Pelvic floor training in pregnancy could help prevent the need for 'barbaric' vaginal mesh surgery
For millions of women, childbirth is a somewhat daunting yet thoroughly rewarding process. In the western world, many years of medical research and professional experience mean that women have access to expert care before, during and after birth. However, there is still one matter that is not being addressed enough during pregnancy: pelvic floor health. Women often do not realise, and are not properly informed, that something can be done to reduce the risks of pelvic floor problems in pregnancy and after childbirth.
The pelvic floor muscles lie across the base of the pelvis, supporting and holding the bladder, uterus and bowel in position. They also help to control the bladder and bowel. Pregnancy and childbirth can cause problems such as weakness, overstretching and tears in the pelvic floor muscle, due to increased pressure.
Weakening or damage may result in inability to control bladder or bowel movements, resulting in incontinence. Muscle weakness can also contribute to pelvic organ prolapse, which is the bulging of one or more of the pelvic organs, such as the uterus, bowel and bladder, into the vagina.
Urinary incontinence is a common problem, affecting over 5m women in the UK alone. Between 30-50% of women will experience some leaking of urine during or after pregnancy. And, according to one study, up to three out of four women still experience symptoms 12 years after giving birth.
Incontinence can make women feel shame and embarrassment, which stops them from seeking help. It is normalised in UK society, with many women believing that incontinence is an unavoidable consequence of having children, further stopping them from accessing treatment. They are exposed to media images of female incontinence as normal and inevitable: young women are portrayed as accepting the condition in adverts for absorbent products, accompanied by tag lines such as "Oops moments happen. C'est la vie."
Prevention rather than treatment
When women do seek help for pelvic floor problems they are offered treatment according to the severity of their symptoms. Pelvic floor muscle training (PFMT) is a first line treatment. PFMT involves pulling up the pelvic floor muscles by pretending to hold in wee or stopping passing wind. The muscles can be strengthened by regularly doing a series of long and short holds. For example, squeezing these muscles slowly ten times in a row, then doing ten fast squeezes and repeating this three times per day.
In more severe cases, surgery may be offered, which can include insertion of mesh through the vagina, to provide extra support when repairing weakened or damaged tissue.
However, vaginal mesh surgery has more problems than benefits. It has been called "barbaric" and recently led to more than 800 women suing the NHS over complications with it such as permanent pain, and an inability to walk, work or have sex.
So why aren't we focusing more on women's pelvic floor health in pregnancy, to try to avoid these conditions developing?
Evidence shows that PFMT can help prevent and treat incontinence in pregnant women or women who have recently given birth. In fact, research has found that women having their first baby who performed PFMT were about 30% less likely to experience incontinence up to six months after delivery. There is also increasing evidence that PFMT may prevent symptoms of pelvic organ prolapse and could reduce the uptake of further treatment.
UK guidelines for antenatal care recommend midwives offer information about pelvic floor exercises at a pregnant woman's first appointment. However, for PFMT to be effective it needs to be delivered through a structured, supervised training programme. Simply giving out information on its own is rarely enough to support people to carry on exercising long term.
Women have reported that the information they received about PFMT in pregnancy was insufficient, and they weren't told about the importance of pelvic floor health. They did not understand why they had to do the exercises or how to do them correctly. The information was not clearly linked to the role of the muscles in reducing the risk of incontinence or pelvic organ prolapse so many women did not think PFMT was worth doing.
Evidently, more could and should be done to improve the quality and delivery of PFMT information during the antenatal period. Incontinence and prolapse do not need to be taboo, but nor should they be normalised as part of the consequences of childbirth and pregnancy.
PFMT during pregnancy presents an opportunity to prevent long-term, debilitating pelvic health problems and may reduce the need for further medical or surgical intervention. But for this to happen, women need to understand the benefits, know how to do it and feel that PFMT is realistic and doable in their daily lives.