New Postnatal Assessment Service teaches mums how to deal with potential post-delivery symptoms

A weak bladder that causes embarrassing leaks is a problem that new mums may get. But at Singapore General Hospital (SGH), a new Postnatal Assessment Service is making sure that women understand the changes that can occur in their bodies during pregnancy and after delivery, and the steps they can take to minimise the risks of developing urinary incontinence later on in life.​

“Our aim is to educate, promote awareness, and get mothers to do relevant exercises so that they will not develop full-blown pelvic floor disorders,” said Dr Jason Lim Shau Khng, Consultant, Department of Obstetrics and Gynaecology​, Singapore General Hospital, a member of the SingHealth​ group.

He is the one who kick-started the service with the hospital’s Physiotherapy Department. “We also want them to know that it’s not a problem that you just accept. There is actually a solution,” he said. The service, which started in January 2015, sees women who are most at risk of developing urinary incontinence. They are the ones who have needed assistance in delivery, especially with the use of forceps, or who have suffered serious tearing of the perineum area, said Ms Yip Wan Hui, Physiotherapist, Singapore General Hospital, a member of the SingHealth group.

Physiotherapists visit new mothers at the wards to teach them pelvic floor exercises as part of their postnatal education and care, Ms Yip said. But the high-risk group will be recommended follow-up care with the Postnatal Assessment Service, which will give each patient a more thorough examination and propose a treatment plan.

Others who are likely to be referred to the service include women who already suffer from poor bladder control, as they are likely to experience a worsening of the condition after delivery. Then there are women who don’t fall into the highrisk category nor suffer any symptoms during pregnancy, but develop weak bladder control after delivery. Dr Lim said that about 10 per cent of pregnant women experience poor bladder control​ as a result of their pregnancy or delivery. Such women will experience urine leaks when pressure is exerted on the bladder – when they cough, sneeze, laugh, exercise or lift heavy things. Regular pelvic floor exercises can help treat this. “Generally, people with these issues do recover. And pretty quickly, too,” said Dr Lim.

​What is the pelvic floor and its uses

The pelvic floor includes the muscles, ligaments and connective tissue in the lowest part of the abdomen. It supports the bladder, bowel, rectum, as well as the uterus and vagina in women and the prostate in men. Weakened pelvic muscles or tears in the connective tissue hurt the ability of the pelvic floor to support these organs. “The pelvic floor acts like a trampoline to absorb shock. During pregnancy, the weight of the baby sits on the pelvic floor and that stretches the muscles. Stretching can cause the muscles to weaken,” said Ms Yip.

As the pregnancy progresses, hormones are also released to prepare the body for delivery, with effects such as the loosening of the ligaments and joints. Although pregnancy and childbirth are huge risk factors to pelvic floor weakening, not all women will develop postnatal pelvic floor dysfunction.

Those who do tend to be older, heavier, have carried larger babies, or have experienced prolonged or assisted vaginal delivery. Women who pay scant attention to weakened pelvic floor muscles postdelivery may go on to develop more serious and complex conditions later in life. They may then need more invasive treatments, including surgery. Patients with serious disorders, including pelvic organ prolapse (where the uterus, bladder or bowel drops through the vagina), urinary and faecal incontinence, or even a combination of all three problems, will be seen by SGH​’s Pelvic Floor Disorders Service, a full and multi-disciplinary service staffed by specialists from the Departments of Colorectal Surgery, Urology and Obstetrics and Gynaecology. “But at the Postnatal Assessment Service, our work is preventive,” said Dr Lim.

Fact or myth: C-sections help to protect the pelvic floor

That childbirth is a risk to the pelvic floor is beyond doubt. The injury imposed on the sling-shaped area of muscles and tissues at the lowest part of the abdomen is much less for a woman who undergoes a shorter period of labour. Given the damaging effects on the pelvic floor muscles, does choosing a caesarean section help in avoiding the weakening and tearing of the muscles in the short term, and possible incontinence later in life?

According to Dr Lim, studies in more recent years have quashed this idea. In the first place, to ensure that a caesarean surgery has a protective effect, the woman must not already have started labour before undergoing the procedure. All subsequent deliveries must also be via C-section.“Studies have shown that even when these two strict criteria were met, other factors can contribute to pelvic floor weakness – age is a big factor, as are increasing BMI (body mass index), carrying heavy weights, and other types of surgery that traumatise the pelvic floor,” said Dr Lim.

Ref: O17​​