Pelvic floor rehabilitation after assisted vaginal delivery

Rodríguez-Colorado S1, Gorbea-Chávez V1, Granados-Martínez V1, Ramírez-Isarraraz C1, Vargas-Luna L1, Zapico-Ortíz C1, Turner-Llaguno A1

Research Type

Clinical

Abstract Category

Rehabilitation

Abstract 672
E-Poster 3
Scientific Open Discussion Session 31
Friday 6th September 2019
13:30 - 13:35 (ePoster Station 12)
Exhibition Hall
Incontinence Pelvic Floor Female Rehabilitation
1.Instituto Nacional de Perinatología
Presenter
A

Ana Laura Turner-Llaguno

Links

Poster

Abstract

Hypothesis / aims of study
Both forceps-assisted and vacuum-assisted delivery (assisted vaginal delivery) increases the risk of injury to the tissues of the vagina, perineum and anus, including severe anal sphincter injuries, constituting an important risk factor for pelvic floor dysfunction (urinary incontinence and anal incontinence).
Incontinence may be solved without a medical intervention in a large group of patients, the least will require treatment and the majority will benefit from a rehabilitation program.  It is proven that in this group of patients a pelvic floor rehabilitation program (behavioral therapy [BT], electrostimulation [ES] and biofeedback [BF]) three months postpartum improves long-term pelvic floor dysfunction. Electrostimulation therapy can increase muscle strength, increase conduction rate of the pudendal nerve, increase de size of motor units, encourage neuronal sprouting, and promote local blood flow; this enhance the squeeze pressure of the striated sphincters. In patients with pelvic floor muscle (PFM) recognition, biofeedback can be additional to this therapy even though its benefit is still uncertain.
HYPOTHESIS: After assisted vaginal delivery, patients with secondary pelvic floor muscle dysfunction can improve their outcome and even get cured with pelvic floor rehabilitation applied on a delayed timing (3 months postpartum).
 
AIMS OF STUDY: To evaluate the efficacy and impact of late pelvic floor rehabilitation therapy on the improvement of urinary, anal and double incontinence after three months of an operative vaginal delivery.
Study design, materials and methods
Simple retrospective cohort of female patients from a tertiary center of urogynecology, which included women with a history of assisted vaginal delivery that conditioned pelvic floor dysfunction such as anal incontinence (AI), urinary incontinence (UI) or double incontinence (DI), during the period of January 2016 to December 2018.
All patients were evaluated for PFM recognition, and the ones who happen to have a contraction were instructed on practicing behavioral therapy (diet rich in insoluble fiber, programed micturition, liquid ingest counseling, etc.) plus a total of 12 sessions of electrostimulation alternated with biofeedback in the same session (one per week) focusing on strengthening of the PFM, lasting 20 minutes each, starting management three months postpartum.
Electrostimulation parameters and type of electrode were selected according to the type of incontinence or the predominant component of it in case of DI.
In patients with urinary incontinence, or predominant UI in a DI, therapy was applied with an intracavitary vaginal electrode using interferential energy with a pulse frequency of 50Hz, continuous cycle time, modulation off and alternate current. 
In case of anal incontinence, or predominant anal/fecal incontinence in a patient with double incontinence, anal electrode was chosen to apply therapy with the same parameters as vaginal. 

For the characterization of patient parameters, we evaluated central tendency measures (the arithmetic mean value) and SD as dispersion indicator. If data did not correspond to normal distribution, interquartile range (IQR) was used to establish an additional median value. 
Wilcoxon test and Students T test was used for related samples, comparing visual analogue scale (VAS) and improvement percentage reported by the patient in session 1, 6 and 12. Statistical data analysis was performed with SPSS version 24.0.0.0 software. The differences of results were evaluated with 5% statistical margin of error (p < 0.05 statistical significance).
Results
A total of 35 women who met the inclusion criteria were analyzed; mean age was 30 YO, all of them had at least one vaginal delivery and a body mass index (BMI) mean of 27.4 kg/m2.
68.5% had a mid-lateral episiotomy without perineal tear, of the rest (31.4%), 11.4% reported a grade IIIC perineal tear.
The pathology that was most associated with assisted vaginal delivery was UI with a prevalence of 45.7%, this group of patients showed a 75% improvement at the end of the therapy. The dysfunction that had the most improvement was AI with a 90% and 88% for DI.
Improvement considered as the diminution of symptoms of at least 50%. 
Table 1 and Table 2.
Interpretation of results
All of the patients showed a significant diminution of visual analogue scale and an improvement of the pelvic floor dysfunction after pelvic floor rehabilitation. 
Anal incontinence showed the most improvement, reporting a 90%, and the least was UI with 75%, all of them with a significant p value after comparing in between sessions.
Concluding message
Rehabilitation of the pelvic floor in women with a history of assisted delivery and pelvic floor dysfunction, started at 3 months postpartum presents significant improvement in the symptoms of AI, UI and DI.
Figure 1
Figure 2
Disclosures
Funding Instituto Nacional de Perinatología Clinical Trial No Subjects Human Ethics not Req'd Retrospective study Helsinki Yes Informed Consent No
28/03/2024 09:03:53