Pregnancy and Delivery : Impact on Pelvic

Floor Wellness

Suskhan Djusad

1
 INTRODUCTION

❐ Pelvic floor dysfunction (PFD), although seems to be

simple, is a complex process that develops secondary
to multifactorial factors

❐ Knowledge of physiological and anatomical changes

during pregnancy is important for optimal prevention
and care.

❐ Pelvic floor symptoms are common in pregnant

women  Mostly bladder related symptoms like
higher micturition frequency, nocturia and stress
urinary incontinence

Yeomans ER, Gilstrap 3rd LC. Physiologic changes in pregnancy and their impact on critical care. Crit Care
Med. 2005;33 Suppl 10:S256–8.
Pelvic Floor Function

https://northwestwellnessgroup.com/the-pelvic-floor/
 Physiological Changes of the
Pelvic Floor During Pregnancy
❐ Pelvic floor symptoms in pregnancy  include
increased urinary frequency, urgency and
incontinence  3rd trimester as the fetal head
engages in the pelvis

❐ Urinary retention may occur in the late first trimester

with prevalence of 1 in 3000 to 1 in 8000 of
pregnancies.

❐ The high progesterone levels :

 Weakness of the detrusor contractility
 Incapacity to relax the urethral sphincter

Yeomans ER, Gilstrap 3rd LC. Physiologic changes in pregnancy and their impact on critical care. Crit Care
4
Med. 2005;33 Suppl 10:S256–8.
 Physiological Changes of the
Pelvic Floor During Pregnancy
❐ Increased pressure on the bladder during pregnancy
 increase urethrovesical angle & decrease support
of the bladder neck and urethra  urethral
hypermobility as well as UI

❐ The use of prostaglandins for induction of labor has

been reported to cause incontinence by reducing
urethral resistance

Betschart, C., & Wisser, J. (2016). The Effect of Pregnancy on the Pelvic Floor. Childbirth Trauma, 43–56.
doi:10.1007/978-1-4471-6711-2_4 5
 Physiological Changes of the
Pelvic Floor During Delivery
❐ During delivery  pelvic floor muscle trauma and
denervation occur  associated with stress urinary
incontinence, defecation disorders and prolapse
postpartum or become apparent decades later in life.

❐ Abnormalities are more often found in multiparae,

correlate with a prolonged second stage of labor,
forceps delivery, and high birthweight

Betschart, C., & Wisser, J. (2016). The Effect of Pregnancy on the Pelvic Floor. Childbirth Trauma, 43–56.
doi:10.1007/978-1-4471-6711-2_4 6
 Physiological Changes of the
Pelvic Floor During Delivery
❐ As pelvic organ prolapse is associated with parity in
many clinical and epidemiological studies, it is
unknown whether pregnancy, parturition, or a
combination of these factors contributes to that.

❐ The influence of the hormonal changes during

pregnancy on the pelvic floor is not easy to assess
and up till now there are only few studies on the
effects of pregnancy on the pelvic floor.

Betschart, C., & Wisser, J. (2016). The Effect of Pregnancy on the Pelvic Floor. Childbirth Trauma, 43–56.
doi:10.1007/978-1-4471-6711-2_4 7
Physiological Changes of the
Pelvic Floor During Pregnancy

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 Pelvic Organ Prolaps After
Pregnancy and Delivery
❐ POP is a common gynecological complaint (mean
prevalence 19.7%)

❐ POP need for surgery estimeted 1.5 per 1000 women

years

❐ POP during pregnancy estimated incidence 1 per

10.000-15.000

Pelvic Organ Prolapse during Pregnancy: A Case Series and Review of Literature Chanderdeep Sharma*,
Manupriya Sharma, Anjali Soni, Pawan Kumar Soni, Ashok Verma and Suresh Verma DR R P G M C Kangra, Tanda
(HP), India
 POP ASSESSMENT
POP-Q
❐ POP is the abnormal descent or herniation of the
pelvic organs from their normal attachment sites in
the pelvis
❐ Pelvic floor changes during pregnancy can be
assessed by measuring the compressing forces
through palpation or vaginally placed balloon-type
sensors.
❐ Quantitative assessments of the pelvic floor anatomy
in pregnancy can be performed by clinical tools like
the POP-Q or imaging like ultrasound and magnetic
resonance technique.

Betschart, C., & Wisser, J. (2016). The Effect of Pregnancy on the Pelvic Floor. Childbirth Trauma, 43–56.
doi:10.1007/978-1-4471-6711-2_4 10
 POP-Q

Fig 1. POP-Q points (Bump RC,1996)

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 POP Q NON PREGNANT VS PREGNANT
WOMEN

Fig. 3. 47.6 % of the pregnant subjects had POP-Q stage 2 (p < .001). Point Ba
Fig. 2 All patients in the nonpregnant group had a POP- (most distal position of the remaining upper anterior vaginal wall) and point Bp
Q stage of 0 or 1 (most distal position of the remaining upper posterior vaginal wall) are
significantly different

Betschart, C., & Wisser, J. (2016). The Effect of Pregnancy on the Pelvic Floor. Childbirth Trauma, 43–56.
doi:10.1007/978-1-4471-6711-2_4 12
 POP-Q in pregnancy
❐ In the non-pregnant group maximal descent was POP-Q
stage 1 in 57 %, whereas in the pregnant group 48 % of the
women presented with a POP-Q stage 2.

❐ Point Aa, which corresponds to the urethrovesical angle,

was significantly more relaxed in pregnant women

Betschart, C., & Wisser, J. (2016). The Effect of Pregnancy on the Pelvic Floor. Childbirth Trauma, 43–56.
doi:10.1007/978-1-4471-6711-2_4
 O’Byole (2002) :
Pelvic organ support in nulliparous pregnant and
nonpregnant women: a case control study.

• A Retrospective study of 21 pregnant women in

the 2nd or 3rd trimester (average 27.8 weeks of
- pregnancy)

• POP-Q higher among pregnant subjects

compared with control  a higher incidence of
- POP (p < 0.001)

• POP-Q points that differed significantly between

pregnant and nonpregnant subjects were points
- Aa, Ba, Ap, Bp and the total vaginal length.

O’Byole AL, Woodman PR, O’Boyle JD, Davis GD, Swift SE. Pelvic organ support in nulliparous pregnant and
nonpregnant women: a case control study. Am J Obstet14Gynecol. 2002;187:99–102.
 Outcome Assessment of Pelvic
Floor Muscle Training (PFMT)

❐ Pelvic floor muscle changes during pregnancy can be

assessed through palpation of the pelvic floor
muscles or vaginally or rectally placed pressure
sensors.

❐ These measurements also allow to assess therapy

outcome of pelvic floor muscle training, the only
recommended therapy during pregnancy to prevent
further pelvic floor disorders.

PROPEL: implementation of an evidence based pelvic floor muscle training intervention for women with pelvic
organ prolapse: a realist evaluation and outcomes study protocol Margaret Maxwell, Karen Semple, [...], and
Suzanne Hagen
 PFMT
❐ Cochrane review :
 There was evidence of a statistically significant effect of
PFMT during pregnancy on prevention of incontinence at
3 and up to 6 months after delivery
 Long-term follow up of participants up to 8 years after
their initial randomization showed that 35.4 % of women
in the PFMT group versus 38.8 % of women in the
control group reported urinary incontinence

❐ PFMT is especially recommended for women with :

 Incontinence prior to pregnancy
 Bladder neck hypermobility in early pregnancy
 Post partum : delivered a large baby & forceps delivery.

Cochrane Database of Systematic Reviews Pelvic floor muscle training versus no treatment, or inactive control
treatments, for urinary incontinence in women
PFMT

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PFMT

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 Postpartum
Urinary Retention
❐ Postpartum voiding dysfuntion – failure to pass urine
spontaneosly within 6 hours of vaginal delivery (0.7-4%
deliveries)
❐ Short term complication : patient distress (outflow
obstruction, hesitancy, frrequency, weak stream, pain,
uncomfortable and overflow incontinence (Ramsay 1993)
❐ Long term complication : persistent retention, SUI,
detrussor instability, chronic kidney disease (Andolf, 1994)
❐ Persistent Postpartum Urinary Retention (PPUR)  Bladder
distention  Irreversible Bladder Damage (Ching-Chung,
2002)
❐ RSCM, 1 death caused by urinary retention in 2001

Ramsay IN, TorbetTE. Incidence of abnormal voiding parameters in the immediate postpartum period. Neurourol
Urodyn 1993;12:179–83. doi:10.1002/nau.1930120212
 Postpartum Urinary Retention
Patophysiology
Outlet
Anatomical
relaxation
disorder
disorder

Weak
Nerve
Detrussor
damage
contraction

Weak
Oestrogen
Bladder
contractility
PPUR fluctuation

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 PPUR DIAGNOSIS

❐ Residual urine measurement

❐ Measure residual urine 6 hour after
delivery
❐ Measurement with catheterisation or
Ultrasound
❐ PPUR if residual urine > 200 ml
❐ Bladder Volume was recalculated using
equation of elipsoid LxDxW x 0.52

Acceptable Postvoid Residual Urine Volume after Vaginal Delivery and Its Association with Various Obstetric
Parameters Wen Sze Choe, Beng Kwang Ng, [...], and Pei Shan Lim
Ultrasound Measurement

https://radiologyassistant.nl/pediatrics/normal-values-ultrasound
 PPUR TREATMENT
I. Catheterization

II. Medical Drugs:

Increase bladder contraction
Parasympathetic drug – cholonergic 
muscarinic effect.
Drugs : betanechol, carbachol, metacholin
Decrease urethra resistency :
Sympathetic drug
Drugs : phenoxybenzamine
Smooth Muscle contraction :
Drugs: Prostaglandin
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E2 (Misoprostol)
 …PPUR TREATMENT…
III Fluid management
Drink 3 litre/24 hours
Benefit prevent bacterial colonization
IV Antibiotic: urine culture

In RSCM treatment performed simultaneously: catheterization,

prostaglandin, antibiotic and fluid menegement.
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 Urinary retention Tx Algorithm
Urinary Retention

Catheterization
Urinalysis, Urine culture
Antibiotic, Drink(3 litre/24 hours), prostaglandin

Urine <500ml Urine 500-1000ml Urine 1000-2000ml Urine > 2000ml

Intermitten Dauer kateter Dauer kateter Dauer kateter

1 x 24 hours 2 x 24 hours 3 x 24 hours

Self control catheter/4-6 hours

For 24 hours (release if urge to urinate)

Take off catheter In the morning

Spontaneus Urinating Cant urinate

Residual urine > 200 ml (Obstetrics) Residual urine < 200 ml (Obstetrics)
Residual urine > 100 ml (Gynecology) Residual urine < 100 ml (Gynecology)

25 Ambulatory
Intermiten is catheterization every 6 hour.
 OBSTETRIC AND ANAL
SPINCHTER INJURIES
(OASIS)
❐ OASIS is a third or fourth degreee perineal laceration
❐ 1-5% of vaginal delivery (under reporting)
❐ Indonesia: 4 million Vaginal Delivery/year 40-200.000
OASIS injury/year  4000 Obgyn  10-50 cases
❐ 53% OASIS injury result in fecal incontinence  persistent
sphincter defect
❐ Women with history of OASIS injury  elective C-Section
for future pregnancy ~ Lv IV Evidence ~ best practices
(Scheer, 2007)
❐ Follow up in perineal clinic 6-12 weeks after repair 
Sphincter Ani Ultrasound
Evans, R. Archer, A. Forrest & J. Barrington. Management of obstetric anal sphincter injuries (OASIS) in
subsequent pregnancy
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 OASIS
❐ Repair of third and fourth degree in operating theatre,
under regional or general anesthesia, with good
lighting and appropriate instruments. (RCOG, 2015)
 Anorectal mucosa repairred with continuous or
interrupted technique ( use 3-0 PGA)
 Repair IAS separately with interrupted or mattress
sutures End to End ( use 2-0 PGA)
 Repair EAS full thickness tear with overlapping or End to
End ( use 2-0 PGA)
 Partial thickness EAS tear use End to End

RCOG green top guideline NO 29, June 2015

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 OASIS

❐ Use laxatives to reduce risk wound dehiscence

❐ Review OASIS at 6-12 weeks postpartum

❐ Future pregnancies: all women who sustained OASIS

in previous pregnancy should be counselled about
mode of delivery

RCOG green top guideline NO 29, June 2015

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 Old Complete Perineal
Laceration
❐ 85% OASIS will have a persistent defect on the
sphinter despite the immediate (primary) repair by the
obstetrician

❐ Secondary repair offered to patients with gross faecal

incontinence (Incontinence score >12)

❐ Secondary repair performed after 3 months post

partum

❐ Use Ultrasound to evaluate injury site and size.

Secondary repair of severe chronic fourth-degree perineal tear due to obstetric trauma Elroy P. Weledji, Adolphe
Elong, and Vincent Verla
Faecal incontinence
score

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 SUI during pregnancy and
after delivery
❐ Stress Urinary Incontinence (SUI) : Involuntary loss of
urine on effort or physical exertion or sneezing or
coughing

❐ 54.3% pregnant women have detrimental effect on

quality of life (QoL): Physical activity, travel, social
and emotional.

❐ C section gave protective effect on bothersome SUI

❐ SUI during pregnancy, increased risk of permanent

incontinence in postapartum or later in life

Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment
Bussara Sangsawang and Nucharee Sangsawang
 SUI during pregnancy and
after delivery
❐ Increasing pressure of the growing uterus and fetal
weight together with pregnancy related hormonal
changes, lead to reduced strength of supportive and
sphincteric function of Pelvic Floor Muscle (PFM)

❐ PFM weakness causes bladder-neck and urethral

mobility leading to urethral sphincter incompetence.

❐ Pelvic Floor Muscle Exercise/Training is an effective

treatment during pregnancy with no significant
adverse effect

Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment
Bussara Sangsawang and Nucharee Sangsawang
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