Objectives

This guideline and screening tool offer evidence-based recommendations for routine screening and risk evaluation for SUI/PFD in pregnancy and the postpartum period for community midwives.  These recommendations are intended to:

• increase prenatal risk assessment and discussion of SUI/PFD; 

• increase recognition of SUI/PFD;

• increase referrals to trained and licensed pelvic floor physical therapists for appropriate diagnosis and treatment.   

Definitions

Pelvic floor – The combination of superficial and deep layer muscles, ligaments, connective tissues, and bones of the pelvis.

Pelvic floor dysfunction (PFD) – Functional disturbance of the pelvic floor, including overactive or underactive musculature, nerve damage, sphincter damage, and displacement of the pelvic organs.

Stress-urinary incontinence (SUI) – Involuntary leaking of urine during or related to laughing, coughing, sneezing, lifting heavy objects, or quick movements.

Pelvic floor muscle training (PFMT)—Any use or combination of guided muscle contraction/relaxation, joint manipulation, joint mobilization, soft tissue mobilization/manipulation, myofascial release, muscle energy, and muscle-assisted range of motion taught by a licensed pelvic floor physical therapist.

Vaginal birth – Spontaneous delivery of a single vertex baby through the vagina. 

Operative birth – Assisted vaginal delivery of a single vertex baby with forceps or vacuum. 

Cesarean section birth – Surgical delivery of a single vertex baby with or without the first and second stages of labor.

Scope

Evidence-based guidance for routine prenatal and postpartum screening for SUI/PFD for community midwives;

Evidence-based prognostic risk evaluation for SUI/PFD in pregnancy. 

Target Population

Intended Users

Methodology

Majory Clinical Recommendations

Respectful Relationships: First and foremost, the provider should make every attempt to establish a respectful relationship with the client while using this guideline and screening tool.  Introducing and discussing the topic of pelvic floor health from a non-judgmental, trauma-informed perspective can help reduce the stigma associated with pelvic floor dysfunction, creating open communication between client and provider to discuss these sensitive topics throughout the course of care.  

Consistency:  The provider should not hesitate to initiate a discussion about pelvic health; do not wait for the client to describe symptoms of SUI/PFD before recommending an assessment.  It is fundamentally important to recognize that the assessing midwife may be the only provider who will discuss and assess pelvic health in this client’s lifetime.  All discussion of pelvic health should be done in the client’s primary language or with a licensed medical interpreter.  

Initial Assessment: During the routine intake review of contributory medical, gynecological, and obstetrical history the midwife should discuss pelvic health as a specific component of a client’s health status.  The first assessment should be done at the initial visit or within the first 20 weeks’ gestation and should focus on any present and past symptoms or episodes of SUI or PFD.  The PPRA Part 1 and Part 2 are tools for this initial assessment.  The community midwife is within their clinical scope to offer a pelvic assessment at the start of care and should do a pelvic exam before recommending pelvic floor contractions or any other pelvic floor muscle training.  

Frequency of Screening: An additional pelvic assessment should occur in the second half of pregnancy, between 28-42 weeks’ gestation.  The PPRA Part 2 can be utilized during this assessment.  The midwife can consider re-administering the PPRA Part 1 if risk factors have changed in the course of pregnancy. In the postpartum period, community midwives should address pelvic health and pelvic recovery.  Postpartum screening and evaluation should be routine for all clients before being discharged from care.  

Referral: To best facilitate the PPRA recommendations, community midwives should have a list of trusted, licensed pelvic floor physical therapists they can easily and readily refer clients to for further evaluation, diagnosis, and treatment.  If evaluation and treatment from a licensed pelvic floor physical therapist is inaccessible due to financial or geographic limitations, it is incumbent upon the midwife to learn the Basic Physical Assessment of the Pelvic Floor and proper technique for teaching pelvic floor contraction and relaxation.  In-person or online teaching tutorials can be accessed by maternity providers through reputable sources like the Herman & Wallace Pelvic Rehabilitation Institute.  

Prenatal Screening and Risk Assessment

Initial Assessment at 6—20 weeks’ gestation: [1]

1. Guided Health History: Within the routine review of significant medical and gynecological history, discuss any relevant history of pelvic floor dysfunction.  Discussion should include bowel health, urinary health, sexual function, and pelvic pain.  Recommended screening questions may include, but are not limited to:

   • “Have you ever seen a pelvic floor physical therapist?” If yes, “what were you seen for?”

   • “Have you had any surgical procedure near or including your pelvis, bladder, rectum, genitals, hips, or low back?”

   • “Have you ever injured your pelvis, low back, hips, or buttocks?”

   • “Do you have a history of pain in your low back, hips, pelvis, genitals, and/or buttocks?” If yes, “how severe is the pain?” “does the pain interfere with your daily activities?”

   • “Do you have a history of constipation or irregular bowel movements?”

   • “Do you have a history of leaking urine?”

   • “Has sex ever been painful?” If yes, “what part of sex has been painful?” 

2. Risk Screening: Administer and score the Perinatal Pelvic Risk Assessment Part 1: Risk Assessment. Refer as indicated. 

3. Baseline Measurement: Administer and score the Perinatal Pelvic Risk Assessment Part 2: Pelvic Health Evaluation as indicated in the Risk Screening.  Otherwise, have currently asymptomatic clients use this questionnaire to establish a baseline measurement of pelvic health.  

4. Physical Exam: Recommend a Basic Physical Assessment of the Pelvic Floor if indicated.  

5. Refer to Secondary Provider: When ineffective or dysfunctional pelvic floor muscle action is found during an exam or through the Perinatal Pelvic Risk Assessment screening tool, refer clients to a licensed pelvic floor physical therapist for further assessment, diagnosis, and treatment.  [2]

[1] History of incontinence and pelvic floor symptoms are a strong predictor of dysfunction in pregnancy and the postpartum period (Baracho et al., 2012). 

[2] Pelvic floor contractions are contraindicated in a short, non-relaxing pelvic floors (Faubion et al., 2012; FitzGerald, M.P. & Kotarinos, 2003)

Second Assessment, 28—42 weeks’ gestation:[1]

1. Symptom Assessment: Within the routine review of pregnancy symptoms of the third trimester, inquire about pelvic floor function. Discussion should include bowel health, urinary health, sexual function, and pain.  Recommended assessment questions may include, but are not limited to:

   • “Are you constipated or straining to have a bowel movement?”

   • “Are you able to urinate normally? Do you leak urine when you don’t want to?”

   • “Do you feel able to completely empty your bladder and bowels?”

   • “Do you have pain in your low back, hips, pelvis, genitals, and/or buttocks?” If yes, “how severe is the pain and what daily activities are impacted by the pain?”

   • “If you are sexually active, does sex cause any pain or discomfort?” If yes, “what part of sex is painful?”

2. Pelvic Health Evaluation: Administer and score the Perinatal Pelvic Risk Assessment, Part 2: Pelvic Health.  Refer as indicated

3. Physical Exam: If the client is currently symptomatic, recommend a Basic Pelvic Floor Physical Assessment to evaluate the location and driver of the dysfunction and clarify the need for a referral to a secondary provider. Only encourage pelvic floor contractions after a Basic Assessment of the Pelvic Floor or as prescribed by a licensed pelvic floor physical therapist. 

4. Prevention: For currently asymptomatic clients, discuss prophylactic pelvic floor muscle training with a licensed pelvic floor physical therapist as a method to prevent incontinence in the postpartum period. If the provider feels comfortable, discuss and teach clients how to find and contract/relax their pelvic floor in relation to activities that increase abdominal pressure (coughing, sneezing, laughing, jumping, etc.). [2]

[1] Signs of incontinence that emerge in pregnancy are a strong predictor of postpartum SUI and PFD (Baracho et al., 2012).  Incontinence symptoms are more likely to emerge in pregnancies of larger babies (> 2988g) because of the sustained and increased bladder pressure (Baracho et al., 2012; Van Geelen et al., 2018).

[2] Research consistently shows that PFMT started prenatally is more successful at preventing SUI in the postpartum period (Boyle et al., 2014; Davenport et al., 2018; Morkved & Bo, 2014; Ko et al., 2010; Fritel et al., 2013).  Beginning PFMT in the postpartum period has limited long-term success at reducing or eliminating SUI symptoms (Boyle et al., 2014; Glazener et al., 2014)

Postpartum Screening and Evaluation

24-hour Visit—3 weeks Postpartum

1. Symptom Assessment: Within the routine assessment of postpartum transition and recovery, inquire about pelvic floor function. Discussion should include bowel health, urinary health, and pain.  Recommended postpartum screening questions may include, but are not limited to:

   • “Are you constipated or straining to have a bowel movement?”

   • “Are you able to urinate normally? Do you leak urine when you don’t want to?”

   • “Do you feel able to completely empty your bladder and bowels?”

   • “Do you have pain in your low back, hips, pelvis, genitals, and/or buttocks?” If yes, “how severe is the pain and what daily activities are impacted by the pain?”

   • “If you are sexually active, does sex cause any pain or discomfort?” If yes, “what part of sex is painful?”

2. Pelvic Health Evaluation: Administer and score the Perinatal Pelvic Risk Assessment Part 2 if you are particularly concerned about a client’s pelvic floor function. It is common to find more dysfunction during periods of acute healing. Advise adequate recovery time spent in a gravity-neutral position as tissues and ligaments return to pre-pregnancy length/function. This recommendation may vary between providers, but should be at least 1 week after delivery.

3. Routine Pelvic Floor Use: Mild pelvic floor contractions are reasonable to recommend if the client is highly motivated, has had a physical exam by a trained provider, and has reviewed how to correctly contract pelvic floor muscles.  Encouragement of diaphragmatic breathing (belly breathing) is a safe recommendation for all postpartum people and does not first require a pelvic exam. 

Final Visit or 6-weeks Postpartum

1. Symptom Assessment: Within the routine assessment of postpartum transition and recovery, special care should be given to pelvic floor function and pain.[1] Discussion should include bowel health, urinary health, sexual function, and pain.  Recommended postpartum screening questions may include, but are not limited to:

   • “Are you constipated or straining to have a bowel movement?”

   • “Are you able to urinate normally? Do you leak urine when you don’t want to?”

   • “Do you feel able to completely empty your bladder and bowels?”

   • “Do you have pain in your low back, hips, pelvis, genitals, and/or buttocks?” If yes, “how severe is the pain and what daily activities are impacted by the pain?”

   • “If you are sexually active, does sex cause any pain or discomfort?” If yes, “what part of sex is painful?”

2. Pelvic Health Evaluation: Administer and score the Perinatal Pelvic Risk Assessment, Part 2: Pelvic Health.  Refer as indicated.

3. Physical Exam: A pelvic floor physical assessment is highly advised to ensure the client does not have ineffective or dysfunctional pelvic floor musculature. This is an ideal time to review correct pelvic floor contraction and relaxation techniques for all currently asymptotic clients in moments of increased abdominal pressure (such as sneezing, coughing, laughing, jumping, etc.).

4. Regardless of the administration of the PPRA, it is reasonable management to refer every postpartum client to a licensed pelvic floor physical therapist for evaluation.

[1] SUI and PFD significantly decrease quality of life and are often ignored by both patient and provider during postpartum visits (De Oliveira et al., 2013; Triviño-Juárez et al., 2017; Dessie, Hacker, Dodge, & Elkadry, 2015).