At least one-third of women suffer from long-term pelvic floor dysfunction as a consequence of pregnancy and childbirth.
The pelvic floor muscles (PFM) help to support the pelvic organs and also, indirectly, the lumbar spine, through their relationship with the abdominal muscle corset. They are involved in the following: parturition; micturition; defaecation; continence of urine, flatus and faeces; and intercourse.
Each function needs to be assessed in the puerperium and this can be challenging with the hospital short-stay imperative. In the acute care setting, a co-ordinated multidisciplinary approach to pelvic floor issues may involve medical, nursing and women’s health (WH) physiotherapy staff.
During vaginal birth, the PFM and connective tissues are stretched by up to 2.5 times their normal resting length and may tear, be cut or directly damaged by instrumental birth. The levator muscle plate, including pubo-rectalis and pubo-coccygeus, can be partially or totally avulsed from the pelvic side wall in 20–36 per cent of vaginal births1,2; this rate increases with increasing maternal age. Stretch or compression damage to the pudendal nerve that innervates the urethral and anal sphincters is estimated to occur in 42–80 per cent of births and is related to length of second stage, size of baby and instrumental delivery.1
Immediately following birth-related soft-tissue injury (as with sporting injuries), WH physiotherapists institute first aid principles in line with the PRICE acronym and continue these for the first 24–72 hours:
- protection to prevent further trauma from unnecessary increases in intra-abdominal pressure;
- rest in recumbent positions;
- ice to assist with pain3 is applied for 20–30 minutes and then re-applied every three hours;
- compression to reduce swelling, using thick padding and firm underwear; and
- elevation to facilitate reabsorption of perineal swelling by lying in supine, side or prone positions rather than sitting or standing, which make swelling dependent.
This process is to reduce oedema, inflammation, subsequent fibrosis and to protect new vascularisation.
The UK National Institute of Health and Clinical Excellence (NICE) guidelines3 recommend that women are also:
- educated about the necessity of perineal hygiene and signs of infection; and
- questioned about perineal pain and discomfort and offered an assessment of the perineum at each contact.
Following normal, instrumental or caesarean birth, bladder management is essential to prevent urinary retention, which can have a long-term deleterious effect on detrusor function. All major hospitals have guidelines for postpartum bladder management, which usually require that the woman’s first void occurs within six hours of birth or an indwelling catheter being removed and women are encouraged to drink normally and to void when urge is present.
An inability to void (overt urinary retention) can be associated with pain and adequate analgesia (preferably without codeine because of the effect of constipation) may be required for women following both vaginal and caesarean birth. The WH physiotherapist teaches women voiding positions and techniques to assist, such as immersion of a hand in cold water or being in a warm bath or shower to void. If there is no sense of urinary urge, the woman is encouraged to perform timed-voiding every three hours.
In cases of covert urinary retention, women are able to void, but do not empty the bladder and experience voiding dysfunction such as a slow or hesitant flow, do not have feeling of an empty bladder or have overflow incontinence. Double and triple voiding techniques may help this problem.
An asymmetrical high fundus can be indicative of a full bladder. In some hospitals, real-time ultrasound examination is available and enables the bladder to be visualised to provide information about its size and volume. This may prevent unnecessary catheterisation, with the attendant risk of urinary tract infection (bladder scanners are considered to be inaccurate after birth, providing false positive information due to the size and vascularity of the uterus). It is generally agreed that catheterisation will be needed by women who have overt urinary retention and cannot void or by women with a residual urine volume of greater than 150ml.
A woman with unresolved urinary retention, which requires an indwelling catheter, will need referral to a continence nurse advisor for a trial of void at one week postpartum. Women who have any voiding dysfunction or no sense of urinary urge at the time of hospital discharge, are advised to seek follow-up if the condition does not resolve by one week postpartum.
Defaecation problems are often overlooked in the puerperium. Constipation is common and is not only uncomfortable for the patient, but creates further pressure on already stretched pelvic floor structures.
Problems with defaecation occur due to constipation (for example, from pain relief), fear of pain or further increasing perineal trauma, and are also common after lower uterine segment caesarean section (LUSCS). If a woman has a known history of constipation, stool softeners and/or laxatives that are safe with breastfeeding, should be prescribed soon after birth. Dietary fibre (including prunes and pear juice) and fluid intake need to be increased. If the woman is breastfeeding, an extra litre of fluid per day is required by the end of the puerperium.
If the woman bears down to defaecate, the rectus abdominus muscle works in conjunction with pubo-rectalis muscle to pull the ano-rectal angle forwards, lengthening and narrowing the anus and causing a bulging of the posterior wall of the vagina. This not only makes defaecation more difficult, but also causes pain through pressure on the LUSCS and perineal wounds.
The WH physiotherapist can teach correct defaecation mechanics to women with a history of constipation, haemorrhoids, anal fissure; obstetric anal sphincter injury and LUSCS; and to those who are fearful. Correct mechanics enable the anus to shorten and open and keep the ano-rectal angle at 90 degrees, the pelvic floor in a supported position and also prevent pain.
Pregnancy is the greatest risk factor for urinary incontinence (UI) and during the last trimester, the incidence of UI has been reported as high as 67 per cent.1 De novo UI following birth may be overflow incontinence from covert urinary retention and pudendal nerve and levator ani damage sustained during labour are associated with the presence of new or worse stress incontinence following birth. It is generally agreed that the rate of incontinence after birth is 33 per cent.1,4 Birth by LUSCS is protective initially, with a UI rate of 15 per cent, but it does not protect ultimately for UI or faecal incontinence.
Flatal and faecal incontinence occur in approximately ten per cent of postpartum women.4 These are psychologically distressing and can occur as a consequence of pregnancy, birth and in particular obstetric anal sphincter injury. Faecal incontinence may also occur as a result of overuse of aperients, leading to liquid stool and rectal urgency that are difficult to control when PFMs are weak.
Teaching PFM exercises to women in pregnancy may be the best way to prevent long-term UI.1,4 Research confirms that women who received an intensive PFM exercise program before 20 weeks gestation are less likely to report UI at six months postpartum.4,6 Physiotherapy muscle rehabilitation should be offered immediately after birth to all women:
- with a history of UI before pregnancy, during pregnancy and after birth;
- who had a forceps delivery;
- who delivered a baby weighing greater than 4000g;
- who sustained an obstetric anal sphincter injury;
- with pelvic organ prolapse; or
- with faecal incontinence.4,5,6
As with other types of muscle injuries, rehabilitation of PFMs should begin three to five days after birth (because the longer the period of immobilisation, the greater the atrophy of muscle fibres). Initial exercises must be gentle and pain free.
It has been found that giving written instructions is ineffective, as only 25 per cent of women will contract the muscle correctly and many will perform a valsalva (bearing down) manoeuvre1, which is counterproductive. It has been found that PFM exercise programs are most effective when they are targeted, individual and specific, rather than general population based4 and that the more intensive the PFM exercise program is, the greater the treatment effect.1,4
Physiotherapists teach women:
- how to contract the muscle using verbal or kinaesthetic cues to ensure the correct technique (which is checked with consent);
- functional bracing of the PFM for any sudden increase in intra-abdominal pressure, such as a cough or sneeze; and
- abdominal bracing via core stabilisers to protect the pelvic floor during functional activities (transversus abdominus will lift the PFM via the endopelvic fascia).
A physiotherapist can also provide advice on how to gradually improve PFM strength and endurance through exercising fast and slow twitch muscle fibres in the first six weeks postpartum, and on the safe return to gym and sport activities.
At three months postpartum, women still experiencing UI should be offered an intensive individual PFM exercise program4,5 from a postgraduate-educated continence physiotherapist and those with faecal incontinence offered dietary and lifestyle interventions as well.
Dyspareunia is a common sequela of instrumental birth and perineal suturing, but can be multifactorial in its aetiology. If conservative measures, including water-based lubrication, do not help the problem after three months, women should be encouraged to seek a medical opinion.3
Pelvic floor dysfunction of any kind occurs at huge psychological, physical and social cost to the woman and places a financial burden on both the individual and society. There is some evidence that long-term incontinence can be prevented or ameliorated though intensive exercise programs before 20 weeks gestation. It is important to stress that attendance at these programs is necessary for long-term pelvic floor health.
Immediately post-birth, pelvic floor functions can be assessed and managed by WH physiotherapists, midwives and continence nurse advisors. Women with problems, especially incontinence and prolapse, that persist after three months will benefit from detailed assessment and conservative treatment from a specialist continence physiotherapist.