Pregnancy and the pelvic floor

Pregnancy and childbirth are known to increase the risk of incontinence. One third of women experience urinary incontinence and approximately one tenth experience faecal incontinence after childbirth1. Prevalence of stress urinary incontinence 12 years postnatally has been shown to be significantly higher in women that initially present with symptoms during their first pregnancy2. This implies that women who experience urinary incontinence during pregnancy are more at risk of reporting ongoing symptoms later in life.

Women who engage in pelvic floor exercises during pregnancy report fewer symptoms of urinary incontinence after giving birth3. Pelvic floor exercises both during pregnancy and after delivery can prevent and treat urinary incontinence1. During pregnancy, it is recommended that women are asked about their pelvic floor health, such as bladder and bowel symptoms, at every point of contact. This can facilitate timely referral to an appropriate health care professional such as a women’s health physiotherapist. Women should also be asked about their normal diet, fluid intake, bowel habits and participation in exercise, as these may also have a negative impact on their pelvic floor.

Research has shown that 30% of pregnant and postnatal women lack confidence in how to perform pelvic floor exercises4. Similarly, research has shown 50% of women were unable to perform an effective pelvic floor contraction with verbal instruction alone5. Whenever possible a visual observation of a pelvic floor contraction should be performed to ensure correct technique. During a pelvic floor contraction the perineum should be seen to draw inwards and the vagina and anus close. Likewise, ultrasound can also be used to confirm a correct pelvic floor contraction. If the woman is unable to perform a correct contraction or remains unconfident with performing pelvic floor exercises, onward referral is recommended.

A basic pelvic floor program could consist of three sets per day. With one set consisting of:

  • 8-12 short (pull up and release) contractions. This builds strength and power.
  • 8-12 long holds (pull up and hold) for 3-10 seconds. This builds endurance.

This is a generalised program. Should a woman be unable to perform this number of repetitions or hold for 10 seconds, this program can be modified according to the woman’s ability. Likewise, if the woman can perform this easily, the number of repetitions or holds should be increased. Pelvic floor exercises can be performed in any position such as lying, sitting, standing or whilst walking.

Pregnant women are at risk of developing pelvic floor dysfunction. All women should be screened, taught pelvic floor exercises and given advice for prevention of symptoms during the antenatal period. Referral pathways to other allied health professionals and specialised physiotherapy should be developed for women identified at risk of developing pelvic floor dysfunction, if further instruction with pelvic floor exercises is required or for treatment of symptoms.

Article submitted by Janette O'Toole, Women's Health Physiotherapist


References
  1. Boyle et al 2012. Cochrane review Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women.
  2. Viktrup, L., Rortveit G., Lose G. Risk of stress urinary incontinence twelve years after the first pregnancy and delivery. Obstetrics and Gynecology, 108(2), 248-254.
  3. Sahakian J & Woodward S (2012). Stress incontinence and pelvic floor exercises in pregnancy. British Journal of Nursing, 21 (18), S10-S15. 
  4. Chiarelli (2003). Neurourology and urodynamics. Vol. 22, issue 3. P246-249 
  5. Bump R, Hurt WG, Fantl JA et al 1991. Assessment of Kegel exercise performance after brief verbal instruction. American Journal o Obstetrics and Gynaecology. 165:322-329.