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Overview of pelvic floor dysfunction associated with pregnancy.

Introduction

The pelvic floor consists of several muscles that span the area underneath the pelvis. These muscles have several important functions, including maintenance of urinary and fecal continence, providing support to pelvic organs (such as the bladder, intestines, and the uterus), and facilitating childbirth. This article seeks to gain a better understanding of the anatomy of the pelvic floor, the changes in the pelvic floor during pregnancy and childbirth, the factors that play into these changes, and techniques that can help treat and prevent pelvic floor dysfunction.

Anatomy

The pelvic floor consists of several muscles, primarily the levator ani and coccygeus muscles. The levator ani is further made up of the pubococcygeus, puborectalis, and iliococcygeus muscles. The urethral and anal sphincter muscles are also part of the pelvic floor. Together, these muscles are responsible for a variety of functions, including maintenance of urinary and fecal continence, providing support to pelvic organs (such as the bladder, intestines, and the uterus), and facilitating childbirth. These muscles and their associated nerves undergo increased stress during childbirth and may be damaged during the process, leading to a decreased ability to perform their basic functions.

Pelvic Floor Changes and Dysfunction in Pregnancy

There is a broad range of pelvic floor changes that can take place during pregnancy and childbirth, leading to dysfunction of the floor. These dysfunctions include urinary incontinence, fecal incontinence, increased flatus, pelvic organ prolapse, overactive bladder, and sexual disorders. Two-thirds of primiparous women within one year post-delivery suffer pelvic floor dysfunction resulting in some degree of bother (Lipschuetz, 2015). Urinary incontinence is one of the most common issues experienced during and after pregnancy. It is reported that new urinary incontinence after a first vaginal birth can be as high as 21% with spontaneous birth (without the use of forceps) (Rorteveit et al., 2003).

Pathophysiology of Pelvic Floor Changes in Pregnancy and Childbirth

During pregnancy, anatomic and physiologic changes occur that may affect the pelvic floor, bladder, and ability to maintain urinary continence. One of these anatomic changes is the growth of the uterus. The progressive increase in uterine volume subjects the pelvic floor, bladder, and other perineal structures to an increased amount of pressure and stress, leading to changes in urinary continence and frequency (Bozkurt et al., 2014). Increased bladder pressure may also narrow the urethrovesical angle (between the female urethra and the posterior bladder wall), which is normally about 90 degrees (Dutton 1960; Tapp et al., 1988). Stretching and increased tension on pelvic floor muscles in pregnancy may also lead to decreased support of the bladder neck and the urethra, allowing the urethra to become hypermobile (Tapp et al., 1988). Both this hypermobility and decreased urethrovesical angle may contribute to the development of urinary incontinence in pregnancy. In addition to the anatomic changes that the body undergoes during pregnancy, there are physiologic and hormonal factors that may play a role in the urinary incontinence associated with pregnancy. These changes can affect the physiology of the kidneys, resulting in increased frequency of voiding, urinary incontinence, urinary urgency, and the sensation of incomplete voiding (Fonti et al., 2009). During delivery, additional compromise of the pelvic floor can occur as the muscles and tissues of the pelvic floor are forced to stretch and can sometimes be damaged in the process. (Bozkurt, 2014). In summary, enlargement of the uterus, increased pressure on the bladder, increased tension on the pelvic floor muscles, and changes in renal physiology are some of the many factors that contribute to the development of urinary incontinence and other urinary changes in pregnancy.

Factors Affecting Development of Urinary

Incontinence

Post-partum and peri-partum urinary incontinence causes are multifactorial (Fonti et al., 2009). Risk factors include increased maternal age, increased fetal head circumference, fetal position, traumatic birth, use of forceps, length of second stage of labor, sphincter damage, obesity, and smoking. In a study by Casey and associates (Casey et al. 2005), it was found that the amount of perineal trauma at delivery played a key role in the improvement of pelvic floor strength and endurance following childbirth (Casey et al. 2005). The study controlled for factors such as parity, maternal age, birth-weight, smoking status, and antepartum scores and found that those that took longer to recover from urinary incontinence and other pelvic floor dysfunctions postpartum were those with 2nd-3rd degree perineal injury and episiotomy. Patients who underwent C-section had the best and fastest recovery of pelvic floor strength and endurance. However, it is important to note that there is currently not enough scientific evidence to recommend elective Csection in the prevention of pelvic floor dysfunction (Thorp et al., 1999). While episiotomy was once used routinely to help prevent pelvic floor dysfunction, it is now only recommended for use in select cases, in which case a mediolateral approach should be taken.

How to Prevent and Treat Pelvic Floor Dysfunction/Urinary Incontinence

Pelvic floor muscle training has been found to be an effective method in the prevention and reduction of urinary incontinence during pregnancy as well as post-partum (Hay-Smith et al. 2001). One review found that women who underwent pelvic floor muscle training during pregnancy were 56% less likely to develop urinary incontinence in late pregnancy, and about 30% less likely to have urinary incontinence post partum as compared with their counterparts who did not undergo pelvic floor muscle training (Hay-Smith et al., 2008).

This type of training should be recommended to all women in their first trimester. (Koc & Duran, 2012). To perform these exercises, it is important to find the correct muscles to contract. The mother can isolate these muscles by starting to urinate then stopping. The muscles used to stop the urination are the pelvic floor muscles and the mother should feel the muscles tighten and move upward. If she is unsure, she can try to insert a finger into her vagina then tighten her muscles as if she were holding in her urine. She should feel her muscles contract around her finger and move up. Have the client to keep the muscles of her abdomen, gluteus, and hip adductors relaxed when performing these exercises, as a common error is the contraction of these muscles instead of the pelvic floor muscles (Medline Plus 2014).

If the mother is still unsure still whether she is performing these contractions correctly, she may consider seeing a healthcare professional. Proper pelvic floor muscle training should include assessment of correct contraction, as more than 30% of women are unable to contract their pelvic floor muscles properly at their first consultation. A physiotherapist can use biofeedback and electrical stimulation to help guide her in finding the correct muscles to contract (Ibrahim et al. 2014). Most people notice some improvement after 4-6 weeks, but it may take as long as 3 months to see major change (Dumoulin & Hay-Smith 2010).

Childbirth educators are an available resource for pelvic floor muscle education and encouragement. While exact parameters regarding the frequency or number of reps needed for PFMT to be effective has yet to be established, it remains known that training the pelvic floor muscles has beneficial effects. These exercises are non-invasive and fairly simple to carry out at home, and so they remain the first-line management for postpartum urinary incontinence. Other treatments may be considered if dysfunction persists. Additionally, patients can consider lifestyle modifications such as obesity prevention and smoking cessation may also prevent the development of pelvic floor dysfunction.

References

Bozkurt, M., Yumru, A. E., & Sahin, L. (2014). Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor. Taiwanese Journal of Obstetrics & Gynecology, 53, 452-458.

Case, B. M., Schaffer, J. I., Bloom, S. L., Heartwell, S.F., McIntire, D. D., Leveno, K. J. (2005). Obstetric antecedents for postpartum pelvic floor dysfunction. American Journal of Obstetrics & Gynecology, 192, 1655-1662.

Chandra, M., Levitt, J., & Pensabene, C. A. (2012). Hydroquinone therapy for post-inflammatory hyperpigmentation secondary to acne: not just prescribable by dermatologists. Acta Dermato-Venereologica, 92(3), 232-235. dohio.2340/00015555-1225

Dumoulin, C. & Hay-Smith, J. (2010). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Systemic Review, 20(1), CD005654. doi: 10.1002/14651858.CD005654.pub2.

Dutton, W. A. W. (1960). The Urethrovesical Angle and Stress Incontinence. Canadian Medical Association Journal, 83(24), 1242-1245.

Hay-Smith, E. J., Bo, K., Berghmans, L. C., Hendriks, H. J., de Bie, R. A., & van Waalwijk van Doorm, E. S. (2001). Pelvic floor muscle training for urinary incontinence in women. The Cochrane Library, 1, CD001407.

Hay-Smith, J., Morkved, S., Fairbrother, K. A., & Herbison, G. P. (2008). Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Systemic Review, 4, CD007471.

Ibrahim, I. K., Hameed, M. M., Taher, E. M., Shaheen, E. M., & Elsawy, M. S. (2014). Efficacy of biofeedback-assisted pelvic floor muscle training in females with pelvic floor dysfunction. Alexandria Journal of Medicine, 51, i37-42.

Koc, O. & Duran, B. Role of elective cesarean section in prevention of pelvic floor disorders. Current Opinions in Obstetrics and Gynecology, 24, 318-323.

Lipschuetz, M., Cohen, S., Liebergall-Wischnitzer, M., Zbedat, K., Hochner-Celnikier, D., Lavy, Y., & Yagel, S. (2015). Degree of bother from pelvic floor dysfunction in women one year after first delivery. European Journal of Obstetrics & Gynecology and Reproductive Biology 191, 90-94.

MedlinePlus. (2015). Pelvic floor muscle training exercises. Bethesda (MD): National Library of Medicine (US). Retrieved November 24, 2015, from https://www.nlm.nih.gov/medlineplus/ency/article/003975.htm

Neumann, P. & Gill, V. (2002). Pelvic floor and abdominal muscle interaction: EMG activity and intra-abdominal pressure. International Urogyencology Journal of Pelvic Floor Dysfunction, 12, 125-132.

Rortveit, G., Daltveit, A.K., Hannestad, Y.S., & Hunskaar, S. (2003). Urinary incontinence after vaginal delivery of cesarean section. New England Journal of Medicine, 348(10), 900-907.

Tapp, A., Cardozo, L., Versi, E., Montgomery, J., & Studd, J. (1988). The effect of vaginal delivery on the urethral sphincter. British Journal of Obstetrics and Gynaecology 95, 142-146.

Thorp, J. M., Norton, P. A., Wall, L. L., Kuller, J. A., Eucker, B., Wells, E. (1999). Urinary incontinence in pregnancy and the puerpeium: a prospective study. American Journal of Obstetrics & Gynecology, 181, 266-273.

by Samantha J. Bartling, BS and Patrick M. Zito, DO PharmD RPh FASCP FRSPH

Samantha J. Bartling is a fourth year medical student at Rowan University School of Osteopathic Medicine. She completed her undergraduate education at The College of New Jersey where she earned her Bachelor of Science in Biology. Upon graduation from medical school, Samantha will continue her medical education as an intern in the United States Navy.

Dr. Patrick M. Zito is both a practicing physician and pharmacist serving as contributing faculty member at Walden University School of Nursing as a clinicalpharmacy/pharmacology specialist. He is also an executive advisory board member at the Center for Applied Health Sciences. His research interests are in infectious diseases, applied sports nutrition, hormone modulation to injury repair, and preventative pharmacological and nonpharmacological approaches to tissue damage and aging, reconstructive surgery, skin cancer therapeutics.
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Author:Bartling, Samantha J.; Zito, Patrick M.
Publication:International Journal of Childbirth Education
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2016
Words:1825
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