Vaginal childbirth is probably the most important factor in the aetiology of pelvic fl oor dysfunction (Fig. 1). This usually arises from trauma to levator ani muscles (LAM), endopelvic fascia and pudendal nerve. However, not all women who deliver vaginally develop lower urinary tract symptoms (LUTS), pelvic organ prolapse (POP) or bowel dysfunction; some are more likely to be at risk than others. If such “at risk” groups can be identifi ed, then prevention might be possible.1
A possible cause of the longterm effect of pregnancy on pelvic floor function is the influence of pregnancy hormones on connective tissues. The hormone relaxin has a putative role in connective tissue remodeling. This occurs in the uterine body, cervix, pelvic joints and perineal tissues in late pregnancy and parturition. Pregnancy triggers a wide range of changes in a woman’s body leading to various muscul oskeletal dysfunctions. Most commonly reported musculoskeletal discomforts by pregnant women as well as childbearing women are low back pain and symphysis pubis pain.
Pathophysiology of pelvic floor dysfunction
LAM injuries occur in 1336% of women who have a vaginal delivery.2 Injury to the LAM is attributed to vaginal delivery resulting in reduced pelvic floor muscle strength, enlargement of the vaginal hiat us and pelvic organ prolapse. LAM injuries increase the risk of cystocele and uterine prolapse but their relationship to posterior wall prolapse and fecal and urinary incontinence is less clear. This is known to be associated with the development of stress urinary incontinence (SUI), pelvic organ prolapses (POP) and anal sphincter defects.3, 4 Most damage of the pelvic floor obviously occurs during first delivery. Objective findings have demonstrated pudendal nerve damage mostly found after forceps delivery, increased duration of second stage of labour, third degree perineal tear and high birth weight. Trauma to the pudendal nerve through stretch injury has been well documented, and although recovery can occur following a first delivery, this is not complete and deterioration in function can arise with subsequent deliveries. Vaginal delivery results in significant pelvic floor tissue stretching and pudendal nerve damage. Women who have a caesarean section during labour may also be at risk of pudendal nerve damage. The proc ess of labour and vaginal delivery can both cause pudendal nerve damage which may be asymmetrical in extent.
Although these injuries were first described using magnetic resonance imaging (MRI), threedimensional transperineal and endovaginal ultrasound has emerged as a more readily available and economic alternative to identify LAM morphology. Although it is possible to detect LAM injuries with MRI and 3D ultrasound, there is a substantial learning curve in carrying out the procedures and interpreting images (Fig. 2). The study of Li and coll.5 aimed to evaluate the contributions of LAM injury, vesical neck movement, and urethral sphincter dysfunction observed on MRI towards SUI after vaginal delivery on fifty primiparous women after 6 months of delivery (15 with SUI and 35 without) and 35 nulliparous. The MRI findings revealed that de novo SUI was associated with major LAM injury, vesical neck downward movement as well as urethral sphincter dysfunction. Vesical neck funneling on sagittal images can be treated as a valuable predictor for SUI.
Constitutionally/genetically weak connective tissue and collagen might represent another risk factor. USI is present in a significant number of nulliparous and pregnancy may adversely affect connective tissue biomechanics. The ratio of type I to type III collagen is altered suggesting a less supportive collagen around the urethra. Genetic and environmental factors contribute to the occurrence of SUI and POP. Dietz and coll.6 demonstrated the heritability of bladderneck mobility. The systematic review by Lince and coll.7 found a substantially greater likelihood of SUI in family members with women with POP compared with women without POP, indicating that genetic predisposition plays an important role in the development of POP.
Over the past decade, with the advent of modern imaging techniques, trauma to the pelvic floor muscles has gained a lot of interest (Fig. 2). There is evidence that 36% of women with prolapse have an underlying LAM avulsion.8 This avulsion occurs mainly during the first vaginal delivery by stretching and tearing of the muscles.8 While partial levator trauma has a tendency to improve over time, this seems to be less common in women with comp lete levator avulsion. Although women with either no longer evident or persistent levator avulsions have signs and symptoms of pelvic floor dysfunction, these are particularly worse in women with persistent levator avulsions. MRI suggests that avulsion of the levator from the pubis is associated with prolapse later in life.9 Braham and coll.10 studied postpartum changes in the LAM using MRI and related these changes to obstetric events and risk factors associated with pelvic floor dysfunction in 57 primiparous women 6 weeks and 6 months after first obstetric delivery and 32 nulliparous women. Subjects with injury to both the puborectalis and ileococcygeous at 6 weeks did not recover to normal at 6 months, whereas those with injury only to the puborectalis tended to have normal magnetic resonance images at 6 months. Nulliparity did not guarantee a normal assessment of LA anatomy. Subjects experiencing more global injury, in particular to the ileococcygeous, tended not to recover muscle bulk. Chan and coll.11 evaluated the morphological outcome of LAM avulsion 35 years after a first delivery and to assess the effect of a second delivery on this condition. They concluded that the risk of developing new LAM avulsion after a second vaginal delivery is low (0.9%). At 35 years after delivery, women with LAM avulsion reported symptoms of SUI more often than did those without, and had higher distress scores, implying more bothersome symptoms. Vaginal laxity, a symptom frequently encountered in parous women and vaginal looseness is a subjective and selfreported sexual health concern. There are few statistics on the prevalence of vaginal laxity following vaginal childbirth.12, 13 Evidence suggests that having multiple vaginal deliveries can increase the risk of vaginal fatigue and incomplete recovery of prepregnancy vaginal tightness. Damage to PFM occur commonly with vaginal delivery, and so this is likely to be a common occurrence. Vaginal laxity is a condition that is distinct from POP, but can sometimes be confused with it and with vaginal looseness the tissue becomes relaxed and stretched with feelings of reduced tightness. Auditory passage of vaginal air (embarrassing vaginal wind) is also a symptom reported in women with PFDs. In our experience the only clinical correlation with POP is more likely to be associated with significant POP especially posterior.
Faecal incontinence (FI)
Incontinence of stool and flatus are frequent complications of childbirth and are more common than was previously believed. FI is associated with forceps delivery and anal sphincter laceration. Anal sphincter laceration is strongly predicted by first vaginal birth, median episiotomy, and forceps or vacuum delivery but not by birth weight or length of the second stage of labour. Andrews and coll.14 established the true prevalence of clinically recognizable and occult obstetric anal sphincter injuries (OASIS). They studied two hundred and fiftyfour women having their first vaginal delivery over a 12month period. Fiftynine (24.5%) women sustained OASIS. They concluded that OASIS occur more frequently than previously reported. Many remain undiagnosed and are subsequently classified as occult when identified on anal endosonography. Genuine occult injuries are rare. Training in perineal anatomy and recognition of OASIS needs to be enhanced in order to increase detection of OASIS and minimize the risk of consequent anal incontinence. Mac Arthur and coll.15 investigated persistent FI after birth and association with delivery mode history and quality of life in a twelveyear longitudinal study. Prevalence of persistent FI was 6.0%; 43% of 12year responders who reported FI at 3 months also reported it at 12 years. This large longitudinal study has demonstrated the persistence of FI and flatus incontinence many years after birth. The findings of this study have some implications for practice. Women who deliver exclusively by caesarean section have no lesser likelihood of persistent FI than those who deliver vaginally. That just one forceps delivery increases the likelihood of persistent FI might be justification to favour vacuum extraction. Laine and coll.16 compared the incidence of OASIS in two time periods, before and after implementing a training program for improved perineal support aimed at reducing the incidence of obstetric anal sphincter injuries. The secondary aim was to study incidence of obstetric anal sphincter injuries in subgroups defined by risk factors for OASIS. After excluding caesarean sections and preterm deliveries (< week 32), the study population consisted of 31 709 deliveries, among which 907 women were identified with obstetric anal sphincter injury. A marked reduction in the incidence of OASIS was observed in all studied subgroups of women after implementing the training programme for perineal protection. These findings indicate that the training program with improved perineal protection markedly reduced the risk of OASIS.
Identification of obstetrical risk factors
Many studies have reported that pregnant women who had UI during pregnancy are at higher risk for postpartum UI than those without UI during pregnancy. Pregnancy and delivery-related factors are considered to be the main risk factors for SUI development during pregnancy.17 Vaginal childbirth is probably the most important factor in the aetiology of pelvic floor dysfunction (PFD) and results in the combination of some or all of the following conditions: UI and anal and POP. However, not all women who deliver develop PFDs. The identification of such women at risk should be achievable by appropriate history (Fig. 3). Among parous women, an increasing number of childbirths further increases the risk of PFDs. Kepenekci and coll.18 reported an increase in the risk of urinary incontinence and other pelvic floor symptoms with increasing parity. Increasing parity also leads to a linear increase in the probability of developing prolapse. Gyhagen and coll.19 investigated the prevalence and risk factors for symptomatic pelvic organ prolapse (sPOP) and sPOP concomitant with urinary incontinence (UI) in women 20 years after one vaginal delivery or one caesarean delivery. The authors concluded that the prevalence of sPOP was doubled after vaginal delivery compared with caesarean section, two decades after one birth. Infant birth weight and current BMI were risk factors for sPOP after vaginal delivery. Similarly, prevalence of fecal incontinence increases with an increase in the number of childbirths. In a recent study of parous women, history of a vaginal childbirth was associated with twice the risk of developing bothersome symptoms of stress incontinence compared with women delivered exclusively via cesarean section.20 Among vaginally parous women, observational studies have identified certain obstetrical factors that may increase the risk of PFDs. These factors include operative vaginal delivery, prolonged second stage of labor, fetal macrosomia and perineal lacerations. In addition, these variables may act as confounders or effect modifiers for each other. A history of incontinence before a first pregnancy appears to be a high-risk factor for long-term LUTS.1 This is more common than previously thought, with an 11% incidence reported. 21 It is possible that some of these women have a constitutionally weak pelvic floor musculature and fascia, with evidence existing for a genetic predisposition.
The identification of such women at risk should be achievable by appropriate history taking in antenatal clinics. Preventative measures can then be put into practice.
The presence of risk groups highlights the need for identification as part of routine antenatal care:
- Taking a history for pre-pregnancy and antenatal incontinence
- Referring such women for supervised PFMT antenatally
- Midwives might be the ideal group to offer this to all women in pregnancy after being trained.
- Women identified as high-risk factors could be referred for PFMT with a physiotherapist or continence advisor postnatally.
Wilson and coll.22 propose a scoring system (UR-CHOICE) to predict the risk of future PFD based on several major risk factors: UI before pregnancy, ethnicity, age at birth of first child, body mass index, family history (mother and sister) of PFD and baby’s weight and maternal height (if <160cm and baby >4kg) have been identified for subsequent PFD risk. This scoring system will help with counselling for women regarding PFD prevention. New evidence exists for the presence of risk groups for obstetric pelvic floor trauma including anal sphincter injury (OASIS), urinary incontinence and pelvic organ prolapse and this highlights the need for identification as part of routine antenatal care.
International Survey Questionnaire on Pelvic Floor Rehabilitation after Childbirth
For more than three decades, the French government has subsidized postnatal pelvic floor physical therapy (PT). This program was instituted in 1985, and paid for by the “Sécurité Sociale”. Women are prescribed 10 sessions of “Rééducation périnéale post-natale”, in the form of pelvic floor muscle exercise by manual internal techniques, biofeedback and electrical stimulation with a probe free of charge. French obs/gyn doctors prescribe postpartum sessions and it is covered as part of the country’s government health care plan (social security).
These services are routinely provided by “kinésithérapeutes or sages femmes”, after 6 weeks postpartum, regardless of symptoms. In France, it’s the standard of care for every new mother to receive PT after she has delivered a baby. France seems to be one of the only countries that supports such a program. We wonder if this is a true reality and wanted more data on this assertion. The study of Bourcier and coll.23 was based on the situation in other countries with regard to the approach of postnatal management. 56 international experts from 28 countries selected according to their interest in this field and have already published articles, filled out a questionnaire which included 21 items on 5 main topics.
The main questions were:
- Do you recommend pelvic floor rehabilitation (PFR) after delivery?
- When do the childbearing women (CW) start PFR in the early postpartum?
- Number of treatments for each individual, number of visits?
- What is the frequency of the treatment sessions?
- What is the percentage of CW attending the postnatal pelvic floor sessions?
- What kind of pelvic floor evaluation do you use for the first check-up visit?
- What type of pelvic floor muscle training (PFMT) is used?
- Do you propose electrical stimulation (ES) and/or biofeedback (BFB) in office therapy or home care?
- Do you propose alternative methods of PFMT (yoga, pilates classes, pelvic core classes)?
- Do you propose in late postpartum (up to 1 year) minimally invasive surgery (sling)?
- Is the treatment covered by your national social security agency?
- What is the percentage of reimbursement?
The main responses were:
- The stay in hospital or private clinic for a vaginal birth: 1-day hospital stay in 56% (in 14%: 6 hrs)
- The stay in hospital or private clinic for a CS: 3-day stay in 30%
- The duration of the maternity leave: 6-12 weeks in 34%, 12-16 weeks in 35%
- Introduction of the PFR in different countries: 1980-1990 in 41%
- PFR is provided: both in 71% for vaginal birth and CS.
- The PFR starts: 6 weeks in 35%, 8 weeks in 34%.
- Number of treatments, number of visits: 1 to 6 sessions in 66%
- Duration of (one-on-one) patient contact: 30 minutes in 38%, 45-60 minutes in 36%
- The frequency of the treatment sessions: weekly in 63%
- The health professionals in charge are: physiotherapists in 82%, trained in 71%.
- The percentage of CW attending the postnatal PFR (only for symptomatic patients): after vaginal delivery: 35%, after CS: 7%
- The CW get patient information by: verbal instruction in 47%, leaflet or booklet in 43%.
- At the first check-up visit, they have to file a questionnaire on pelvic floor dysfunction symptoms: UI, FI, POP, sexual dysfunction: 50%.
- At the first visit, they have: a pelvic floor muscles assessment by digital palpation in 100%, Oxford Grading Scale (digital evaluation with scale) in 20%, use of perineometry EMG in 18%.
- The therapy is usually office therapy, outpatient clinic with health professionals in 86%.
- The type of therapy is voluntary pelvic floor muscle contractions under supervision (manual therapy) in 38%.
- Adjunct therapies offered: biofeedback in 95%, electrical stimulation in 95%
- When ES is recommended, the device used is: vaginal probe in 93%.
- Alternative methods: pelvic floor core exercises in 38%, Swiss balls or gym balls in 36%, pelvic floor exercises classes with average of 8 participants in 25%
- Minimally invasive surgery (sling) in the late postpartum (up to 1 year) is proposed: 85%.
- The reimbursement by private health insurance (partly covered only): 75%
- The percentage of reimbursement: 50- 75% coverage rate
In conclusion of this survey:
- PFR for CW is proposed 6 weeks after vaginal delivery only on symptomatic patients.
- The number of sessions is limited to 6, on weekly basis and between 30 to 45 minutes, under a control of a trained physiotherapist (physical therapist).
- The therapy is mostly pelvic floor exercises training program and Kegel unsupervised exercises as home care.
- BFB and ES are not firstline treatments.
- Health insurance covers rarely these services and the amount to pay for this therapy depends on the coverage from national health insurance and private health insurer.
- There is no routine standardized program of PFR provided for CW. However, some doctors are starting to prescribe postpartum PT, women are starting to request it, and PTs are starting to offer it.
Currently, there are no clear guidelines for new mothers on prevention and avoidance of pelvic floor dysfunction after childbirth. Therefore, a multidisciplinary strategy to make women aware during and after their first pregnancy of the importance of PFMT as a normal part of healthy lifestyle and general wellbeing may be necessary. It seems important to propose adequate recovery/rehabilitation guidance in order to get a consensus about the management of postpartum care.
Physiotherapy/physical therapy after childbirth
During pregnancy and postpartum, conservative therapy or PFR by PFME is the first-line intervention to treat SUI.24 Pregnant women are often instructed to perform PFME to prevent the development and treat symptoms of SUI during pregnancy. Other treatments, whether medical or surgical, must not be proposed at as the first intervention during pregnancy or during the immediate postpartum period.24 It is beneficial for all new CW to have their PFM evaluated after they’ve been cleared to resume sex and exercise. This kind of early intervention can help address any concerns, and ultimately enable new moms to return to functional and active lives while possibly preventing future pelvic floor dysfunction. An evaluation may include:
- Musculoskeletal examination: It is necessary to assess the structure, the muscles, tissue for identification of damaged muscles and scar tissue in order to develop a treatment plan based on the findings.
- Diastasis recti examination: Patients with a diastasis recti are given specific exercises to correct the problem because standard exercises, Pilates, and yoga can make this problem worse and should only be introduced after the diastasis recti is addressed.
- Scar mobilization for C-section, episiotomy, and other vaginal scars: Scar tissue can cause persistent pain and lead to discomfort and pain with intercourse. In addition, scars from a C-section can contribute to urgency/frequency.
PFME prescribed during pregnancy improves pregnancy UI and reduces the prevalence of UI in late pregnancy and early postpartum. Undoubtedly, their PFM strength increased to a larger extent. Sangsawang and Serisathien25 investigated the effects of a PFME on the severity of SUI in 66 pregnant women who had SUI at gestational ages of 20–30 weeks. After the PFME program, women in the experimental group had significantly reduced frequency, volume of urine leakage, and score of perceived SUI severity compared with those in the control group. They concluded that the 6-week PFME program was able to decrease symptom severity in pregnant women with SUI. Most women are told about Kegel exercises, however, it is unknown how many women presenting for primary care can appropriately contract their PFM or whether this ability differs between women with or without PFDs. Henderson and coll.26 sought to describe the proportion of women who initially incorrectly contract the PFM, and how many can learn after basic instruction. Most women with no or mild PFDs can correctly contract their PFM after a simple verbal cue, suggesting that population- based prevention interventions can be initiated without clinical confirmation of correct PFM technique. Monitoring, pelvic floor physiotherapy and exercise can be effective both in treatment and prevention of functional disorders of the pelvic floor. Eisenberg and Kafri27 discuss pelvic floor problems and their appearance throughout pregnancy and childbirth, and the means of treatment from the physiotherapist’s perspective. They raise the question as to whether all postpartum women could benefit from a training program of pelvic floor muscles. Most women with no or mild pelvic floor disorders can correctly contract their PFM after a simple verbal cue, suggesting that populationbased prevention interventions can be initiated without clinical confirmation of correct PFM technique. The literature regarding the long-term effects of PFMT for primigravid women with urinary UI is inconsistent. Berghmans and Seleme28 decided to perform a systematic review to evaluate the evidence that pre- and postpartum women should be advised to do PFMT to treat UI, both short and long term and to find out the optimal training dosage. They recommend that PFMT should be offered as first line conservative therapy to women with persistent UI symptoms three months after delivery; intensive PFMT program (in terms of supervision and exercise content) is likely to increase the treatment effect. Overall, there is evidence that PFMT, that is begun to treat postpartum UI, is effective up to one year after delivery (Level of Evidence: 1).
Role of midwives
Prepartum services might help women achieve maximum pelvic floor and musculoskeletal function. Additionally, prenatal exercises can enhance body awareness, flexibility, and endurance. Training primary care staff to teach basic PFMT in pregnancy seems to be effective and midwives might be the ideal group to offer this to all women in pregnancy because midwives build up a relationship with the woman and this might help with compliance. Alternatively, women identified as high risk (as described above) could be referred for intensive PFMT with a midwife or a continence advisor during and after pregnancy. Stafne and coll.29 assessed whether pregnant women following a general exercise course, including PFMT, were less likely to report urinary and anal incontinence in late pregnancy than a group of 855 women receiving standard care in two-centred randomised controlled trial, conducted between 20 and 36 weeks of gestation. They concluded that pregnant women should exercise, and in particular do PFMT, to prevent and treat urinary incontinence in late pregnancy. Thorough instruction is important, and specific pelvic floor muscle exercises should be included in exercise classes for pregnant women.
So, believing that an opportunity for prevention may begin in nursing consultations during the prenatal period, pregnancy is the ideal time to educate women regarding their health. At this stage, a woman has constant contact with various health professionals and is encouraged to improve her physical condition during the pregnancy. It also calls on maternity service providers to develop clear standards and a referral pathway to specialist physiotherapy for women who are at risk of developing problems relating to pelvic floor dysfunction. Midwives should be enquiring antenatally about bowel and bladder function. The teaching of pelvic floor muscle exercises during pregnancy tends to fall between different health professionals. Midwives are the key profession working with pregnant women, but they have also said they need more training to confidently deliver pelvic health education. Additionally, prenatal exercises can enhance body awareness, flexibility, and endurance. The midwives’ responsibility is to promote the natural process during pregnancy, childbirth and puerperium within every woman. Targeting continent antenatal women early in pregnancy and offering a structured PFMT program may prevent the onset of UI in late pregnancy and postpartum. However, the cost-effectiveness of this is unknown. Prenatal nursing consultation is an excellent tool that identifies the risk factors for UI: high body mass index; inadequate bowel habits, constipation; urinary symptoms, i.e. episodes of involuntary loss of urine when coughing, sneezing, squatting, lifting weights (during the pregnancy or earlier); and the number of pregnancies and parity between them.30
The midwife should investigate urinary symptoms, since many pregnant women do not report their complaints because they believe that the loss of urine is normal and transient or is related to the gestation process. During the midwives’ visits during pregnancy, the strength of the pelvic floor muscles can be assessed. This finding is one of the main data to be recorded in order to prevent SUI and from this information, nurses can guide pregnant women about the risk of weight gain, poor bowel function and its relationship to UI.
Among the key recommendations is that all women should be given evidencebased information and advice about PFME and an opportunity to discuss pelvic care with a qualified healthcare professional, like a midwife or a continence nurse. Most continence problems do resolve during the first couple of weeks following birth, but midwives should be checking antenatally.
It is really important that this becomes part of normal practice. Physiotherapists/ physical therapists have the expertise to deliver this training, there is not an interface between physiotherapists and pregnant women unless there is a problem. Midwives are the key profession working with pregnant women, but they have also said they need more training to confidently deliver pelvic health education. Given the prevalence of female UI and its impact on exercise participation, PFMT should be incorporated as a routine part of women’s exercise programs in general. Embracing the unique skill set of specialized physical therapists for women during and after pregnancy can help the moms of today and tomorrow make such comments a thing of the past.
There’s a knowledge gap between women’s health and orthopedic physical therapy, there’s a communication gap between obstetricians and physical therapists, and there’s a gap between what’s considered “fully recovered” from pregnancy and the demands today’s fit woman places on her body. It is really important to find a midwife or a specialist nurse during pregnancy as well as it’s important to find a physiotherapist/physical therapist with advanced training in assessment and treatment of the pelvic floor. They can treat a myriad of issues, including pelvic and back pain, incontinence, and other ailments. Because of heterogeneity and the varying quality of the studies no strong evidence exists concerning the effect of physical therapy interventions on the prevention and treatment of pelvic floor disorders related to pregnancy and childbirth. A consensus-based report for pregnant and childbearing women has to be produced aimed at being a significant aid to clinical practice and a stimulus for research, with decision-making by collective opinion (consensus). Currently, there are no clear guidelines for new mothers on prevention and, avoidance of pelvic floor dysfunction after childbirth. It seems important to propose adequate recovery/ rehabilitation guidance in order to get a consensus about the management of postpartum care.
Finally, there are so many terms for the conservative management of postnatal urinary, faecal incontinence, prolapse and pelvic pain that it will be important to clarify the proper terminology for better understanding of childbearing women as well as health care professionals. A basic terminology is necessary and can make the better choice of appellation between: physiotherapy after childbirth, pelvic rehabilitation therapy, postpartum physical therapy, postnatal physiotherapy, postpartum reeducation, pelvic health physiotherapy, …