women's health physiotherapists, when prompt treatment is often most effective. This project can serve as both an opportunity to refresh established relationships between local physiotherapy and midwifery services and where they do not currently exist, to develop new ones.
It is acknowledged that midwives only see women for a limited time, especially postnatally, and pelvic floor issues may well only occur or be identified as an issue later on. However, they have an unique opportunity to be pro-active in preventative measures and raising awareness of the importance of PFM exercises to all pregnant women. All health professionals, including GPs, practice nurses, and health visitors should also be pro-active in asking women about their pelvic floor health and know when to refer appropriately.
Conclusion
Midwives are the main contact throughout the perinatal period and are therefore ideally placed to teach and re-enforce the importance of continuation of PFM exercises. Using the specialist skills of physiotherapists to identify and then hone appropriate knowledge and teaching techniques in an accessible platform should simplify the tasks for midwives. Additionally, more appropriate referral to specialists, as outlined in the patient pathways, will lead to better use of resources and enhanced patient care. Joint initiatives between professional bodies such as the RCM and CSP can identify and address areas of clinical need and opportunities for collaborative working.