Pelvic floor assessment after delivery: how should women be selected?

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Abstract

Objective

Pelvic floor dysfunction after delivery is quite common. New mothers deserve to receive targeted care for pelvic floor dysfunction, but how should women who are at risk be identified and selected for treatment? This study investigated risk factors and puerperal health-seeking behaviours to develop a restrictive patient selection model for postpartum pelvic floor dysfunction assessment.

Study design

This prospective observational study involved women who were at ≥32 weeks gestational age when they delivered in a tertiary referral maternity hospital in Milan, Italy, between July and December 2014. Eligible women were scheduled for a 3-month postnatal pelvic floor clinic. The adherence rate to the pelvic floor clinic and the prevalence of pelvic floor dysfunctions at 3 months postpartum were recorded. Univariable and logistic multivariable analyses were performed to select risk factors for pelvic floor dysfunctions. Risk factors were then tested for sensitivity and specificity for 3-month postpartum pelvic floor dysfunctions.

Results

Of 1606 eligible women, 1293 (80.5%) were included in the analysis; 685 puerperal women (53.0%) adhered to the 3-month postnatal pelvic floor clinic; pelvic floor dysfunctions were detected in 238 women (34.7%). Four elements emerged as risk factors: symptoms before pregnancy (OR 1.72, 95% CI 1.15–2.56; p = 0.008), symptoms during pregnancy (OR 2.13, 95% CI 1.49–3.06; p < 0.0001), vacuum extractor use (OR 1.62, 95% CI 1.04–2.54; p = 0.034), and severe perineal tears (OR 19.45, 95% CI 2.42–156.15; p = 0.005). The combined sensitivity and specificity for the 4 risk factors were 82% and 39%, respectively.

Conclusion

Internal risk factors analysis offers the potential to efficiently restrict patient selection for follow-up.

Introduction

Childbirth and vaginal delivery in particular are commonly considered to be the major aetiological factors for pelvic floor dysfunctions (PFDs), specifically urinary incontinence (UI), anal incontinence (AI) and pelvic organ prolapse (POP). PFDs after delivery are estimated to occur in up to 46% of puerperal women [1]. While only a small minority of women experience severe injury, the effect of PFDs on the quality of life of young, active women is disastrous and cannot be ignored by caregivers. Furthermore, the occurrence of obstetric pelvic floor trauma has to be considered in the medium to long term as an important predisposing factor for significant morbidity later in life [2]. The importance of monitoring PFDs after delivery is also reinforced by the availability of effective preventable measures as demonstrated by a recent Cochrane collaboration review on the effectiveness of physiotherapy in the treatment of UI after delivery [3].

Identifying strategies for selecting women who are at risk for PFDs after delivery is increasingly acknowledged as a critical issue [4]. Scenarios range from the adoption of an extensive to a selective approach on the basis of well-known risk factors (RFs). Therefore, health system decision-makers require precise data to develop feasible and effective programs. Unfortunately, the picture is far from clear. The literature is still controversial regarding the identification of RFs. This controversy reflects both methodological issues as well as substantial differences related to the different settings and populations included in these studies [5]. Good quality data from different countries are therefore of paramount importance. However, the health-seeking behaviours of new mothers, particularly as they relate to PFDs, has not been sufficiently investigated [6], [7].

We designed a study to test patient adherence to an offer for an extensive pelvic floor assessment 3 months after delivery in an Italian tertiary obstetric referral centre. We also aimed to investigate the prevalence of PFDs at 3 months after delivery and their related RFs to develop a customized model for hypothetical restrictive selection criteria. The identification of an efficient model to select patients for pelvic floor assessment after delivery is a critical point in daily clinical practice in an era of limited resources.

Section snippets

Materials and methods

This prospective observational study was approved by the Milano Area C—Ethics Review Committee (reference no. 319-052015). The study included all women who were ≥32 weeks gestational age when they delivered at Buzzi Children’s Hospital, a tertiary referral maternity hospital in Milan, Italy, between July and December 2014. At admission, while obtaining a patient history, each woman was questioned about the presence of PFDs before or during her pregnancy. Before discharge from the hospital, the

Results

Among the 1606 eligible women who delivered during the study period, 313 (19.5%) were not included in the analysis: 44 (14.1%) refused to participate in the study, 74 (23.6%) were not enrolled due to linguistic difficulties, 41 (13.1%) were not enrolled due to logistic and/or neonatal/maternal complications and 154 (49.2%) had missing data. A total of 1293 women signed the consent form and were scheduled for the postnatal PFC at 3 months after delivery; 685 women (53.0%) attended the 3-month

Comment

The impact of pregnancy and delivery on pelvic floor function is an increasingly popular topic among both women and clinicians. Nevertheless, the actual burden of PFDs after delivery is quite complex and difficult to determine.

According to the epidemiological data, detectable PFDs soon after delivery are estimated to occur in approximately 1/3 of all deliveries [1], [4]. The results of our study are consistent with previously published articles, indicating a prevalence of 34.7% at the time of

Funding

No specific funding was dedicated to this study.

Acknowledgement

We are particularly grateful to the midwives, nurses and medical staff of our unit for their support.

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