Pelvic floor dysfunction (PFD), although seems to be simple, is a complex process that develops secondary to multifactorial factors.1
Pregnancy and childbirth have long been considered as risk factors in the genesis of pelvic floor dysfunction.2 There has been little guidance for pregnant women to help determine their individual risk for development of pelvic floor dysfunction. Recently two studies have provided new insights to the link between pregnancy and pelvic floor disorders (PFDs).
PFDs are caused by weakness of the pelvic muscles or tears in the pelvic floor tissues. They include both bladder and bowel control problems. During pregnancy, the weight of the baby pushes down on the bladder and pelvic floor. This pressure can lead to PFDs. Researchers analyzed risk factors for PFDs. Based on this review, they developed the UR-CHOICE system as a way to help doctors predict the risk of developing PFDs following a vaginal delivery.3
This proposed tool weighs risks such as:
U = Urinary incontinence (UI), or urine leakage—a history of UI before pregnancy increases risk for PFDs
R = Race/ethnicity: Stress incontinence is more common among Caucasian women and urgency incontinence among African American women.
C = Age when first child was delivered.
H = Mother’s height and baby’s weight risk is higher if you are shorter than 5’ 3’’ and, at birth, the baby is over 8 ½ pounds.
O = Overweight—being overweight and having a higher body mass index (BMI), a measure of body fat, increases risk for PFDs.
I = Inheritance—Family history (mother and sister) of PFDs.
C = Children: number of children desired.
E = Estimated fetal weight.
A low score will reassure mothers wanting a vaginal delivery, or inform mothers considering an elective caesarean that their risk of pelvic floor complications is low. Pelvic floor strength should still be assessed post-natally and a pelvic floor muscle exercise program given.
A mid-range score would indicate a referral for pelvic floor physiotherapy antenatally and postnatally for pelvic floor exercise training.
A high score would indicate a pelvic floor physiotherapy referral, antenatally, postnatally and annually. Depending on how she feels about caesarean section, and the number of children she desires (if she wants 3 or more children increased risks of repeat surgeries outweigh any pelvic floor benefits), the women may choose to opt for a c-section. Or plan to go to a c-section early in labor if there are any signs of obstruction.
An online calculator can be found here: https://riskcalc.org/UR_CHOICE/
Another group of researchers looked at how many women developed urinary incontinence during the third trimester and immediately after birth. They found that:
∙ Women who experienced UI during pregnancy were more likely to have UI after the birth of their baby.
∙ Women who had Caesareans were less likely to experience UI. That said, Caesareans have other types of associated risks that accompany surgeries in general.
About 7% of the women in the study continued to have UI six months after delivery. These women participated in pelvic floor exercises, with reported improvement after.4
So how effective are pelvic floor exercises in this group? A study suggests that pelvic floor physical therapy is quite impactful on this population. The study titled “Pelvic Floor Exercises During and After Pregnancy: A Systematic Review of Their Role in Preventing Pelvic Floor Dysfunction” had the objective to review the literature on the origin, anatomical rationale, techniques, and evidence-based effectiveness of peripartum pelvic floor exercises (PFEs) in the prevention of pelvic floor problems including urinary and anal incontinence, and prolapse.
The results were: Postpartum PFEs, when performed with a vaginal device providing resistance or feedback, appear to decrease postpartum urinary incontinence and to increase strength. Reminder and motivational systems to perform “Kegel” exercises are ineffective in preventing postpartum urinary incontinence. Postpartum PFEs do not consistently reduce the incidence of anal incontinence. Postpartum PFEs appear to be effective in decreasing postpartum urinary incontinence.5
While there is much more research needed it is helpful to give expecting mothers some guidance and care in order to allow them to better prepare and avoid future problems. In fact, personalized pelvic floor rehabilitation consults given immediately after childbirth to new mothers are reported to be very useful. The majority of new mothers in one study recommend pelvic floor education after childbirth and personalized evaluation of their first attempts to contract the pelvic floor muscles. In-person consultations are more successful than information leaflets. Providing good-quality and well-accepted pelvic floor education might encourage better patient participation in their health care.6
References
- Bozkurt M, Yumru AE, Şahin L. Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor. Taiwan J Obstet Gynecol. 2014;53(4):452-458. doi:10.1016/j.tjog.2014.08.001
- Chitra TV, Panicker S. Child birth, pregnancy and pelvic floor dysfunction. J Obstet Gynaecol India. 2011;61(6):635-637. doi:10.1007/s13224-011-0095-7
- Wilson D, Dornan J, Milsom I, Freeman R. UR-CHOICE: Can we provide mothers-to-be with information about the risk of future pelvic floor dysfunction? International Urogynecology Journal; April 2014.
- Martin-Martin, S, et al. Urinary incontinence during pregnancy and postpartum. Associated risk factors and influence of pelvic floor exercises. Arch Esp Urol., Volume 67, Number 4; May 2014.
- Harvey, M. Pelvic Floor Exercises During and After Pregnancy: A Systematic Review of Their Role in Preventing Pelvic Floor Dysfunction. Journal of Obstetrics and Gynaecology Canada.Volume 25, Issue 6, Pages 487–498; June 2003.
- Neels H, De Wachter S, Wyndaele JJ, Van Aggelpoel T, Vermandel A (2018) Common errors made in attempt to contract the pelvic floor muscles in women early after delivery: A prospective observational study. Eur J Obstet Gynecol Reprod Biol 220:113-117. doi:10.1016/j.ejogrb.2017.11.019
