Childbearing

1
Childbearing the Pelvic Floor A Review of the
Literature

• Nancy H. Sullivan, CNM, MS, FACNM
• Manager, Providence Continence Center
• Nancy.sullivan_at_providence.org

2
Types of pelvic floor disorders

• Pelvic pain
• Nerve damage
• Pelvic organ prolapse cystocele, rectocele,
  enterocele, uterine prolapse
• Urinary incontinence stress, urge, mixed
• Fecal incontinence

3
Prevalence of pelvic floor disorders

• Pelvic organ prolapse is common and is seen in
  50 of parous women.
• Around 10 of women in the community undergo
  surgery at some time of their lives for the
  management of prolapse (Olsen et al.).
• Urinary and fecal incontinence are common and
  prevalence estimates vary from 9 of women over
  15 (UK study) to 38 of women over 60 (US study).

4
Luber K et al, 2001. Demographics of pelvic floor
disorders current observations and future
projections.

• Studied 2070 women who sought care for UI or PFD
  at Kaiser Permanente, San Diego.
• Forty-six percent had undergone previous
  hysterectomy ten percent had undergone previous
  anti-incontinence surgery six percent had
  undergone previous anterior or posterior repair
  (or both).
• Median age of women seeking care was 61 half of
  women were from 30-60 years of age.

5
. Luber K et al, 2001, cond. Demographics of
pelvic floor disorders current observations and
future projections

• Genuine stress incontinence was more common in
  younger patients than in older patients (78 vs
  57)
• Detrusor instability/urge incontinence was more
  common in older women than in younger ones (67
  vs 56)
• Mixed incontinence was common 38 of all
  patients had this diagnosis.
• Pelvic organ prolapse was similar in both groups
  (27 vs 30).

6
MacLennan AH et al, 2000. The prevalence of
pelvic floor disorders and their relationship to
gender, age, parity and mode of delivery.

• Population survey in South Australia 3010
  interviews in respondents homes
• Prevalence of all types of incontinence in women
  was 35.3.
• Pregnancy 20 weeks, regardless of mode of
  delivery, greatly increased the prevalence of
  major pelvic floor dysfunction.

7
MacLennan AH et al, 2000. The prevalence of
pelvic floor disorders and their relationship to
gender, age, parity and mode of delivery.

• Significant increase in PFD for women with
  history of instrumental delivery over women with
  CS, but not for women with SVD over women with CS
• Other risk factors for PFD were age, obesity or
  increased BMI, coughing, osteoporosis, arthritis,
  and reduced quality of life scores.

8
Additional associated factors identified in the
literature

• Menopause and estrogen depletion
• However HRT increases the risk of developing
  urinary incontinence in post-menopausal women,
  according to new data from the Nurses Health
  Study (Grodstein et al, 2004) and from the
  Australian Longitudinal Study of Womens Health
  (Miller et al, 2003).
• This increased risk does not vary by route of
  administration, type of hormone, or dose taken,
  but is diminished upon cessation of use.

9
Additional associated factors identified in the
literature

• Depression individuals with UI more likely to be
  depressed- which comes first?
• Impaired mobility relationship among UI, urinary
  urgency, and falling which comes first?
• Medications, bladder irritants
• Smoking possibly because of smokers cough?

10
Additional associated factors identified in the
literature

• Work environment, including limited access to
  bathroom, heavy lifting, bending, walking, or
  standing.
• Chronic disease causing cognitive impairment,
  peripheral neuropathy or decreased mobility.
  Examples are Alzheimers Disease, stroke
  Parkinsons Disease, diabetes, multiple
  sclerosis.

11
Additional associated factors identified in the
literature

• Physical and occupational activity, especially
  high-impact exercise, are risk factors.
• Butthere is evidence that women who have better
  ability to absorb impact forces (more
  flexibility) have less stress incontinence.
• Nygaard et al (1996) studied the relationship
  between urinary incontinence in elite nulliparous
  athletes and force absorption as assessed by foot
  arch flexibility, and found a significant
  correlation between decreased foot flexibility
  and stress urinary incontinence.

12
Childbearing is a leading cause of pelvic floor
disorders.

• Research studies are heterogeneous in definition
  and design, controversial, and inconclusive.
• Pregnancy itself, regardless of mode of delivery,
  is a risk factor. However, much of the
  professional as well as the lay literature
  ignores or minimizes this and focuses the blame
  on the birth process.

13
Childbearing is a leading cause of pelvic floor
disorders, cond.

• Significant confounding factors are age and
  hysterectomy by around 60 years of age,
  nulliparous women have the same rate of
  incontinence as parous women.
• However, most studies show an increased risk with
  vaginal delivery or cesarean after trial of labor
  over elective cesarean.

14
Marshall K, Walsh DM Baxter GD, 2002. The
effect of a first vaginal delivery on the
integrity of the pelvic floor musculature.

• Survey by the authors reported that 61 of women
  in a Dublin population (n7771) reported the
  onset of symptoms of urinary incontinence before
  or during pregnancy.
• In another study, the authors compared two groups
  of healthy physio-therapists, 20-28 years, one
  nulliparous (n10)and one primiparous (VD only)
  (n10).
• Each group was assessed with a manual digital
  exam, electromyography (EMG) and perineometry on
  one occasion only.

15
Marshall K, Walsh DM Baxter GD, 2002, cond.
The effect of a first vaginal delivery on the
integrity of the pelvic floor musculature.

• Statistical analysis of digital assessment data
  showed significant differences between groups for
  all four types of assessment, with the
  nulliparous group scoring higher.
• Despite measured loss of pelvic floor integrity
  in primiparous group, none of the subjects had
  symptoms of urinary incontinence.
• Authors suggest program of pelvic floor exercises
  for all women postpartum.

16
Rortveit et al, 2003. Urinary incontinence after
vaginal delivery or Cesarean section

• Authors looked at a community-based cohort of
  15,307 women younger than 65 years of age
  enrolled in an epidemiology of incontinence
  study, and linked data to data from the Medical
  Birth Registry of Norway.

17
Rortveit et al, 2003, cond. Urinary incontinence
after vaginal delivery or Cesarean section

• About 20 of respondents answered yes to entry
  question about involuntary loss of urine these
  women were then directed to answer follow-up
  questions about type and severity.
• Age, BMI, parity, years since last delivery,
  birth weight, and gestational age at delivery
  were considered potential confounders. Except for
  BMI, all these factors were higher in the vaginal
  delivery group.

18
Rortveit et al, 2003, cond. Urinary incontinence
after vaginal delivery or Cesarean section
19
Rortveit et al, 2003, cond. Urinary incontinence
after vaginal delivery or Cesarean section
20
Rortveit et al, 2003, cond. Urinary incontinence
after vaginal delivery or Cesarean section

• Did not investigate the effect of
  instrument-assisted deliveries, shown to be a
  major factor in other studies
• Did not look at length of second stage or pushing
  phase
• Found no significant difference between rate in
  elective CS and CS after labor, shown to be a
  factor in other studies
• Found no association of incontinence with mode of
  delivery for women over 50, consistent with other
  studies

21
Rortveit et al, 2003, cond. Urinary incontinence
after vaginal delivery or Cesarean section

• Mean age of nulliparae lowest, women who had a
  vaginal birth highest
• Gestational age and birthweight significantly
  higher in vaginally-delivered group than in
  cesarean group
• Concluded that an individual womans risk of
  moderate or severe incontinence would be
  decreased from about 10 to about 5 if she
  delivered all her children by CS. This decrease
  would apply only until 50 years of age.

22
Wilson PD et al., 1996. Obstetric practice and
the prevalence of urinary incontinence three
months after delivery.

• Postal questionnaires sent to all women in a
  district of New Zealand who were three months
  postpartum over a two-year time period 1505
  questionnaires returned (70 response rate)
• Prevalence of incontinence after VD 24.5,
  following a primary CS 5.2 again no difference
  between elective CS and CS after TOL.

23
Wilson PD et al., 1996. Obstetric practice and
the prevalence of urinary incontinence three
months after delivery.

• For women having had two CS, odds still lower
  than for women with a VD however, by third CS,
  odds were the same.
• Women who performed daily antenatal pelvic floor
  exercises had lower rate than those who did not
  women with higher BMI and parity of 5 or greater
  had higher rates.

24
Goer, H (2001). The case against elective
cesarean section.

• Medial episiotomy increases anal tears (up to
  22-fold in one study).
• Even without extending, episiotomy is associated
  with 2.4 times more fecal incontinence than
  spontaneous second-degree lacerations.
• Three months after childbirth, primiparae with
  intact perineums had the strongest pelvic floors,
  followed by women with spontaneous tears, women
  with episiotomies, and, weakest of all, women
  whose episiotomy extended.

25
MacLennan AH et al, 2000. The prevalence of
pelvic floor disorders and their relationship to
gender, age, parity and mode of delivery.

• Compared with nulliparity, pelvic floor
  dysfunction is significantly associated with
  cesarean section (OR 2.5), with spontaneous
  vaginal delivery (OR 3.4) and with at least one
  instrumental delivery (OR 4.3). The difference
  between cesarean and instrumental delivery was
  significant, but not the difference between CS
  and VD.

26
Groutz et al, 2004. Cesarean section does it
really prevent the development of postpartum
stress urinary incontinence? A prospective study
of 363 women one year after their first delivery.

• Looked at elective CS vs SVD vs CS performed for
  obstructed labor
• Study population 363 primiparae delivering in
  maternity ward in Tel Aviv interviewed them one
  year postpartum regarding symptoms of SUI
  excluded those with SUI prior to childbirth

27
Groutz et al, 2004, cond. Cesarean section
does it really prevent the development of
postpartum stress urinary incontinence? A
prospective study of 363 women one year after
their first delivery.

• Subgroups comparable with respect to age,
  weight/height, gestational age at delivery, Apgar
  scores, and use of epidural anesthesia
• Women with postpartum SUI significantly heavier,
  older, and had increased prevalence of SUI during
  pregnancy duration of first and second stage of
  labor significantly longer in these women.

28
Groutz et al, 2004, cond. Cesarean section
does it really prevent the development of
postpartum stress urinary incontinence? A
prospective study of 363 women one year after
their first delivery.
29
Tunn R et al, 1999. MR imaging of levator ani
muscle recovery following vaginal delivery.

• Aim of study was to quantify the changes that
  occur in the levator ani muscles after vaginal
  delivery using MRI.
• Scanned 6 women one day, one, two and six weeks,
  and six months postpartum
• Changes noted at one day postpartum had
  completely returned to normal by 6 weeks
  postpartum in 5 out of six women, and on one side
  in the sixth.
• Timing of sampling is very important.

30
Dietz HP, Steensma AB, 2003. Delivery-related
changes in pelvic floor mobility

• Vaginal delivery leads to increased anterior
  vaginal wall mobility.
• These alterations are more marked in women with
  limited pelvic organ mobility prior to
  childbirth.
• Postpartum sampling varied from 2-5 months, a
  variation of 3 months during which substantial
  changes may be happening.

31
Lal, 2003. Prevention of urinary and anal
incontinence role of elective cesarean delivery
(Review article).

• Current advanced imaging studies can delineate
  clearly the musculo-fascial defects associated
  with vaginal birth and could enhance our
  understanding of post-cesarean incontinence.
• Incidence of anal incontinence similar in
  primiparae with elective CS and non-instrumental
  VD higher in primiparae with forceps delivery
  SUI more frequent after all VD than after CS.

32
Lal, 2003, cond. Prevention of urinary and anal
incontinence role of elective cesarean delivery.

• Prevalence of both increases with parity, but the
  association with UI is lost in the elderly
  (hence, study showing elderly nuns with SUI).
• Postpartum urinary incontinence can persist,
  resolve spontaneously, or symptoms can arise de
  novo within a 7-year period. Primagravidae who
  develop incontinence in the immediate postpartum
  period usually regain continence within three
  months.

33
Lal, 2003, cond. Prevention of urinary and anal
incontinence role of elective cesarean delivery.

• Prevalence of UI following one CS is similar to
  that following one VD.
• Pelvic floor exercises following an instrumental
  vaginal delivery may be beneficial.
• A new method to detect collagen weakness may help
  identify women susceptible to stress
  incontinence.

34
Lal, 2003, cond. Prevention of urinary and anal
incontinence role of elective cesarean delivery.

• Existing evidence does not allow us to measure
  the risk/benefit of elective cesarean delivery
  against that of vaginal delivery and the
  propensity of either mode to cause incontinence.
  Hence, the mode of delivery will have to be
  decided on obstetric considerations modulated by
  informed maternal choice.

35
Pelvic floor exercises Can they prevent PFD?
Review of the evidence.

• Hay-Smith et al, 2002. There is not enough
  evidence on whether pelvic floor exercises can
  prevent incontinence after childbirth or prostate
  surgery, but the evidence is most promising for
  women at high risk after childbirth. (Cochrane
  Review)

36
Pelvic floor exercises Can they prevent PFD?
Review of the evidence.

• Sampselle, 2003. Taken together, RCTs of pelvic
  muscle training to prevent or to treat UI
  associated with pregnancy and in the postpartum
  period demonstrate effectiveness.
• The absence of adverse effects and the role of
  parity in development of UI make it advisable to
  incorporate patient education about PFE into the
  care of all pregnant and postpartum women.

37
Mørkved et al, 2003. Pelvic floor muscle training
during pregnancy to prevent urinary incontinence
A single-blind randomized controlled trial.

• RCT with 301 nulliparae randomized to 12-week
  intensive pelvic floor muscle training program
  during pregnancy control group received
  customary information.
• Concluded that Intensive pelvic floor muscle
  training during pregnancy prevents urinary
  incontinence during pregnancy and after
  childbirth.

38
Mørkved et al, 2003, cond. Pelvic floor muscle
training during pregnancy to prevent urinary
incontinence A single-blind randomized
controlled trial.
39
Mørkved S Bø K, 2000. Effect of postpartum
pelvic floor muscle training in prevention and
treatment of urinary incontinence a one-year
follow up.

• At one year follow-up, significantly fewer women
  in the former training group than in the control
  group reported SUI and/or showed urinary leakage
  at the pad test women in the training group
  demonstrated significantly greater muscle
  strength increase in the period between 16 weeks
  and one year postpartum than the control group.
• Authors concluded that benefits from pelvic floor
  muscle training are still present one year after
  delivery.

40
Reilly E, Freeman R et al, 2002. Prevention of
postpartum stress incontinence in primagravidae
with increased bladder neck mobility a
randomised controlled trial of antenatal pelvic
floor exercises.

• 268 primigravidae with bladder neck mobility of
  5mm randomized to (1)supervised PFE with PT from
  20 weeks until delivery or (2) usual advice from
  midwives.
• Fewer women in study group reported postpartum
  SUI. No difference in bladder neck mobility or in
  pelvic floor strength.
• Difference attributed to the knack of
  contracting pelvic floor muscles prior to
  exertion, cough, sneeze, etc.

41
Chiarelli P Cockburn J, 2002 Promoting urinary
continence in women after delivery randomised
controlled trial.

• 676 women who had forceps/vacuum delivery and/or
  baby with birth weight 4000g randomized to
  receive (1)postpartum training in pelvic floor
  exercises and incorporated strategies to improve
  adherence or (2) usual postpartum care.
• At three months postpartum, study group had
  reduced prevalence of UI and were more likely to
  perform pelvic floor exercises at adequate levels.

42
Chiarelli P Cockburn J, 2002 Promoting urinary
continence in women after delivery randomised
controlled trial.
43
Meyer S, Hohlfeld P et al, 2001. Pelvic floor
education after vaginal delivery.

• Examined 107 nulliparae during pregnancy and at 9
  weeks and 10 months postpartum (questionnaire,
  clinical exam, perineosonography, urethral
  pressure profiles, intra-vaginal and intra-anal
  pressure during pelvic floor contraction). After
  second exam, women assigned to (1) 12 sessions of
  PFE with biofeedback and electro-stimulation or
  (2) no training.

44
Meyer S, Hohlfeld P et al, 2001, cond. Pelvic
floor education after vaginal delivery.

• Stress urinary incontinence decreased in 2 of
  controls vs 19 of study subjects.
• Incidence of fecal incontinence was the same in
  both groups.
• There was no difference in the percentage of
  women who recovered pre-delivery pelvic floor
  contraction strength.
• There were no differences in bladder neck
  position and mobility.

45
So, what can we learn from the literature?

• Pregnancy itself changes the pelvic floor.
• Vaginal delivery is implicated in pudendal nerve
  damage and levator ani stretching. However, these
  morphological changes do not always result in
  symptoms.

46
What else can we learn from the literature?

• Instrumental deliveries, episiotomies, third- and
  fourth-degree tears,large babies, prolonged
  second stages increase risk for PFD.
• Pelvic floor exercises during and after pregnancy
  may be beneficial. Women with high-risk birth
  profiles should be referred for postpartum
  physical therapy.

47
What else can we learn from the literature?

• Other factors increasing risk of postpartum
  incontinence are incontinence during pregnancy,
  increased BMI, smoking.
• Some women are at higher risk than others.
• There may soon be a risk-scoring mechanism to
  identify women at high risk for PFD following
  childbirth.

48
What else can we learn from the literature?

• Currently, there is not sufficient evidence to
  predict which women will develop pelvic floor
  problems following childbirth or what mode of
  delivery is best for an individual woman.

49
We can say with some certainty that

• Forceps deliveries increase the likelihood of
  anal incontinence .
• Severe sphincter tear is the single most
  important factor leading to anal incontinence in
  women occult sphincter defects are rarely
  associated with short-term sequelae (Faridi A et
  al, 2002 Fenner DE et al, 2003 Hall et al,
  2003).

50
Currently, we cannot say that

• Epidural anesthesia is associated with symptoms
  related to perineal trauma and pelvic floor
  muscle weakness (Fitzpatrick Colm, 2000,
  Sartore et al, 2003).
• Occult sphincter defects are always associated
  with symptoms.
• Elective cesarean section can prevent
  incontinence.

51
Counseling Women About Elective Cesarean Section

• JMWH 49(2)155-9 (March-April 2004) is a balanced
  clinical resource for midwives who are counseling
  women.

52
Binnie A. Dansby, paper delivered at the Congress
of the International Society for Pre- and
Perinatal Psychology and Medicine, 1989.

• The quality of birth affects the quality of life,
  and in turn, impacts and shapes the quality of
  society. Birth is the cornerstone of our
  thoughts, it is the root of our thinking. It is
  the origin of our emotional response to every
  situation we encounter. Birth is the source
  experience in the body - And we are conscious at
  birth. Birth affects our whole subsequent mental,
  emotional, and spiritual well being. The
  decisions we make at birth are the foundation for
  the beliefs and patterns activated in this
  lifetime. Those individual attitudes and patterns
  translate to the attitudes and patterns displayed
  by nations.