For Obstetric and Paediatric Professionals in Ireland
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Welcome to our Spring 2015 edition of Mums, Babies & You.
Mums, Babies & You, consists of a medical article written by experts in the healthcare industry, it also keeps you up to date with upcoming seminars and study days, you will also be the first to hear of any new studies coming on board and product launches as they arrive. We welcome any feedback you may have on how the programme can work for you – or indeed on topics that you would like us to include in upcoming editions. Please contact us on 1800 371 371 or email firstname.lastname@example.org In this edition, we focus on the subject of How we can help to protect a woman’s pelvic floor in Pregnancy and Beyond by Clinical Midwife Specialist, Eleanor O’Connell. We also have some information on our recent Antenatal Seminar held in the Guinness Storehouse and dates for upcoming meetings. We hope you enjoy your Spring edition of Mums, Babies & You.
The Cow & Gate HCP Team
Pregnancy and Beyond: How we can help to protect a woman’s pelvic floor
Eleanor O’Connell, Clinical Midwife Specialist
Eleanor O’Connell is Clinical Midwife Specialist, Continence Promotion, in the Cork University Maternity Hospital. Having qualified as a General Nurse in 1981 she did post graduate training in Midwifery, Sick Children’s Nursing and Public Health Nursing. She worked in paediatrics for 7 years before spending 15 years in Public Health Nursing. During that time she developed an interest in continence promotion and management of incontinence and specialised in that area for 5 years before moving to become part of the Urogynaecology team when The Cork University Maternity Hospital opened in 2007. She is a midwife prescriber and her client group include women who attend the antenatal, postnatal and gynaecology services.
The pelvis is made up of a ring of bones whose joints have little movement except during pregnancy. The pelvic floor incorporates several muscles, both deep and superficial, nerves and fascia. Functions include coordinating with the transverse abdominus and diaphragm for pelvospinal stability and support, closure of sphincters to prevent loss of urine, flatus or faeces, resistance of increased intraabdominal pressure, support pelvic organs, contribute to sexual sensation and orgasm and to facilitate effective defecation.
Pelvic floor dysfunction (PFD) affects many women during pregnancy and may continue for several months post delivery. For some it may be the beginning of a lifetime of embarrassment with physical and social limitations. PFD incorporates symptoms of urinary (UI) or faecal (FI) incontinence, pelvic organ prolapse (POP), abnormalities of the lower urinary tract including urgency and incomplete emptying, defecation dysfunction, sexual problems and chronic pain syndromes. These symptoms can present individually or several can co-exist. There are numerous variables associated with pelvic floor dysfunction some of which are not modifiable including race, gender, genetics, chronic disease, foetal size and age. The physiological changes affecting the muscles, nerves and fascia during pregnancy and childbirth are key components in PFD development. This article will discuss contributing changes in pregnancy, modifiable risk factors and how we as healthcare professionals can promote awareness, identify women at risk and influence change if needed.
The facts pregnancy and postpartum
Pregnancy, vaginal delivery and instrumental delivery have been shown by many studies to negatively affect pelvic floor function1,2. Others would suggest that underlying preconditions often co-exist which predisposes a woman to potential dysfunction3. A recent Irish study of 1,484 nulliparous women at 15 weeks gestation showed more than one type of PFD present in 57.6% of participants4 . Throughout the literature, however, it is acknowledged that pregnancy, childbirth and multiparity are key elements. Discussion is ongoing as to whether the mode of delivery, parity or pregnancy itself causes deficits. The increasing weight of the pregnant uterus and hormonal changes, especially raised progesterone and relaxin levels, affect the bladder, urethra and the pelvic floor. Collagen and connective tissues changes may cause laxity before a woman gives birth. Older primigravida women are at greater risk of stress urinary incontinence as aging reduces urethral fibres with a 40% loss identifiable by age 355,6. Urinary incontinence in pregnancy and postpartum is a significant risk factor for urinary incontinence in later life7. Instrumental delivery increases the risk8. Caesarean section is not a preventative measure9. Many women do not seek help for PFD as they often see it as an inevitable consequence of childbirth and ageing.
Modifiable Risk Factors
Modifiable risks are where the healthcare professional can provide education and support. Positive changes to lifestyle including smoking cessation, weight reduction, and behavioural changes can help reduce symptoms. These include increasing physical activity, reducing lifting, avoiding constipation and a daily pelvic floor muscle exercise regime. Appropriate treatment of underlying lung disease e.g. asthma can significantly reduce pelvic pressure and subsequent symptoms. Wesnes and Lose7 undertook a comprehensive review of the literature on the modifiable risk factors for urinary incontinence in pregnancy and post partum. They urged health care professionals to discuss preventative measures at antenatal visits and post partum encounters.
Constipation can be problematic for many women during pregnancy and for some it can be a symptom secondary to an increase in progesterone which reduces bowel motility. From 20 weeks gestation the enlarging uterus can also cause pressure on the bowel. Oral iron supplements may exacerbate symptoms. For others, constipation may be a chronic condition related to low fibre diet and poor toileting habits. Prolonged straining during defecation can cause pudendal nerve damage over time. A full rectum can hinder bladder emptying and will exacerbate pelvic floor laxity and vaginal prolapse. A Chinese study involving 10,000 women found constipation to be a risk factor for stress urinary incontinence during pregnancy and up to 6 months after delivery10. We need to advise women to increase fluids and fibre, encourage physical activity, especially walking and improve toileting habits. Many women are unaware of the fibre content of food and a few changes to their daily diet may be sufficient. For example the fibre content of Cornflakes is 1 grm per 40grm serving and Weetabix is 4grms for a 2 biscuit serving. Dietary fibre needs to be increased slowly as bloating may occur if too much is introduced too soon. Information about the difference between soluble and insoluble fibre is also helpful as some women complaining of loose stools and faecal urgency may have too much soluble fibre in their diet. The recommended daily dietary fibre intake is 25grms.
Obesity is a major problem for health providers in the 21st century and maternity units are dealing with the consequences of obesity on a daily basis. An increased BMI prior to pregnancy has been shown to be a significant risk factor for urinary incontinence and other pelvic floor disorders11. Chronic increased intra abdominal pressure will weaken the pelvic floor. The strong association with gestational diabetes and raised BMI adds another potential risk factor for urinary symptoms which are associated with diabetes especially urgency incontinence. Pre pregnancy planning with weight reduction should be advised if possible; but if not careful monitoring of weight gain to not exceed the norm is needed. All women should be encouraged to return to their pre pregnancy weight by 6 months postpartum.
Smoking and its detrimental effects on the foetus in pregnancy has been well documented. Smokers have a higher incidence of chronic cough and chest conditions including asthma and bronchitis. Subsequent increased abdominal and pelvic pressure is a factor in pelvic dysfunction. American and Norwegian studies of non pregnant women found smoking to be a significant risk factor in urinary incontinence12,13.
Pelvic floor muscle exercises have been shown to be an effective preventative and first line treatment for pelvic floor dysfunction especially stress urinary incontinence. NICE guidelines recommend pelvic floor muscle exercises (PFME) be taught to all first time mothers and also be used as a first line treatment for stress urinary incontinence14. A PFME programme should continue for at least 3 months although women should be encouraged to consider them a lifetime routine. They must however be done correctly to be effective so therefore must be taught properly. Bump found that many health care professionals did not know how to teach PFME programmes15. A PFME exercise leaflet given as a back up to verbal instruction is supportive and more effective than one placed in the antenatal pack given at a woman’s first visit.
Partnership in care
When we speak about health promotion, disease prevention and particularly the care of the pregnant woman we often refer to the term “partnership in care”. This implies co-commitment and dialogue. In truth what often occurs is that the health provider gives the information, prescribes the medication, hands out a leaflet or plans a treatment programme. It is then hoped or expected that the recipient adopts the advice, takes the tablet or follows the diet and exercise regime. Experience has shown us compliance can be problematic. Prochaska and DiClemtis developed a transtheoritical model in 1985 proposing that change, especially behavioural change, comes from within and are not externally imposed16. This model has been used in many health promotion initiatives including smoking cessation and weight reduction programmes. Six stages of behavioural change were identified: precontemplation, contemplation, preparation, action, maintenance and relapse. Weinstein adapted this theory further with the Precaution Adoption Process Model17. By studying components of behavioural change the health care provider may understand the process better. This avoids blaming the patient if advice is not taken on board. It also invites the health professional to identify what stage of change the patient is at and then to provide the appropriate intervention. Meeting a woman during pregnancy offers an opportunity for health promotion and behavioural changes as pregnant women are usually very receptive of advice as they wish to provide a healthy environment for their baby. For example many women give up smoking during pregnancy for their baby’s health. This should be acknowledged and applauded. An opportunity exists, here, for the health care professional to encourage maintenance of this behavioural change post partum for the woman’s own and her family’s wellbeing.
Identifying those at risk
PromoCon is a UK based charity service that aims to improve the life for all people with bladder or bowel problems. They offer advice and product information to both professionals and the general public. In 2003 PromoCon responded to a lack of available appropriate services and information for women with pelvic floor dysfunction. A multi disciplinary specialist team reviewed services and literature in the UK. They found large variations in services. Referrals for treatment were adhoc and no clear pathway of care existed in many areas. The need for a pelvic floor risk assessment tool was identified and one was developed which consisted of 3 parts. Part 1 involves screening at the first antenatal visit which highlights existing problems and past history leading to appropriate referral and/or delivery planning. Part 2 is used in the immediate post natal period identifying potential risk factors including large baby, prolonged 2nd stage of labour, urinary retention, instrumental delivery or perineal trauma. Part 3 recommends appropriate referral pathway for the woman which involves hospital and primary care team members18. In our hospital, with 9000 births per year, we adapted the PromoCon tool to develop our bladder care guidelines which involve antenatal pelvic floor dysfunction screening, intrapartum monitoring and a postnatal flowchart for care. It ensures that women are identified early if any problems pre-exist or develop while attending our service. It also places the onus on to the midwife to initiate discussion rather than leaving it to the woman. Appropriate intervention and follow up is provided by our multidisciplinary team who offer a collaborative service.
Pelvic floor dysfunction can persist for many years: possibly for the rest of the woman’s life. Health care professionals need to be aware of and raise this issue when meeting women. Midwives and physiotherapists working in close collaboration can identify problems early. Asking trigger questions enables women to discuss symptoms that may have gone unnoticed previously by professionals or accepted as normal by women. By involving women and raising their awareness; self help with lifestyle changes and a comprehensive pelvic floor muscle exercise programme can be planned. Public Health Nurses, GP’s and practice nurses can be proactive during pregnancy and in the post natal period ensuring women are true partners in care and can avail of a service focused on their individual needs. Promoting awareness, ensuring swift access and early intervention will produce better outcomes for women with pelvic floor dysfunction.
- Mac Lennon, A.H. , Taylor, A.W., Wilson D.H. and Wilson, D (2000) The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. British Journal of Obstetrics & Gynaecology: 101:305-312
- Nygaard I et al (2008) Prevalence of symptomatic pelvic floor disorders in U.S.women JAMA 300(11):1311-1316
- Dietz, H.P., Lanzarone, V (2005) Levator trauma after vaginal delivery. Obstetrics and Gynaecology: 106:4,707-712
- Durnea C.M, et al (2014). An insight into pelvic floor status in nulliparous women. International Urogynaecology Journal 25: 337-345
- Perucchini, D (2002) Age effects on urethral striated muscle: changes in number and diameter of striated muscle fibres in the ventral urethra. American Journal of Obstetrics and Gynaecology: 186 (3) 351-355
- Hijaz,A et al(2012) Advanced maternal age as a risk factor for stress urinary incontinence: a review of the literature. Int Urogynaecol J 23:395-401.
- Wesnes SL, Lose G (2013) Preventing urinary incontinence during pregnancy and postpartum: a review. Int Urogynecol J 24: 889-899
- Viktrup, L et al (2006) Risk of stress urinary incontinence twelve years after the first pregnancy and delivery. Obstetrics & Gynaecology 108: 248-254
- Press, J.Z. et al (2007). Does caesarean section reduce post partum urinary incontinence? A systemic review. Birth 34: 228-237
- Zhu L, Li L, Lang JH, et al (2012) Prevalence and risk factors for peri- and postpartum urinary incontinence in primiparous women in China: a prospective longitudinal study. Int Urogynecol J 23: 563-574
- Burgio KL, Borello- France D, Richter HE ET AL (2007) Risk factors for faecal and urinary incontinence after childbirth: the childbirth and pelvic symptoms study. Am J Gastroenterol 102:1998- 2004
- Hannestad YS et al (2003) Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT study. BJOG 110: 247-254
- Burgio K.L. et al( 2003) Urinary incontinence in the 12-month postpartum period. Obstetrics and Gynaecology 102: 1291-1298
- NICE ( 2013) Urinary incontinence: The management of Urinary Incontinence in Women. London
- Bump,R.C. et al (1991) Assessment of Kegal pelvic floor muscle exercise performance after brief verbal instruction. American Journal of Obstetrics and Gynaecology: 165: 2,322-327
- Prochaska JO and DiClemente CC (1984). The Transtheoritical Approach: Towards a Systematic Eclectic Framework. Dow Jones Irwin, Homewood, IL, USA.
- Weinstein, N. D., Rothman, A. J., & Sutton, S. R. (1998). Stage theories of health behaviour: Conceptual and methodological issues. Health Psychology, 17, 290-299
- Pearl, G and Herbert ,JH (2008). Assessing pelvic floor during childbearing year. Nursing Times: 104, 18, 40-44
The 8th National Antenatal Seminar took place on Saturday, 7th March 2015 at the Guinness Storehouse, St. James’s Gate, Dublin 8
Topics covered on the day, included:
The long term effects of Caesarean section – a legacy for the next pregnancy and beyond
Dr. Sinéad O’Neill, Post-Doctoral Research Fellow at the Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland
Hypnobirthing: Taking the birthing world by calm
Brenda Harkin, Midwife and Hypnobirthing practitioner
Pregnancy after Miscarriage
Dr. Keelin O’Donoghue PhD FRCOG, Senior Lecturer, Department of Obstetrics and Gynaecology, University College Cork, Consultant Obstetrician and Gynaecologist
“An absolutely fantastic day- very informative and well presented content-really enjoyable thanks a million to you all” – Midwife from Dublin
On Wednesday the 25th of March 2015 in the Alexander Hotel, 41-47 Fenian Street, Dublin 2 we had the first meeting of our lecture series on “How Nutrition and Play impact Toddlers – insights to share with Parents”.
Topics covered on the evening, included:
Toddler diets in Ireland – What Healthcare Professionals need to know.
Findings from the National Pre-School Nutrition Survey
Janette Walton, BSc, MSc, PhD Research nutritionist in UCC School of Food & Nutritional Sciences
Learning the language of your child: the therapeutic benefits of teaching parents to play
Joanna Fortune, Psychotherapist and Child Attachment Specialist
Similar lectures in this series include the following dates:
Galway- 7th May 2015, G Hotel
Belfast- 10th June 2015, Ramanda Plaza Hotel
Tullamore- 21st May 2015, Tullamore Court
Cork- 29th April 2015, Hayfield Manor