Motherhood and Incontinence: Teaching Patients How to Rebuild the Pelvic Floor After Delivery

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by Marilyn-Lu Webb NP-BC, PhD

Prenatal classes may not mention the possibility of several consequences, as an aftermath of the birth of beautiful new human life. Some of these are urinary leakage, fecal incontinence, vaginal prolapse and depression! Honestly, these are not what most patients might expect following a vaginal birth. However, as I asked my daughter after the birth of her first daughter, “Are you running anymore?” I knew she wanted to regain her previously svelte shape that had been possible through her tri-weekly runs with a friend. “No”, she replied. “I am leaking too much and you know there is nothing you can do about it!”

As a Continence Nurse Practitioner, I was agast…my own daughter, a college educated business major had missed the whole chapter about healthy pelvic floors. Probably her sorority sisters had also missed it. Unfortunately, she is not alone. The incidence of pelvic floor disorders after child birth is alarmingly common among otherwise healthy, young women. Just for the record, you should know that urinary leakage affects up to 70% of women during or after pregnancy and this raises the lifetime risk of incontinence, too.1

Your patients may be coming to asking, what happened? There is a lot of clinical evidence and studies that confirm that vaginal delivery, especially the first, is the probable cause of the incontinence. Many clinical studies have attempted to find the event(s) that are the specific cause. However, despite large babies and long labors with lots of pushing, no single event has been held responsible.2

Despite “a multi-factorial” causation, there is good news for your patients with postpartum incontinence. There are several constructive actions you can teach your patients to correct the leakage and help to rehabilitate the pelvic floor. I can already hear you saying, “Not Kegels again”! You are right; it is more than Kegels, the exercise that Dr. Arnold Kegel proposed back in 1948. To encompass a more comprehensive program, the words, pelvic floor exercises (PFE) have been coined. First, let’s start by helping the patient identify the right muscles (levator ani, the coccygeous and associated connective tissue which spans the area underneath the pelvis. First, have your patient pretend that they are stopping gas. In order to accomplish this, they’ll need to squeeze anus together and pull it up. A Pilates instructor may ask their students to squeeze their rectums, lift it to their spines and then, tuck it under their hearts – this would be another good demonstrative example of performing this exercise. You may need your patient to repeat this motion deliberately two or three times to get all the muscles synchronized.

Now, we need to put a regimen together like building biceps. I recommend my patients start by holding the contraction while counting to 5 slowly. Then, have them relax s-l-o-w-l-y and rest for a slow count of 5. Have them repeat this for 5 times, at least three times a day for the next week. The following week, have them increase the reps to 10 and hold for a count of 8. CAUTION: If your patient feels the pelvic floor relaxing while counting, advise them to stop, relax slowly and rest. Have them resume at a decreased number for a couple of days, then try to hold for the desired time and continue to have them increase their reps by 5 each week. Remember, if the pelvic floor was damaged significantly, your patient may need to gently work up to this regimen.

Ask your patients experiencing incontinence to take this program on as challenge. This is truly a training program with a great reward…significant decrease in leakage or hopefully, no leakage at all.

Tell your patients to not become discouraged if they don’t feel there is much progress at first. Support them in keeping up the program. They will be building their pelvic floor and toning the nerves which take time. They may not notice a difference for 4-6 weeks. The 6 week return visit to your office, whether you’re a doctor, midwife, nurse practitioner or Continence Specialist hopefully will include refining the process. At this visit, suggest that you observe to see if they’re contracting their pelvic floor muscles correctly: No abdominal or gluteal muscle contractions should be noticed and they may even be able to breathe while holding their pelvic floor to a count of 10!

You may also teach a quick contraction, which is the other type of muscle fiber in the pelvic floor. These exercises can be performed in any position: laying down, standing, sitting….for long lasting, lifetime success, encourage your patient to attach their exercise routine to something they know they will do every day. My patients have taught me little tricks like putting a day glow sticker on their tooth brush or resolving to do their pelvic floor regimen every time they feed or change the baby. There are other moments that can be captured in a busy day without having to isolate oneself…like standing in line! Relay to patients that if PFEs are done correctly, no one will know. PFEs are an isometric contraction—only that set of muscle and ligaments move. Have them try squeezing the pelvic floor before a cough, sneeze or lift, too.

A recent research study points out that there is a significant amount of vitamin D deficiency in women with pelvic floor disorders. The research found that the likelihood of urinary incontinence was significantly reduced in women aged 20 or older. To overcome this deficiency, suggest that your patient add 2000 units of vitamin D daily. Exposure to sunshine for 20-30 minutes daily is also a good addition. Do not use sunscreen, for maximum benefits of the rays. 3

A great source of information for you and your patients can be found by contacting the National Association for Continence or by calling 1-800-BLADDER.

This blog is the first in a series on continence issues. I will talk about vaginal prolapse, fecal incontinence and depression in upcoming posts.

References
1. What Every Woman Should Know (brochure). National Association for Continence, 2011; p 3.

2. Brubaker L. Postpartum urinary incontinence: The problem is clear, but there is no simple solution. BMJ 2002 May25; 324(7348):1227-1228.

3. Badalian SS, Rosenbaum PF.Vitamin D and pelvic floor disorders in women: results from the National Health and Nutrition Examination Survey. Obstet Gynecol. 2010 Apr;115(4):795-803

Source
Department of Obstetrics and Gynecology, SUNY Upstate Medical University, and Gynecology and Urogynecology Center, St. Joseph's Hospital Health Center, Syracuse, New York 13203, USA. badalian@netzero.com

About the Author
Marilyn-Lu Webb, NP-BC, PhD is a Continence Nurse Practitioner and Chief Operating Officer of The Center for Continence Care, Inc. in Fresno, CA. She lectures frequently to students in the nursing program at baccalaureate and associate degree
programs as well as the masters level Nurse Practitioners and the public.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of IncontinenceSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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