Q&A: PELVIC HEALTH PHYSIOTHERAPY

AMELLIA KAPA COMMUNICATIONS ADVISOR

Q&A: pelvic health physiotherapy perspective

Tania McLean is a pelvic health physiotherapist and works as both a private practitioner and for Te Whatu Ora Waitematā. With over 20 years of experience in the field, Tania has worked with countless women throughout her career and lends her expertise to midwives in this Q&A on pelvic floor health and assessment.

WHY DID YOU CHOOSE TO SPECIALISE IN PELVIC HEALTH PHYSIOTHERAPY?

I’d always worked in musculoskeletal/ sports therapy and found I enjoyed getting women back to activity postnatally. I completed formal training with WHAT (Women’s Health Training Associates Australia), which provided a learning platform of internal pelvic muscle assessment and specialist pelvic floor dysfunction education, including: stress urinary incontinence; overactive bladder; bowel dysfunction; prolapse; and pelvic pain. I felt I was able to connect the dots well between various pelvic dysfunctions women are often too embarrassed to talk about.

WHAT ARE THE MOST COMMON PREGNANCY OR BIRTH-RELATED PELVIC FLOOR INJURIES/ISSUES YOU SEE IN YOUR PRACTICE?

By far the most common issues I see as a physiotherapist in pregnancy are pelvic girdle pain, back pain, and symphysis pubis pain, but these aren’t directly related to the pelvic floor. The most common pelvic floor issue would be urinary incontinence; mainly stress incontinence, but occasionally urge. The next most common would be constipation, which overloads the pelvic floor, hence the need for pelvic health physiotherapy input in some of these cases.

The most common birth-related pelvic floor injuries I see are: • Perineal tears: unfortunately in the DHB setting we don’t have capacity to see all women who’ve sustained a perineal tear, so only those with 3rd and 4th degree tears are routinely seen on the ward before discharge. These women are followed up at 4-6 weeks postpartum to assess any associated pelvic floor dysfunction.

• Levator ani avulsion: the true incidence of this is debatable and reports vary throughout the literature, but rates could be up to 20%. Levator ani avulsion is often not diagnosed postpartum but detected 5-10 years down the line, when a woman presents with other pelvic floor dysfunction. • Pudendal neuropraxia: transient pudendal neuropathy occurs in up to 70% of women. Associated with prolonged pushing (traction on the nerves) and forceps births, it may cause initial inability to contract superficial pelvic floor muscles. This usually resolves between six weeks and six months.

WHAT CAN MIDWIVES DO - BOTH ANTENATALLY AND POSTNATALLY - TO ASSIST WOMEN IN PREVENTING OR REDUCING THE EFFECTS OF THESE INJURIES?

Obviously the care of the perineum during birth is paramount, but aside from this I believe the best thing a midwife can offer is education. Creating a safe space for women to disclose any existing pelvic floor dysfunction - including any issues following previous births - is vital. Bladder - and to a greater extent bowel - dysfunction is often taboo and not talked about, particularly in certain cultural groups. Midwives get to know women intimately and are positioned well to use this as a platform to ask about any issues and then refer for appropriate advice or treatment.

Midwives’ jobs are busy enough as it is, so we don’t expect them to be able to diagnose and treat pelvic floor dysfunction, but even just starting the conversation - discussing with women what is and isn’t normal and providing appropriate channels of help can make all the difference. It’s never normal to leak urine or faeces, and this really needs to be emphasised to women if they are to seek help early.

The other thing midwives can do is ensure they are identifying issues and/or referring early in the presence of risk factors, regardless of whether the woman reports any pelvic floor dysfunction. Known risk factors for levator ani avulsion are: forceps birth, prolonged second stage of labour and birth weight of >4kg, so the presence of any of these warrants careful assessment and consideration of referral.

WHAT ARE THE KEY ASSESSMENTS MIDWIVES SHOULD BE CARRYING OUT POSTNATALLY TO ENSURE WOMEN’S PELVIC FLOOR HEALTH IS OPTIMAL PRIOR TO DISCHARGE FROM MIDWIFERY CARE?

I think one of the most important checks a midwife can perform is assessment/ observation of a pelvic floor contraction after any perineal trauma has healed. This involves asking the woman to contract her pelvic floor muscles and observing whether there is an indrawing motion of the perineum and an anal wink. Often, women unconsciously bear down when asked to do this, which needs eliminating, but will not be obvious unless the perineum is actually observed during the contraction. If a woman is bearing down, try to teach her to lift her pelvic floor by providing verbal feedback and observing for change. If there is no visible motion during a contraction, it may be that there is either a transient pudendal neuropathy, or a more significant trauma. Flagging any of these signs for pelvic physiotherapy assessment is vital.

HOW EARLY IN PREGNANCY SHOULD WOMEN BE FOCUSING ON STRENGTHENING PELVIC FLOOR MUSCLES?

Whilst a certain degree of strength is important, it shouldn’t be the only focus of pelvic floor health. From initial stages of conception, a woman should be able to contract her pelvic floor effectively to brace for a cough and in my practice, I tend to focus on using the pelvic floor functionally - so that women can cough, sneeze and lift comfortably. Then I move on to teach women how to relax and lengthen the pelvic floor.

All too commonly - even more so these days with the pressures of social media and so much focus on tensing core muscles - a young woman will have a hypertonic/ hyperactive pelvic floor. But the pelvic floor doesn’t just need to be strong; it needs to be able to stretch beyond its resting length - up to 259% of its resting length in fact - in order to allow a baby safe passage during labour and birth. Total, optimal pelvic floor muscle function requires adequate relaxation to allow optimal lengthening. Personally, I believe the correlation between pelvic floor hypertonicity and levator ani avulsion is an area worthy of further research.

The postpartum period is where the strengthening begins. Initially post-birth, gentle, quick contractions of the pelvic floor to assist circulation and healing are optimal, rather than focusing on strength. From there, I like to make it easy for mums. Every time they sit to feed, I recommend doing 10 contractions, holding for as many seconds as the baby is old, in weeks:

Week 1: 10 x contractions, hold 1 second Week 2: 10 x contractions, hold 2 seconds Week 3: 10 x contractions, hold 3 seconds

WHAT IS THE MOST REWARDING PART OF YOUR JOB?

In any healthcare role we are given great insight into our clients’ lives. With pelvic health physiotherapy, we celebrate the little gains - like picking a baby up without leaking, coughing without fear and returning to activities like walking or running without needing to know in advance where every public toilet is en route. Leaking is never normal and showing our clients practical ways to prevent this and regain confidence gives me great pleasure. square