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Analysis

Preventing pelvic flaws

2 December, 2013

Preventing pelvic flaws

A new joint venture between the RCM and the Chartered Society of Physiotherapy aims to ensure that all women receive pelvic health advice during and after pregnancy, as Louise Hunt explains.
Midwives magazine: Issue 6 :: 2013

A new joint venture between the RCM and the Chartered Society of Physiotherapy aims to ensure that all women receive pelvic health advice during and after pregnancy, as Louise Hunt explains.

Evidence suggests that approximately 19% of women have urinary continence problems following childbirth (Labrecque et al, 2000), and it is likely that many more women are affected but are too embarrassed to seek help. By capitalising on women’s general receptiveness to public health messages during and immediately after pregnancy, the joint campaign from the RCM and the Chartered Society of Physiotherapy (CSP) aims to reinforce the message among midwives that pelvic health is a key public health issue. The reasons and recommendations to maternity service providers have been set out in a joint position statement, which can be viewed on the RCM website.


Among the key recommendations is that all women should be given evidence-based information and advice about pelvic floor muscle exercises (PFME) and an opportunity to discuss pelvic care with a qualified healthcare professional. 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. 


Bladder and bowel dysfunction caused by pelvic floor damage can be severely distressing and disruptive to women’s lives, potentially affecting personal relationships and their ability to work and look after young children. 


‘For women with incontinence, their whole day is planned around being able to access a toilet. This is a very powerful message: if we don’t pick up on this issue and embrace pelvic health, these problems will continue into older age and probably cause worse problems,’ says RCM director for England Jacque Gerrard, who has been leading on this work with the CSP.


It is not only the physical impact on a woman’s quality of life: one study found that women who experience urinary incontinence following childbirth are nearly twice as likely to develop postnatal depression (Sword et al, 2011). 


Mary Steen, professor of midwifery at the University of Chester, says it is important that midwives connect the physical with the potential psychological consequences and think about all the issues around a woman’s wellbeing and quality of life.


‘Most continence problems do resolve during the first couple of weeks following birth, but midwives should be checking antenatally if everything is ok with bowel and bladder function, not just at booking in, but as they build up a relationship with the woman, because it is a sensitive subject. They have got to be proactive and reiterate on a few occasions that if a woman thinks there is something abnormal, not to be afraid to seek help,’ she says.


The joint work builds on the pelvic health advice that midwives currently provide, with a focus on equipping them with the knowledge to deliver PFME during the antenatal and postnatal periods. 


The collaboration has been driven by women’s health physiotherapists, who see a need for a more preventive approach to pelvic health, since many of the women they treat with continence problems already have long-term damage that could have been avoided with timely advice and early intervention. 


‘The teaching of pelvic floor muscle exercises during pregnancy tends to fall between different health professionals,’ says CSP professional adviser Ruth ten Hove. ‘Even if some people are being told about these exercises, they often don’t get the information at the right time or realise they have to carry on doing them. It is really important that this becomes part of normal practice.’ 


Physiotherapists have the expertise to deliver this training, but with just 650 specialist physiotherapists in women’s health, ‘there are simply not enough to teach pelvic floor exercises as a preventative measure’, Ruth says. 


‘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.’ 


To this end, the RCM, along with the CSP, is developing new resources for midwives to use with clients that will be available in spring 2014 on the RCM’s i-learn platform. They will cover the basics of what midwives need to know in anatomy, function and dysfunction of the pelvic floor, including PFME and when to refer women to specialist physiotherapists. There will also be a video featuring the case study of a woman affected by incontinence. 


Patient information leaflets are also being developed that will be available to download from the NHS Choices website, which midwives can use to signpost women as part of antenatal discussions. 


Mary says: ‘Many maternity services already provide patient information on pelvic health and exercises, and there are lots of examples of good practice out there. But there will be variation in how pelvic health advice is given because of midwives’ workloads and resources. These will be additional, evidence-based tools that midwives can use.’ 


In the meantime, the benefits of early intervention in PFME teaching for combating pregnancy-related continence problems or prolapse later in life are well documented. For example, a recent systematic review published in the British Medical Journal (Mørkved and Bø, 2013) concluded that pelvic floor exercise training during pregnancy and following childbirth can prevent and help to treat urinary incontinence. In addition, the NICE (2006) guidance for treating stress incontinence recommends PFME as a first line of treatment.


The collaborative goal has so far been well received by HoMs consulted by the two bodies, but Jacque acknowledges the challenges its implementation will incur. ‘Midwives can see there is a need to do this work and we will incorporate more pelvic health into our workload. But, with the current midwife shortages, we will be stressing the societal cost of not treating incontinence early enough, which is £117m a year for the NHS (Imamura et al, 2010), as part of our call for 5000 more midwives.’


Jacque’s key message to midwives is to take on board the importance of disseminating information on good pelvic health to all women in their care. ‘My aspiration is that this message takes on the same resonance as skin-to-skin contact and breastfeeding,’ she says.  


► To view the joint RCM and CSP statement, visit: rcm.org.uk/college/policy-practice/joint-statements-and-reports



References


Imamura M, Abrams P, Bain C, Buckley B, Cardozo L, Cody J, Cook J, Eustice S, Glazener C, Grant A, Hay-Smith J, Hislop J, Jenkinson D, Kilonzo M, Nabi G,N'Dow J, Pickard R, Ternent L, Wallace S, Wardle J, Zhu S, Vale L. (2010) Systematic review and economic modelling of the effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence. Health Technology Assessment 14(40): 1-188, iii-iv. See:  www.hta.ac.uk/execsumm/summ1440.htm (accessed 4 November 2013).

Labrecque M, Eason E, Marcoux S. (2000) Randomised trial of perineal massage during pregnancy: perineal symptoms three months after delivery. American Journal of Obstetrics and Gynecology 182(1 Pt 1): 76-80.

Mørkved S, Bø K. (2013) Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. British Journal of Sports Medicine. See: bjsm.bmj.com/content/early/2013/01/29/bjsports-2012-091758.short (accessed 4 November 2013).

NICE. (2006) Urinary incontinence: the management of urinary incontinence in women. Clinical guidelines (CG40). See: guidance.nice.org.uk/CG40 (accessed 4 November 2013).

Sword W, Landy CK, Thabane L, Watt S, Krueger P, FarineD, Foster G. (2011) Is mode of delivery associated with postpartum depression at six weeks: a prospective cohort study. British Journal of Obstetrics and Gynaecology 118(8): 966-77.





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